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Brief Eclectic Psychotherapy for
PTSD: An introduction
Prof. Ulrich Schnyder, M.D.
Past President, ISTSS
Head, Department of Psychiatry and Psychotherapy
University Hospital Zurich, Switzerland
[email protected]
page 1
“There is an airplane in my head”
page 2
Brief Eclectic Psychotherapy for PTSD (BEPP)
Manualized, multimodal, 16 sessions, combination of psychoeducation, cognitive-behavioral and psychodynamic elements:
! 
Psychoeducation
! 
! 
! 
! 
Imaginal exposure
Writing tasks, working with mementos
Domain of meaning and integration
Farewell ritual
____________________________________________________________________
Gersons BPR, Carlier IVE, Lamberts RD, van der Kolk BA (2000) Randomized clinical trial of brief
eclectic psychotherapy for police officers with posttraumatic stress disorder. Journal of Traumatic
Stress 13: 333-348
−  Schnyder U, Müller J, Maercker A, Wittmann L (2011) Brief Eclectic Psychotherapy for PTSD: a
randomized controlled trial. Journal of Clinical Psychiatry 72: 564-566
− 
page 3
Brief Eclectic Psychotherapy for PTSD (BEPP)
Gersons BPR et al. (2000) Journal of Traumatic Stress 13: 333-348
1. Psychoeducation
2.-6. Imaginal exposure
3.-6. Writing tasks &
mementos
7.-16. Domain of meaning
13.-16. Farewell ritual
page 4
Brief Eclectic Psychotherapy for PTSD:
An introduction
! 
Trauma and trauma related disorders
! 
Why new psychotherapies for PTSD?
! 
BEPP Background
! 
BEPP protocol
! 
BEPP exercises (psychoeducation, exposure)
page 5
Brief Eclectic Psychotherapy for PTSD:
An introduction
! 
Trauma and trauma related disorders
! 
Why new psychotherapies for PTSD?
! 
BEPP Background
! 
BEPP protocol
! 
BEPP exercises (psychoeducation, exposure)
page 6
Trauma and PTSD: Epidemiology
!  Lifetime prevalence for potentially traumatic events: 50-90%
!  Posttraumatic stress disorders
following traumatic events:
~10%
!  Lifetime prevalence for posttraumatic stress disorders:
8%
Men:
6%
Women:
12%
page 7
Trauma-related mental disorders
!  Specific posttraumatic disorders:
-  Acute Stress Reaction (ICD-10) / Acute Stress Disorder (DSM-5)
-  Posttraumatic Stress Disorder (ICD-10 / DSM-5)
-  Enduring Personality Change after Catastrophic Exp. (ICD-10)
!  Unspecific posttraumatic disorders, e.g.:
-  Depression
-  Anxiety Disorders
-  Somatoform Disorders
-  Obsessive Compulsive Disorder
page 8
Posttraumatic Stress Disorder (DSM-5)
A)  Stressor criterion:
−  Exposure to death, serious injury, or sexual violence
−  Directly exposed, witnesssing, learning, or professional context
B) Intrusion symptoms associated with the traumatic event (1 of 5)
C) Persistent avoidance of specific stimuli (1 of 2)
D) Negative alterations in cognitions and mood (2 of 7)
E)  Marked alterations in arousal and reactivity (2 of 6)
F) Duration of disturbance more than one month
G) Clinically significant distress or impairment in social, occupational,
or other important areas of functioning
page 9
The natural history of PTSD
Traumatic
Event
1 month
Usual onset of
symptoms
9 months
3 years
Many recover without
treatment within
months/years of event
(45-80% natural
remission at 9 months)
page 10
Generally 33% remain
symptomatic for 3 years or
longer with greater risk of
secondary problems
PTSD is a disorder …
!  …of the memory; the working memory is still loaded with the
traumatic images
!  …with scanning behavior and high arousal
!  …with avoidance of the memory of details
!  …with avoidance of the intense emotions connected
!  …with expectation of new traumatic events
page 11
Levels of psychological interventions after trauma
!  Self help
(± professional conselling)
!  Peer support
(± professional conselling)
Counselors
!  Psychoeducation
(explanatory therapy)
!  4-6 CBT (group) sessions
!  Evidence-based therapies,
including exposure,
cognitive restructuring, etc.
