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

1

BriefImagery Rescripting and Reprocessing
TherapyPresented by

• Bob Stahn, Ed.M, LCPC, MAC, ICADC
• Well Spring Counseling, LLC
• Idaho Falls, ID

2
Brief Imagery Rescripting and Reprocessing
Therapy (BIRRT)

• One in five people who experience trauma
• will develop PTSD

3

Brief Imagery Rescripting and Reprocessing
Therapy (BIRRT)

• 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

4

Brief Imagery Rescripting and Reprocessing
Therapy (BIRRT)

• 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....

5

Brief Imagery Rescripting and Reprocessing
Therapy (BIRRT)

• 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 activatedalong with
  the affectand cognitive restructuring can occur.

6
BriefImagery 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.

7
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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)

8
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

9
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

10
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

11
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 3 Steps of Dr. Smucker's IRRT Imagery
• Step 1Imaginal Exposure (re-experience the
  truamatic episode)
• Step 2Mastery Imagery (episode starts the same
  but onto it is spliced the perfect ending)
• Step 3Adult-Child Imagery (nurturing, comforting
  and educating the person who experienced the
  traumatic episode)

12
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• Comparing IRRT and BIRRT
• Same principles
• Same results
• But BIRRT is... well... brief!

13
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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.

14
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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.

15
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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.

16
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• The Bad News (cont.)
• There is homework. It includes rehearsing the
  new ending and spending time nurturing the
  younger clienttwice 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.

17
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

18
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

19
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

20
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

21
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

22
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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.

23
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

24
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

25
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

26
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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

27
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• 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)

28
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• The Results
• The Measuring ToolThe PTSD 30
• - A 30-item questionnaire
• - Based on DSM-IV Diagnostic Criteria
• - A six-point severity scale (0low, 5high)

29
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• PTSD 30 Items
• You 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.

30
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• You feel less interested or participate less in
  previously enjoyed activities.
• You feel like you have no future or that its
  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.

31
BriefImagery Rescripting and Reprocessing
Therapy(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.

32
BriefImagery Rescripting and Reprocessing
Therapy(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

33
BriefImagery Rescripting and Reprocessing
Therapy(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

34
BriefImagery Rescripting and Reprocessing
Therapy(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!

35
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)
36
BriefImagery Rescripting and Reprocessing
Therapy(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

37
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• BIRRT Client Comments
• Im very different than I was a year ago. The
  rescripting got out a tremendous amount of
  darkness. I dont explode as I used to. I see
  life from a different perspective. I feel a lot
  of peace. Its wonderful! -Lisa
• "Im more relaxed.Im much more hopeful than in
  the past. I have a more positive outlook at life.
  Im very impressed with the effectiveness of the
  technique.  -Casey (Veteran)

38
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• A weight or block thats always been there is
  now gone! Its amazing to me. I dont feel
  responsible even though I didnt realize I was
  feeling that way before. I have carried anger for
  years but didnt realize it. Its night and day
  difference. It is surprising where I am today.
   -Teresa
• Im happier and I feel more relaxed and good.
  Its cool! I feel more confident more peaceful.
  Its almost like a memory nowa sense of serenity
  that I never knew I could have. -Katie

39
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• I met with Bob just once, but it made a world of
  differencedefinitely great improvement. Im
  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
  dont feel the guilt and shame. Its gone. I
  wasnt sure this process was going to work but it
  did. It was excellent. I havent wanted to use
  anymore. Im not afraid anymore after years of
  being afraid. I dont feel powerless (especially
  about men) anymore. BIRRT was absolutely worth
  it.  -Sandy

40
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• I feel more relaxed than Ive ever been! I can
  hardly stand this. I feel like Im on a retreat
  and I never have to leave! This is just
  incredible! .I now feel joy coming from within
  and its increasing.  Im feeling a lot of peace
  and happiness on a regular basis. Jo
• Its completely different since Brief IRRT.
  Before Id be curled up on the floor but now Im
  dealing with it. Its amazing!  -Billie

41
BriefImagery Rescripting and Reprocessing
Therapy(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 myselfIm down to one
  medication from seven! And that one is going
  pretty soon. Im more positive and not so
  depressed. I am so very grateful.  -D'Arcy
• Life is quite joyful. Im doing fantastic.
  BIRRT was very effective for me--extremely,
  extremely beneficial for me. I wish Id known
  about this decades earlier.   -Kathy

42
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• Wow! I feel better. I feel relief. I feel
  confident. Im less anxious. Wow! This is the
  most confident Ive felt in probably 10 years. I
  didnt think this would work but wow! Feeling
  this is really amazing. I havent 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

43
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• Im freed from the traumatic moment. Im
  shocked at the outcome. Before doing it I
  thought It aint going to work! But it did. I
  feel great. Just one IRRT session--I didnt
  think it would work but it did. All my symptoms
  are gone except a small amount of anxiety. Im
  surprised it worked so well. Im
  doing really good.  -Patricia

44
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• THE RESULTS

• Interesting phenomenon at Post-BIRRT scoring
• Client comments

45
BriefImagery Rescripting and Reprocessing
Therapy(BIRRT)

• Questions
• and
• Answers