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

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Presentation on theme: "ACTIVE INGREDIENTS of Trauma Therapy J. Eric Gentry, PhD CAPSULE 2."— Presentation transcript:

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

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

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

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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.gov/PTSD-Full-2010c.pdf 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 LevelTreatments A CBT (PE, DTE, CPT, SIT) EMDR B None C Patient Education, Imagery Rehearsal Therapy, Psychodynamic Therapy, Hypnosis, Relaxation Techniques, Group Therapy, and Family Therapy [Trauma-focused Supportive Therapy] D None 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 C HANGING THE P ARADIGM T HE 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). 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 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

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

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-educationValidationNormalizing 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 CAMMassageMovement/YogaExerciseAcupuncture 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. (www.scottdmiller.com)

23 Positive Outcomes & Excellence in Treatment Positive Outcomes & Excellence in Treatment www.scottdmiller.com 1.Collect empirical data evaluating the quality of the therapeutic relationship 1.Generate honest feedback from client on methods to improve therapy (i.e. relational) 2.Be willing to change toward what works best for client—demonstrate that change

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


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