Normal and pathological phases of poststress response (From Horowitz (1986))
As in the work of Lindemann (see later), the loss of a loved person and following mourning was seen as analogous to processing a traumatic event. The normal process starts with an outcry of emotions like fear, sadness, and rage. This is followed by denial, refusing to face the memory of the disaster which subsequently leads to intrusions. Horowitz hypothesized a dynamic alternation between intrusions and avoidance (Gersons 1989). The next step is working through, facing the reality of what happened which ends in completion, going on with life. In principle, a person is capable of processing a loss of a loved one without professional mental healthcare.
On the right side of the figure, pathological responses are summarized in hierarchical order. It is interesting to carefully study the wording used by Horowitz. It starts with overwhelmed directly after the event. He then described panic or exhaustion “resulting from escalated emotional reactions.” The ability to tolerate extreme emotions is the key hypothesis of Mardi Horowitz for healthy processing of trauma. When emotions are suppressed, this will result in panic and exhaustion that disturbs the daily life of a person. This is in accordance with psychoanalytic theory stating that feeling and accepting emotions is essential for coping with negative events. This is the central hypothesis in BEPP. In learning theory, the central hypothesis is that PTSD is a conditioned response in which a person is still irrationally fearful for recurrence of a traumatic event from the past. In BEPP, however, it is hypothesized that the irrational fear of repetition of the traumatic event is in fact a subconscious anxiety for the suppressed intense emotions. This is in line with the model of Horowitz in which panic and exhaustion are explained as results from escalated emotional reactions. In earlier days, Erich Lindemann (1944) described the diversity of grief reactions after a huge fire in a night club in which 500 people died. His observations were not limited to the consultation room but came directly from stories of mourning families, friends, and colleagues in the Boston area as he himself was part of the community. Besides a healthy process of mourning, he also described more pathological routes. Like Horowitz, he also showed that denial and suppression of emotions are the driving force of unhealthy patterns.
13.2.2 Understanding the Meaning of Emotions
Tolerating and accepting extreme emotions is the key toward a healthy outcome after negative life events. When no energy is taken up for suppression and avoidance anymore, the dysfunctional high level of arousal will diminish which helps to relax. Unnecessary scanning for danger that results from high levels of arousal will subsequently stop. Acceptance of strong emotions like grief and anger helps to understand the effect of the traumatic experiences on one’s life and the meaning of life itself. Tolerating strong emotions will help to feel self-compassion for what one went through and also self-acceptance as someone who survived and wants to go on with life. Remembering the traumatic event and just feeling powerless will not lead to improvement; however, contact with underlying emotions of healthy anger because of the terrible experiences will activate the patient to feel in control of one’s personal territory. Feeling anger is also very valuable because it helps to accept one’s own reaction toward evil. When someone expresses anger in a controlled manner, it helps to prevent the acting out of aggression because the idea of being powerless vanishes. Subsequently, others will no longer be pushed away. Commonly, it also helps patients to get in touch with underlying emotions of sorrow as this promotes attachment to others.
Notwithstanding the negative consequences of avoiding emotions after trauma, patients with PTSD have had their reasons to do so. When people become highly emotionally aroused, they need others for their psychological support. Intense emotions in themselves become a danger when they lead to distancing from important others and to abandonment. Research findings emphasize the role of past and current attachment relationships in trauma-related psychopathology. Parental neglect for instance is a risk factor for enduring psychopathology after a traumatic event in adulthood (Meewisse et al. 2011), and the most important predictor for PTSD is a lack of perceived social support after trauma (for review, see Ozer et al. 2003; Brewin et al. 2000). When one has experienced a life-threatening event and there is no one to share this horrific threatening experience with, the danger continues and one will feel terribly lonesome.
Patient: “I am haunted by my son’s accident. I have a loving relationship with my wife, but I am afraid to lose her when I reveal the details of what is troubling me as she will learn that I am a monster as part of it was my fault.”
Patient: “I cannot allow myself to think about what has happened as it is pointless and painfully repelling. I‘d better forget it all because when I open up about the sexual acts my father did, others will be disgusted by me and it will drive my family apart.”
Intense emotions become overwhelming when they are perceived as a threat for the self and the relationships with others.