page 12
Psychotherapists
Psychotherapy versus Drug Treatment for PTSD
van Etten & Taylor, 1998
Pre-Post Effect Size (d)
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Psychotherapy
Pharmacotherapy
page 13
Controls
Psychotherapies for PTSD: The evidence
!  Trauma-focused cognitive behavioral therapy (TF-CBT):
-  Exposure therapy, specifically „Prolonged Exposure“ (PE)
-  Cognitive Therapy, Cognitive Processing Therapy (CPT)
-  Eye Movement Desensitization and Reprocessing (EMDR)
-  Narrative Exposure Therapy (NET)
-  Brief Eclectic Psychotherapy (BEPP)
!  Psychodynamic (psychoanalytic) approaches:
-  Currently no sufficient scientific evidence available, i.e., not
empirically supported
page 14
Brief Eclectic Psychotherapy for PTSD:
An introduction
! 
Trauma and trauma related disorders
! 
Why new psychotherapies for PTSD?
! 
BEPP Background
! 
BEPP protocol
! 
BEPP exercises (psychoeducation, exposure)
page 15
Why new psychotherapies for PTSD?
Schnyder U (2005) Psychotherapy and Psychosomatics 74: 199-201
1)  ~ 20% dropout rates in empirically supported therapies for
PTSD, including CBT and EMDR
2)  ~ 50% who completed CBT are still diagnosed with PTSD at
posttreatment assessment
3)  ~ 50% of patients do not achieve good end-state functioning
page 16
Prolonged Exposure versus Present-Centered Therapy
for PTSD in female veterans: CAPS mean scores
Schnurr et al. (2007) JAMA 297: 820-830
Intention to Treat Sample
Completer Sample
80
80
70
60
50
40
70
60
50
40
Prolonged Exposure
Present-Centered Therapy
Prolonged Exposure
Present-Centered Therapy
page 17
Why new psychotherapies for PTSD?
Schnyder U (2005) Psychotherapy and Psychosomatics 74: 199-201
4)  The mean duration of PTSD episodes amounts to several
years.
Thus, treatment for PTSD should not focus on specific
symptoms such as flashbacks and avoidance only, but on
basic life changes and existential questions as well, since
such issues are important for patients who suffer from
chronic PTSD
page 18
Why new psychotherapies for PTSD?
Schnyder U (2005) Psychotherapy and Psychosomatics 74: 199-201
5)  Strict exclusion criteria in randomized controlled trials, and,
in the majority of studies, failure to address comorbidity
make it difficult to translate results of outcome research into
clinical practice.
Psychotherapy research should start evaluating multimodal,
integrative treatment protocols that do justice to the various
aspects of posttraumatic psychiatric morbidity in realistic
clinical settings.
page 19
Brief Eclectic Psychotherapy for PTSD:
An introduction
! 
Trauma and trauma related disorders
! 
Why new psychotherapies for PTSD?
! 
BEPP Background
! 
BEPP protocol
! 
BEPP exercises (psychoeducation, exposure)
page 20
Theoretical model of BEPP
Crisis theory:
Bereavement:
Life events
Psychotrauma
" regaining control
Process
Exposure
" working through
Psychodynamic theory: Emotions are key
Childhood
" getting insight
Learning theory:
Conditioned learning
Phobia
" reconditioning
Neurobiology:
Amygdala
Memory systems
page 21
" resetting
Why treatment?
!  Working through traumatic events?
!  Getting back control over life?
!  Diminishing symptoms of PTSD?
!  Lowering the fear response?
page 22
Why eclectic?
Limitations of:
!  psychodynamic treatment
!  cognitive behavioral treatment
!  pharmacological treatment
Eclectic because BEPP is based on a precise bringing together
of psychodynamic, cognitive-behavioral and directive
psychotherapeutic theory.
page 23
BEPP: Protocol essentials
1. Psychoeducation
2.-6. Imaginal exposure
3.-6. Writing tasks &
mementos
7.-16. Domain of meaning
13.-16. Farewell ritual
page 24
Brief Eclectic Psychotherapy for PTSD:
An introduction
! 
