Brief
Imagery Rescripting and
Reprocessing Therapy
Presented by
Bob Stahn, Ed.M, LCPC, MAC, ICADC
Well Spring Counseling, LLC
Idaho Falls, ID
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
One in five people who experience
trauma
will develop PTSD
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)

CBT works most effectively on PTSD

Historically, CBT is effective up to 60%

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If the emotion is predominantly fear based, then
exposure therapy may be up to 90% effective
Exposure therapy often takes10-12 90-minute
sessions
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....”
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 activated—along with
the affect—and cognitive restructuring can
occur.”
Brief
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.
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)


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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)
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
Dr. Smucker's Therapeutic Goals of IRRT:

Decrease physiological arousal

Eliminate intrusive PTSD symptoms
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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
Brief
Imagery 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
Brief
Imagery 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
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
3 Steps of Dr. Smucker's IRRT Imagery:

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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)
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
Comparing IRRT and BIRRT

Same principles

Same results

But BIRRT is... well... brief!
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
The Good News


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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.
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
The Good News (cont.)
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
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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.
Brief
Imagery 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.
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
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.
Brief
Imagery 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
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
THE STEPS
Preparation for Step 1 (cont):

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
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
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
THE STEPS
Step 1:
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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
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
THE STEPS
Step 1 (cont.):


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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
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
THE STEPS
Step 2:
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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
Brief
Imagery 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
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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.
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
THE STEPS
Step 2 (cont):
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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
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
THE STEPS
Step 3:


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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
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
THE STEPS
Step 3 (cont):
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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
Brief
Imagery 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
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
THE STEPS
After Step 3:
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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)
Brief
Imagery 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)
Brief
Imagery 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.
Brief
Imagery 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 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.
Brief
Imagery 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.
Brief
Imagery 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
Brief
Imagery 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
Brief
Imagery 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!
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
Brief
Imagery 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
Brief
Imagery Rescripting and Reprocessing Therapy
(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)
Brief
Imagery Rescripting and Reprocessing Therapy
(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
Brief
Imagery Rescripting and Reprocessing Therapy
(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
Brief
Imagery Rescripting and Reprocessing Therapy
(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
Brief
Imagery 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
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
Brief
Imagery Rescripting and Reprocessing Therapy
(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
Brief
Imagery Rescripting and Reprocessing Therapy
(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
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
THE RESULTS
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
Interesting phenomenon at Post-BIRRT scoring
Client comments
Brief
Imagery Rescripting and Reprocessing Therapy
(BIRRT)
Questions
and
Answers