13.2.3 Facing the Often Horrific Reality of the Trauma
Rebuilding one’s life after trauma implies that one faces reality and stops denying the current circumstances even if this means risking rejection or abandonment. After a crisis, people frequently reevaluate their relationships with others. Some people are valued much more than before because of their unexpected support; others who have been disappointing are set at a distance.
Lindemann (1944) also paid attention to the context of loss of a loved one. This is not only a personal emotional process but also a process in which one has to deal with the reaction of others like family or community members. For instance, someone’s children will miss their deceased brother and sister or react to the loss of the other parent. When a loved one has died, the daily life and routines have changed. Positions and responsibilities of family members shift, and unexpected financial problems can arise due to loss of income. The method of crisis intervention was based on Lindemann’s paper (1944). Crisis intervention combines working through the emotions and uses problem solving until a new equilibrium has been found and established.
In BEPP, the first part of the treatment is devoted to the expression of emotions which helps to diminish the symptoms of PTSD. The second part which is called “the domain of meaning” is focused on the awareness and realization of fundamental change in daily life.
After imaginal exposure, patients often use words like “it is as if I wake up and see the world again, but differently.” Ulman and Brothers (1988) and also Wilson et al. (2001) have pointed to the importance of loss of trust in the world and changes in the view on oneself after traumatic events. Without severe traumatic events, one experiences a constant safety of the surrounding world. One can trust others and institutions like the government, employers, doctors, and police. Traumatic experiences like floods, earthquakes, traffic accidents, and especially interpersonal events like murder, rape, and assaults dissolve trust in others and in the world. Subsequently, a person will blame himself or herself for the tragedy he or she has experienced and for not having been prepared enough to avoid the horror. In trauma-focused treatments like EMDR and CBT, this self-blame is targeted by cognitive restructuring to let people realize that the self-blame is irrational. In BEPP, these feelings are more often accepted as such while their origin is explored. Memories of similar feelings in childhood might surface which can help patients understand why they cling to such interpretations. Going back to childhood is not a prerequisite in BEPP; however, it is often helpful to understand that expectations about others, the world, and oneself originate from critical experiences in childhood. Ulman and Brothers (1988) described how traumatic events can destroy feelings and fantasies of invulnerability and how this may lead to a shattered self. Self-blame, which is frequently felt, is often a shield for feelings of anger caused by failure and deception about oneself. When the pain of the loss of illusions is felt and understood in the second part of BEPP, it helps to redefine oneself as vulnerable and resilient at the same time. It also helps to adopt a realistic view on the world, one that is not totally safe, nor completely dangerous. This helps a person to be aware of future negative life experiences and also motivates to enjoy the gift of life more. Posttraumatic growth is seen as a very valuable opportunity in BEPP to learn from trauma and to overcome the sadness.
From crisis theory we know that a period of uncertainty follows an unknown or unexpected incident or situation. This will result in stress and in loss of control. People suffering from PTSD excessively try to keep control over everything around them because they expect danger to strike again. In BEPP, we therefore start the treatment with psychoeducation to start restoring the feeling of being in control. By explaining the symptoms of PTSD as resulting from the traumatic experiences, people start to understand they are not “mad” and that the symptoms have a function in the face of real danger.
In developing BEPP, we have discovered that solely talking about the traumatic incident and emotions resulting from the experience will help to better understand what happened to the patient. However, this will not lead to a decrease in PTSD symptoms.
Patient: “I have told over a hundred times how I was robbed, but that did not help me.”
Involuntary vivid reexperiencing symptoms which spontaneously arise or are evoked in response to triggers need more specific intervening. Theories about memory systems (Brewin 2014) help to give some explanation of these special memories. It is remarkable how patients with PTSD easily forget ordinary things like groceries, while specific details of an assault vividly stay present in memory. It seems that a traumatized person is not able to forget the details of the traumatic incident because information about danger is extremely important for survival.