Trauma and trauma related disorders
! 
Why new psychotherapies for PTSD?
! 
BEPP Background
! 
BEPP protocol
! 
BEPP exercises (psychoeducation, exposure)
page 25
Session 1
!  Partner or significant other is present if possible
!  Psychoeducation
!  Explanation of the treatment
!  Recounting of the traumatic experience
page 26
Psychoeducation
Explain why the partner was invited:
! 
! 
Clarify the therapy (techniques, rationale)
Role of partner: background support
Explain the goals of therapy:
! 
! 
! 
! 
Acceptance of emotions
Normalising disturbed views
Symptom reduction
Integration of the traumatic event into the patient’s life
Explain the techniques to be used
page 27
page 28
page 29
PTSD symptoms (CAPS) in accident survivors over 3 years (N=90)
Hepp U, et al. (2008) British Journal of Psychiatry 192: 376-383
80
70
60
50
40
30
20
10
0
T1
T2
T3
page 30
T4
Psychoeducation
Therapist describes:
!  how symptoms interfere with functioning
!  that client not only experienced traumatic event(s) in the past,
but still behaves as if such events will strike again
!  that his psychobiological make-up is dysfunctional
This ‘framing’ of symptoms is essential to understand the
elements of therapy
page 31
Psychoeducation
Therapist explains:
!  that the symptoms still exist because extreme - frightening emotions are not tolerated to be felt and still hinder the fading
away of symptoms
!  how relaxation and imaginal exposure are tools to bring back
the experience and to feel and express the extreme emotions
!  how writing and the use of memorabilia are helpful to this end
page 32
Psychoeducation
Therapist further explains:
!  how after the experience of all emotions the patient will pay
attention to how he sees the world and him- or herself now
and how he will adapt to the world
!  and that a key problem of PTSD is to leave behind the
traumatic experience in one’s own history
!  That the farewell ritual is designed to help leaving behind the
traumatic experience
page 33
Neurobiology of human responses to traumatic
events
…involves mechanisms related to
!  bodily survival
!  learned conditioning
!  autobiographical memory formation
!  complex, socially-modulated, adaptation to change
Shalev AY, Ursano RJ (2003)
page 34
Neurobiology of human responses to traumatic
events
…is heavily modulated by
!  Appraisal (perceived threat, available resources)
!  Controllability
!  Attribution of meaning
!  Coping with tasks related to survival and learning
!  Prior experiences
!  Individual and group beliefs
Shalev AY, Ursano RJ (2003)
page 35
Important elements of the trauma reaction
Frontal lobe:
• Thinking
• Basic assumptions
Temperament:
Vulnerability
Anxiousness
Biological rhythms
Limbic system:
• Amygdala
• Hippocampus
Amygdala:
Emotions,
particularly anxiety
Hippocampus:
Memory formation
images, smells,
noises etc.
Brain stem:
• Biological rhythms
• Sleep
page 36
Neurobiology of the trauma reaction
Traumatic changes of
awareness and
memory
(re-experiencing,
dissociation)
Avoidance behavior
social withdrawal
Activation of the
arousal system:
„constant alarm“
page 37
Neurobiology of human responses to traumatic
events
Fragments of seconds
# defense reflexes such as auditory
startle reaction
Seconds
# Sympathetic activation (epinephrin)
Minutes
# activation of the hypothalamicpituitary-adrenal axis (cortisol)
Hours
# early gene expression
Days
# memory consolidation
Months
# permanent changes in the CNS
Shalev AY, Ursano RJ (2003)
page 38
Successive and overlapping stages of the
response to traumatic events
Acute Response
Early
Syndromes
9M
Survival……………..
Adjustment……………..
Appraisal……………..
Learning & integration……………..
Shalev AY, Ursano RJ (2003)
page 39
Resting heart rate in PTSD and controls
Shalev et al. (1998) Arch Gen Psychiatry 55: 553-559
100
95
PTSD
90
No PTSD
85
80
75
70
65
60
ER
1 week
1 month
page 40
4 months
Heart rate in patients who later develop PTSD,
depression, or anxiety
Shalev et al. (1998) Arch Gen Psychiatry 55: 553-559
100
95
PTSD
Depression
Anxiety
Neither
90
85
80
75
Heart rate
page 41
Recounting of the traumatic event
Pay attention to:
! 
