Trauma Competency Revisited: Updated Active Ingredients Approach to Treating Posttraumatic Stress Disorder

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Context

Below is a revised article that updates and expands upon Gentry, Baranowsky, and Rhoton’s (2017) four active ingredients approach to treating PTSD. This updated version incorporates more recent research findings (post-2017) and addresses developments in trauma-informed treatment, emerging evidence-based modalities, and evolving guidelines for posttraumatic stress care. A References section in APA 7th style is provided at the end.

Abstract

Recent research affirms that multiple evidence-based therapies for posttraumatic stress disorder (PTSD) are roughly equivalent in their efficacy, yet share common core elements underlying their success. Drawing on updates to the Veterans Affairs (VA) and Department of Defense (DoD) Clinical Practice Guideline (2017, with minor revisions in subsequent years), the World Health Organization (WHO; 2019) guidelines, and new meta-analytic findings, this article revisits the “active ingredients” approach to trauma treatment. Originally identified as cognitive restructuring and psychoeducation, a strong therapeutic relationship, self-regulation and relaxation, and exposure-based or narrative techniques, these foundational elements continue to drive positive outcomes across treatment modalities. However, new findings highlight the importance of recognizing complex PTSD (cPTSD), leveraging emerging technologies (e.g., telehealth, virtual reality), attending to cultural and social determinants of health, and integrating innovative treatments such as brief intensive programs and adjunctive pharmacological approaches (e.g., MDMA-assisted therapy). This updated article proposes a four-stage treatment structure—relationship building, psychoeducation and self-regulation, trauma-focused resolution, and posttraumatic growth—reinforced by the latest evidence-based research and practice guidelines.

Introduction

The field of posttraumatic stress disorder (PTSD) intervention continues to evolve rapidly. Since the original introduction of PTSD into the Diagnostic and Statistical Manual of Mental Disorders in 1980, the mental health community has witnessed an explosion of promising interventions. By 2017, systematic reviews and meta-analyses demonstrated that while many treatments were deemed “evidence-based,” their effectiveness appeared to hinge on a set of common elements, rather than on highly specific techniques unique to any one modality (Benish et al., 2008; Karatzias et al., 2011).

Over the past several years, new data have reinforced this perspective (Ho & Lee, 2022; Lewis et al., 2020). Sophisticated meta-analyses and network analyses continue to show minimal differences in outcomes among leading trauma-focused therapies—such as prolonged exposure (PE), cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy (NET)—provided these approaches include key therapeutic elements (Bisson et al., 2021; Watts et al., 2022). In addition, revised treatment guidelines from the VA/DoD (2017), the World Health Organization (2019), and the National Institute for Health and Care Excellence (NICE; 2018) encourage an integrative perspective that prioritizes trauma-focused interventions, strong therapeutic alliances, attention to client readiness, and an individualized approach.

The original four “active ingredients” identified by Gentry, Baranowsky, and Rhoton (2017)—(a) psychoeducation/cognitive restructuring, (b) a well-established therapeutic relationship, (c) self-regulation and relaxation skills, and (d) exposure or narrative processing—remain central. This updated review incorporates recent developments, including recognition of complex PTSD (cPTSD) in the ICD-11, further evidence on culturally informed care, expanded telehealth services (particularly after the COVID-19 pandemic), and novel adjunctive treatments (e.g., brief intensive outpatient protocols, MDMA-assisted therapy). We close with an updated four-stage treatment structure that we recommend as a minimal competency for trauma-informed counselors and mental health professionals.

Identifying Effective Treatments for Trauma Survivors: 2017–2025 Updates

Renewed Guidelines and Complex PTSD

Building on the 2017 VA/DoD Clinical Practice Guideline, more recent publications (e.g., updated NICE guidelines, WHO, 2019) have clarified the utility of trauma-focused approaches as first-line treatments for PTSD. They emphasize that trauma-focused psychotherapies outperform non–trauma-focused methods, especially over the long term (Lewis et al., 2020). Meanwhile, the formal recognition of complex PTSD (cPTSD) in ICD-11 prompted a refinement of recommended treatments for individuals enduring prolonged, repeated, or early-life trauma (Brewin et al., 2017). These guidelines advocate additional attention to safety, relational repair, emotional regulation, and longer or more flexible treatment durations for cPTSD (Cloitre et al., 2020).

