1. ACTIVE INGREDIENTS of Trauma Therapy
CAPSULE 2
ACTIVE INGREDIENTS of Trauma Therapy
J. Eric Gentry, PhD

2. Capsule 2: Active Ingredients & Therapeutic Relationship
Viktor Frankl & Positive Expectancy
Effective Treatment – VA/DoD Guidelines
Changing the Paradigm – Benish, Imel & Wampold (2008)
Active Ingredients of Trauma Therapy
Therapeutic Relationship & FIT

3. A very important and often overlooked component of treatment.
Positive Expectancy
A very important and often overlooked component of treatment.

4. “That which is to give light
Resiliency
“That which is to give light
Must endure burning”
- Viktor Frankl

5. Between stimulus and response there is a space
Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.
- Viktor Frankl

6. Effective Treatment
Trauma-focused treatment is up to 86% more effective than no treatment
Trauma focused treatment is more effective than supportive therapy
Maturation - No longer need to prove trauma-focused treatment is effective
Rift in Field: Evidence-Based Manualized Tx vs. Non-specific Components
No difference among treatments that work
All effective treatments share common components

7. 2010 VA/DoD Guidelines http://www. healthquality. va
VA/DoD CLINICAL PRACTICE GUIDELINE
FOR MANAGEMENT OF POST-TRAUMATIC STRESS
Department of Veterans Affairs
Department of Defense
Prepared by:
The Management of Post-Traumatic Stress Working Group
With support from:
The Office of Quality and Performance, VA, Washington, DC & Quality Management Division, United States Army MEDCOM

8. RECOMMENDATIONS
1. A supportive and collaborative treatment relationship or therapeutic alliance should be developed and maintained with patients with PTSD.
Evidence-based psychotherapy and/or evidence-based pharmacotherapy are recommended as first-line treatment options.
Specialized PTSD psychotherapies may be augmented by additional problem- specific methods/services and pharmacotherapy.
Consider referral for alternative carem odalities (Complementary Alternative Medicine) for patient symptoms, consistent with available resources and resonant with patient belief systems. [See Module I-2]
Patients with PTSD who are experiencing clinically significant symptoms, including chronic pain, insomnia, anxiety, should receive symptom-specific management interventions. [See Module I-3]
Management of PTSD or related symptoms may be initiated based on a presumptive diagnosis of PTSD. Long-term pharmacotherapy will be coordinated with other intervention.

9. A B C D I Level Treatments CBT (PE, DTE, CPT, SIT) EMDR None
Patient Education, Imagery Rehearsal Therapy, Psychodynamic Therapy, Hypnosis, Relaxation Techniques, Group Therapy, and Family Therapy [Trauma-focused Supportive Therapy] D I
Web-based Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Acceptance and Commitment Therapy, along with Complimentary and Alternative Medicine approaches such as yoga, acupuncture, mindfulness, massage
A = Strong evidence + First-line Recommendation / B = Good evidence + recommendation (second line) / C = Fair evidence + no recommendation / D = Contraindicated / I = Inconclusive

10. Changing the Paradigm
The relative efficacy of bona fide psychotherapies for treating post- traumatic stress disorder:
A meta-analysis of direct comparisons
Steven G. Benish, Zac E. Imel, Bruce E. Wampold
The primary analysis revealed that effect sizes were Homogenously distributed
around zero for measures of PTSD symptomology, and for all measures of
psychological functioning, indicating that there were no differences
between psychotherapies…. The results suggest that despite strong
evidence of psychotherapy efficaciousness vis-à-vis no treatment or common
factor controls, bona fide psychotherapies produce equivalent benefits for
patients with PTSD.
© 2007 Elsevier Ltd. All rights reserved.