! 
! 
! 
! 
! 
! 
the details of the event
salient cues that trigger emotions
what happened just before?
what happened afterwards?
reactions of the patient, partner, others
secondary victimization?
ask about feelings but don’0t go into them deeply
Ask the patient to bring memorabilia linked to the event for
the next session.
page 42
Session 2
!  Explanation of procedure
!  Relaxation
!  Imaginal exposure
!  Examination of memorabilia
page 43
Imaginal exposure
The imaginal exposure is a technique to bring to the surface
extreme emotions of anger, guilt, sorrow, grief and sadness
which are not or not fully felt yet.
The catharsis of yet unfelt emotions precedes psychodynamic
insight which may lead to the domain of meaning.
In contrast to most cognitive and/or behavioral therapies, BEPP
does not use repeated exposure as a tool to diminish fear.
BEPP rather uses a technique to help the person feel how fearful
and terrible the experience was by remembering the traumatic
event in great detail.
page 44
Imaginal exposure
Procedure:
Short relaxation
Here-and-now approach
Start with bringing back the memories of the beginning of the day
of the trauma and find out at what moment the first vivid sensory
memories emerge
The patient can stop the imaginal exposure at any moment by
opening eyes, walking around, etc.
➜➜➜ control!
page 45
Imaginal exposure
Therapist asks the patient to tell exactly what he sees, hears,
feels, in all sensory modalities as precisely as possible.
Therapist encourages a vivid and sensory remembrance of the
event and to focus on the feelings of fear, embarrassment, pain,
anger, sadness, etc. during the imagined exposure.
As a result, the patient will discover new memory details in which
extreme fear or pain are hidden.
Proceed very slowly, between 15 and 20 minutes per session.
Going through the whole traumatic event in a chronological order
bit by bit usually takes 4-6 sessions to complete.
page 46
Imaginal exposure
To avoid dissociation during the exposure:
!  contralateral and short relaxation of distal muscle groups
!  keep eyes open
Dissociation often results from the therapist’s endeavor to speed
up the session, not respecting the pace of the patient.
page 47
Sessions 3 - 6
!  Review of past week
!  Continue imaginal exposure
!  Review of emotions
!  Working with memorabilia
!  Assignment of writing task
page 48
Memorabilia
Memorabila are things which have a concrete or symbolic
relationship with a traumatic event:
!  clothes people were wearing during the event
!  newspaper articles and photos
!  certain tools like a gun in police work
!  a bag taken from an aircrash, etc.
page 49
Writing task
Helps expressing in a controlled way difficult, mainly aggressive
feelings, but also guilt feelings towards those who are blamed or
organizations to be blamed. Letters can also be written to say
goodbye to those who died
No censorship. Letter will not be sent to anyone but used in the
farewell ritual
Ask the patient to write every day for half an hour but not more to
avoid becoming overwhelmed
Patient reads the content of the letter during the following
session while the therapist focuses on patient’s emotions
page 50
Sessions 7 - 12
!  Discussion of writing assignment
!  Cognitive restructuring and integration of meaning
!  Pay attention to the real world issues
page 51
Domain of meaning
Patient starts to think about basic existential questions: How has
the traumatic experience and the ensuing treatment changed
!  patient’s life, his view on the world and himself
!  patient’s family, work environment and so on
!  detachment from the world
!  “sadder but wiser”
page 52
Domain of meaning
!  After the catharsis of emotions, patients start to appreciate
life and love more intense than before.
!  Practical consequences such as resuming work
!  “Illusion of safety” replaced by better anticipation
page 53
page 54
Sessions 13-16
!  Planning of farewell ritual
!  Evaluation of treatment
page 55
Farewell ritual
Before treatment, the patient’s behavior was determined by
events in the past, as if the patient “lived with his back to the
future”. The farewell ritual is done
!  to leave behind the traumatic event, not to forget but to give it
a place in one’s own life.