In BEPP, imaginal exposure is applied as the method by which the traumatic memories are treated and changed to become a memory of a past event instead of an overly significant one for the present. After a brief relaxation exercise, imaginal exposure is started. The therapist helps the patient to return to the traumatic events with eyes closed for a detailed and vivid mode. This results in feeling tense and frightened. Just bringing a person back to such a nasty memory is not helpful. In BEPP, we therefore focus on feelings of sorrow about what happened. Commonly, patients start to cry intensely or show ‘silent’ grief. When they open their eyes after exposure, they feel sad and tired but relieved that they felt the pain and that they accepted to feel this as it led to self-compassion. We discovered that it is necessary to go back in such vivid details to discharge the emotions. In 4–6 exposure sessions, we follow the chronological course of the event in great detail until all moments with an affective load have been addressed. The result is that patients may still feel sad about what has happened, but that it is not so overwhelming anymore. This outcome is similar to other trauma-focused treatments like CBT and EMDR. The method of exposure however is different in these three treatment modalities for PTSD. In all three, the patient has to go back to the worst images of the event. In CBT, the result of the exposure is explained by the extinction of fear by repetitive confrontation with the trauma memories. In EMDR also a repetitive confrontation is used directly followed by a visual or audible distraction. Therapists report that such forms of exposure are also often accompanied by crying or sadness, but it is not considered to be the essential ingredient like it is hypothesized in BEPP.
13.3 BEPP Protocol
The BEPP protocol consists of 16 weekly sessions of 45 min each. The sessions are structured in the following order (Gersons and Olff 2005):
The overlapping numbers indicate that the separate elements of the therapy may both be the focus in a single session. In practice, the number of sessions needed for the different modules can vary dependent on the complexity of the case and the experience of the therapist.
13.3.1 First Session: Psychoeducation
Psychoeducation is a powerful tool to help patients understand the relationship between the traumatic event(s) and their symptoms of PTSD. Symptoms of PTSD are explained as a psychological and physiological state which is functional when danger looms but is dysfunctional and exhausting when there is no threat anymore. For instance, to avoid walking on the grass because one fears mines under the surface, like in Afghanistan, is not functional in most other countries. Most symptoms are beyond control and triggered by conscious and unconscious associations related to past traumatic experiences. One is hyperalert, agitated, and easily startled and has difficulty sleeping and concentrating on the daily routines, because one cannot relax and does not feel safe due to experiencing ongoing danger. By explaining the symptoms of PTSD as resulting from the traumatic experiences, people start to understand that they are not crazy and that the symptoms have had their function in the face of real danger. Avoidance of triggers of the trauma helps to briefly suppress emotions but is counterproductive in the long run. When a traumatized person wants to process the trauma, it is necessary and very helpful to feel, accept, and understand the strong emotions. Being overwhelmed by remembrances of the traumatic event and the feeling as if this is going to happen again creates the feeling of being powerless and in desperate need of control. Psychoeducation helps to regain some feeling of control. The next step in this first, or sometimes second, session is to explain the rationale of the BEPP treatment. The imaginal exposure, the letter writing, and the use of memorabilia are explained as tools to return to the terrible experiences in a vivid way in order to feel and accept the intense emotions and connect them to the trauma. It concerns emotions like sorrow, grief, anger, hate, shame, disgust, and horror. After this phase, which is emotionally heavy, the meaning-making part will start. The patient learns that the world is not as safe as we want it to be and that we are not invulnerable. It will take time and effort to start trusting others again. Also the farewell ritual will be explained as the last confrontation with the frightening memories of the trauma and one’s suffering from the experiences for closure, followed by celebrating the comeback to normal life. In fact, it is a transitional ritual as well, to end the treatment and to go on without the therapist from this point on. Prediction of the difficult processes involved in the various parts of the therapy will motivate the patient for the hard work, especially during imaginal exposure. As dropout is a significant problem during trauma treatment (Bisson et al. 2013; Schnyder 2005; Bradley et al. 2005), therapists explicitly draw attention to avoidance as a serious pitfall. Significant others are also asked to attend this first session of psychoeducation, as they usually play a supportive role in keeping patients motivated. Appointments are made in collaboration with the patient on how to act when they struggle badly and wish to stop therapy.