11. ACTIVE INGREDIENTS
Figley & Carbonell (1995 & 1996). Clinical Demonstration Project
EMDR, CBT, TIR, TFT, NLP, TAT & Others
Demonstrate effectiveness
Discussion of “active ingredients”
Led to my qualitative research on the same

12. 54 Trauma Experts
First-line interventions matched to specific symptoms included emotion regulation strategies, narration of trauma memory, cognitive restructuring, anxiety and stress management, and interpersonal skills. Meditation and mindfulness interventions were frequently identified as an effective second-line approach for emotional, attentional, and behavioral (e.g., aggression) disturbances
Cloitre, Courtois, Charuvastra, Carapezza, Stolbach & Green, 2011

13. ACTIVE INGREDIENTS CBT

14. Healing Trauma: Active Ingredients (Gentry, 1999)
Therapeutic Relationship – develop and maintain. Emotional bond + Completion of Tasks + Mutual Goals + Positive expectancy.
Relaxation – Reciprocal Inhibition (exposure + relaxation). Parasympathetic dominance
Exposure/Narrative – sharing with safe other chronology of “micro-events” of traumatic experience (making non-verbal explicit)
Cognitive Restructuring – Normalizing symptoms, psychoeducation, correcting perceptions
Seems Non-sequiter
1999 research that looked at effective treatment of traumatic stress
[I will be doing a training for PESI on Trauma and greif all over the country over the next year. Please come to this if you’d like tot learn more about this]

15. Treating Trauma Eric’s Hierarchy
Cognitive Restructuring
Exposure/Narrative
Relaxation/
Self-Regulation
FIT
Building & Maintaining
THERAPEUTIC RELATIONSHIP

16. Therapeutic Relationship
A supportive and collaborative treatment relationship or therapeutic alliance should be developed and maintained with patients with PTSD [2010; VA/DoD Guidelines]
the therapeutic relationship is most often cited as one, if not the most, potent transtheoretical ingredient of psy- chotherapy (2013; Miller, Hubble, Chow & Siedel).
A “supportive & Collaborative” relationship is assumed for all evidence-based treatments, however, not many therapists practice evidence-based demonstration achieving and maintaining therapeutic relationship.

17. Relaxation/Self-Regulation
Indigenous to ALL effective treatments
ANS Dysregulation central to the symptoms and distress of trauma survivors.
“You cannot have PTSD inside of a relaxed body” – Eg
TX must go beyond teaching relaxation into coaching toward mastery our clients to monitor and regulate their ANS.
Soften muscles while confronting perceived threats IS trauma treatment
MUST be able to keep body relaxed while confronting traumata or treatment can be retraumatizing

18. EXPOSURE/NARRATIVE Indigenous to ALL effective treatments
Integrating traumata that is repressed, suppressed or dissociated
Reciprocal Inhibition (Wolpe, 1964)
Conditioned Stimulus = CR of Anxiety (> ANS)
Conditioned Stimulus + Relaxation = Extinction of CR
Exposure + Relaxation
Narrative most potent form of exposure
Sequencing & languaging of traumata (i.e., sensory memories) with relaxed body completes both integration & desensitizaton

19. Cognitive Reprocessing
Psycho-education
Validation
Normalizing
Correcting distortions (causation/world-view)
Mindfulness
Monitoring and evolving “self-talk”

20. Examples “Normal” response - Over-adapted (Hard part done)
Understanding of relationship of painful learning, perceived threat & ANS reaction
PTSD = System attempting to heal itself
Memory fragments attempting to integrate but paired with terror. Requires relaxation + intentional exposure
Stress = perceived threat = dysregulated ANS
Shame = absence of narrative
“That which doesn't’t kill you makes you stronger” … only if it is integrated. Disintegrated it weakens you.

21. Additional CAM Family Therapy Group Therapy Substance Use Tx
Massage
Movement/Yoga
Exercise
Acupuncture
Body-oriented Treatment (TRE – Berceli)
Family Therapy
Group Therapy
Substance Use Tx
Community Resources

22. In 2013, Feedback Informed Treatment (FIT)–that is, formally using measures of progress and the therapeutic alliance to guide care–was deemed an evidence-based practice by SAMHSA, and listed on the official NREPP website.  It’s one of those good ideas.  Research to date shows that FIT as much as doubles the effectiveness of behavioral health services, while decreasing costs, deterioration and dropout rates. (

23. Positive Outcomes & Excellence in Treatment www.scottdmiller.com
Collect empirical data evaluating the quality of the therapeutic relationship
Generate honest feedback from client on methods to improve therapy (i.e. relational)
Be willing to change toward what works best for client—demonstrate that change

25. Treating Trauma Eric’s Hierarchy
Cognitive Restructuring
Exposure/Narrative
Relaxation/
Self-Regulation
FIT
Building & Maintaining
THERAPEUTIC RELATIONSHIP