!  to end treatment by grieving for one last time with close ones
around, and to re-attach to the world and to close ones
(transitional ritual)
!  to celebrate the end a period of great disturbance in life
With the ritual, it is time to turn around, to actively take part in the
future, and to turn passive into active (no longer victim)
page 56
Farewell ritual
The patient, with the help of the therapist, develops an
individually taylored and carefully planned farewell ritual. The
ritual usually contains two parts:
1.  Leaving behind:
!  burning letters, clothes, drawings, and other mementos
!  throwing pieces away, or burying them in the sea or river
2.  Celebrating and reuniting with significant others:
!  “Cleansing” ritual, e.g., taking a shower, visiting a Turkish
bath or sauna
!  Family dinner, party, picknick or similar
page 57
page 58
page 59
Evaluation
!  Repeat psychoeducation
!  How does the patient look back on the relation between
trauma and symptoms?
!  Symptoms may reoccur!
!  What has the patient learned?
!  How to apply learning lessons in future situations?
!  Ending the therapeutic relationship
page 60
RCT of BEPP versus EMDR
Nijdam et al. (2012) British Journal of Psychiatry 200: 224-231
100
BEP (N=70)
IES-R Total scores
80
EMDR (N=70)
60
40
20
0
Time of Assessment (weeks)
Significant difference between response patterns of BEP and EMDR, t(169)=3.49; p<0.005; no significant
difference at endpoint, t(340)=0.70, p=0.48.
page 61
Contra-indications
Relative contra-indications:
$ 
$ 
$ 
$ 
major depressive disorder
substance use disorder
panic disorder
agoraphobia
Absolute contra-indications:
$ 
$ 
$ 
$ 
all psychotic disorders
severe depressive disorder
severe personality disorder
severe substance use
page 62
www.traumatreatment.eu
page 63
Brief Eclectic Psychotherapy for PTSD (BEPP)
Treatment manual available in English, German, Dutch,
French, Italian, Lithuanian
www.traumatreatment.eu
[email protected]
page 64
ISBN 978-3-319-07108-4
9
783319 071084
Schnyder
Cloitre
Editors
Evidence Based
Treatments for
Trauma-Related
Psychological
Disorders
A Practical Guide for
Clinicians
Evidence Based
Treatments for
Trauma-Related
Psychological Disorders
1
Evidence Based Treatments for
Trauma-Related Psychological Disorders
Psychiatry & Psychotherapy
Schnyder · Cloitre Eds.
This book offers an evidence based guide
for clinical psychologists, psychiatrists, psychotherapists and other clinicians working
with trauma survivors in various settings. It
provides easily digestible, up-to-date information on the basic principles of traumatic
stress research and practice, including psychological and sociological theories as well
as epidemiological, psychopathological,
and neurobiological findings. However, as
therapists are primarily interested in how
to best treat their traumatized patients, the
core focus of the book is on evidence based
psychological treatments for trauma-related
mental disorders. Importantly, the full
range of trauma and stress related disorders
is covered, including Acute Stress Reaction, Complex PTSD and Prolonged Grief
Disorder, reflecting important anticipated
developments in diagnostic classification.
Each of the treatment chapters begins with
a short summary of the theoretical underpinnings of the approach, presents a case
illustrating the treatment protocol, addresses
special challenges typically encountered in
implementing this treatment, and ends with
an overview of related outcomes and other
research findings. Additional chapters are
devoted to the treatment of comorbidities,
special populations and special treatment
modalities, and to pharmacological treatments for trauma-related disorders. The
book concludes by addressing the fundamental question of how to treat whom, and
when.
page 65
A Practical Guide
for Clinicians
Ulrich Schnyder
Marylène Cloitre Editors
1 23
Brief Eclectic Psychotherapy for PTSD:
An introduction
! 
Trauma and trauma related disorders
! 
Why new psychotherapies for PTSD?
! 
BEPP Background
! 
BEPP protocol
! 
BEPP exercises (psychoeducation, exposure)
page 66
Thank you for your
attention!
Prof. Ulrich Schnyder, M.D.
Department of Psychiatry and Psychotherapy
University Hospital Zurich
Culmannstrasse 8
8091 Zurich
Switzerland
E-mail: [email protected]
Phone: +41 44 255 52 51
Pablo Picasso: Le Bouquet
page 67