13.3.2 Sessions 2–6: Imaginal Exposure
The following five sessions aim to accept and express emotions to process the trauma using several interventions: imaginal exposure, mementos of the trauma, and letter writing. During imaginal exposure, patients recount their trauma in the first person and present tense while they have their eyes shut. This is preceded by a brief muscle and breathing relaxation to facilitate focus and concentration. In every session, a part of the trauma narrative is recounted in chronological order. The therapist helps patients to experience and label feelings by focusing on sensory information. What is happening, and what do patients see, hear, feel, and think? Those moments with a high emotional load are specifically explored during imaginal exposure. These so-named hotspots can be recognized by a change in intonation of the patient’s voice, body language, lack of detail due to speeding up the story, a change of subject, or suddenly opening the eyes. The responsibility of the therapist is to locate the hotspot, reflect on the feelings of the patient, and, if necessary, slow down the pace of the exposure when encountering such a moment.
During exposure, arousal has to be at an optimal level for the patient to be able to process the trauma emotionally and make sense of one’s reactions.
When arousal is too low, for instance in the case of dissociation, no change will occur in information processing, as emotions are lacking. To help patients get in touch with their feelings, therapists prompt for sensory information. Following these prompts, they focus on physical awareness of emotions to make the bridge to the feelings.
Patient: (in a calm voice) “He just grabs my bag and walks away.”
Therapist: “Stop for a second and rewind a bit. Look at him; watch his face when he grabs your bag. What do you see?”
Patient: “His face has no emotional expression. His eyes are dead.”
Therapist: “You seem to shiver. What do you feel now?”
Patient: “I am so afraid.”
Therapist: “What scares you so much about his appearance?”
Patient: “It is like I am nothing to him. One wrong move and he will shoot me.”
When arousal is too high, information processing stops also because it blocks the possibility to think logically. In this case, the therapist helps the patient to label the current feelings as this will downregulate the arousal. Following a reflection on the patient’s feelings, the therapist prompts a new perspective in order to let the feeling emerge in a controlled way. In the case of repression of sorrow, this could be worked out during a session in the following way:
Patient: “My heart is beating. He tries to suffocate me and I am powerless. I am afraid to die” (silently crying).
Therapist: “You almost died? You were so scared. It is really upsetting to realize what you went through, isn’t it?”
In the case of repression of aggression, it could be done like this:
Patient: “I am 12 years old and I am held down by this man. I cannot move. It leaves me no choice but to let him do what he wants” (patient shivers).
Therapist: “He is so much stronger than you are. You shiver by what he does to you. You despise him, am I right? (pause).”
The usual course in BEPP is that the perspective turns from fear, as was experienced during the actual traumatic event, to feelings of sorrow in the present. This is accomplished by looking back from the present how awful it has been. The result is that the trauma is experienced as an event that happened in the past, which is crucially different from flashbacks that lack context and feel as if the traumatic event happens in the here and now. During exposure, patients usually remember details of the trauma that were forgotten and that shed a new perspective on the event.
In BEPP, the focus is on the meaning of the trauma for the sense of self and the view on others. Since it is not aimed at habituation of fear or decrease of arousal as such, exposure is not prolonged. The first half of the session is spent on imaginal exposure, while the second half of the session is spent to elaborate on issues that patients become aware of during exposure.
After imaginal exposure, patients feel sad and tired but also relieved as they start to understand their anguish. It feels awful to remember how helpless one has been during the traumatic event, but at the same time it helps to realize that there was no choice but to act during the trauma as they did. This is essential to modify one’s perspective on guilt and self-blame. Feelings of sadness arise as patients experience the loss of cherished beliefs, particularly, the illusion of safety and of a sense of self as master of one’s own experiences.
Recounting a personal trauma narrative can be retraumatizing when it leads to rejection and distancing in the therapeutic relationship, as arousal levels are high and subsequently attachment needs increase. In therapy, patients often start recounting little bits of a horrifying experience. Usually patients attend carefully to how a therapist reacts to hearing the story. The interpretation of the reaction of the therapist may affirm the meaning of the trauma. For instance, seeing an aversive reaction on the therapists face when recounting a sexual trauma could confirm the patients’ idea that they themselves are disgusting as a person. On the other hand, an assertive reaction of the therapist that this traumatic event is horrible may be interpreted as a sign that the trauma is too cruel and scary for others to hear, which leaves the patient alone once again. In BEPP, therapists use their own emotions as a guideline to understand internal states of patients. The therapist’s own emotions are also used to encourage patients by normalizing their fears, such as in the following example:
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