Technological Advances and Telehealth

Beginning in 2020, telehealth rapidly became a mainstay in PTSD care due to the global pandemic (Evans et al., 2021). Research indicates that PE and CPT can be delivered effectively via secure video, with outcomes comparable to in-person sessions for many clients (Maieritsch et al., 2022). Virtual reality exposure therapy (VRET) has also gained traction, particularly among veterans, demonstrating efficacy comparable to standard PE (Le et al., 2021). These modern delivery systems still hinge on the same fundamental mechanisms: strong rapport, gradual exposure, and effective self-regulation skills.

Pharmacological and Adjunctive Treatments

Although cognitive-behavioral interventions remain the gold standard, multiple clinical trials have investigated novel pharmacological adjuncts. The FDA’s “Breakthrough Therapy” designation for MDMA-assisted therapy for PTSD underscores growing interest in psychedelics as a catalyst for emotional processing (Mitchell et al., 2021). Early-phase research reports substantial short-term symptom reduction (Williams et al., 2022), although findings are still preliminary. Critically, these promising interventions also rely on a strong therapeutic frame, psychoeducation, and facilitation of exposure-based processing—again consistent with the four core elements.

Common “Active Ingredients” Revisited

Since 2017, no major study has contradicted the observation that the following four elements drive most (if not all) effective PTSD interventions (Benish et al., 2008; Ehlers et al., 2020):

Cognitive Restructuring and Psychoeducation
Teaching the client about the physiological, neurobiological, and psychological effects of trauma.
Encouraging adaptive reappraisal of maladaptive beliefs (“I’m unsafe,” “It’s my fault,” etc.).
Reinforcing a non-pathologizing framework that reduces stigma and guilt.
Therapeutic Relationship
Recent studies reinforce the importance of a collaborative alliance, empathy, and counselor self-regulation (Knerr et al., 2023).
Feedback-Informed Treatment (FIT) remains a top recommendation for monitoring alliance quality, client progress, and session impact (Miller et al., 2020).
Counselors’ cultural humility and capacity to address intersectionality have emerged as crucial ingredients for marginalized or diverse groups (Hinton & Jalal, 2020).
Self-Regulation and Relaxation
Trauma survivors benefit greatly from skills that help regulate the autonomic nervous system, including diaphragmatic breathing, mindfulness-based stress reduction (MBSR), and grounding techniques (Lang et al., 2019).
Tailoring these skills to clients’ cultural and personal contexts improves buy-in and reduces dropout (Zhu et al., 2022).
Exposure or Narrative Processing
Whether via prolonged exposure, EMDR, NET, or written narratives, the underlying mechanism relies on gradual confrontation of trauma memories paired with arousal modulation (Foa et al., 2019).
Evidence for narrative-based treatments continues to grow, including brief intensive models that compress daily sessions and show high efficacy (Zalta et al., 2021).

Updated Four-Stage Treatment Structure

Building on Herman’s (1992) triphasic model and Gentry et al. (2017), below is an updated and expanded four-stage framework. This approach remains flexible, accommodating recent guidelines for cPTSD, digital delivery, and individual client factors.

Establishing Safety and Alliance
Acculturation to Treatment: Provide psychoeducation on therapy structure (in-person or remote), confidentiality, and cultural/contextual considerations.
Feedback Tools: Use FIT or other outcome measures (e.g., PC-PTSD-5, PCL-5) to monitor client symptoms and alliance quality in real time.
Psychoeducation and Self-Regulation
Neurobiology of Trauma: Demystify hyperarousal, triggers, and avoidance using accessible metaphors.
Self-Regulation Skills: Integrate mindfulness-based techniques, guided relaxation, or mobile apps to track and manage arousal between sessions.
Trauma-Focused Resolution
Exposure or Narrative Work: Select from PE, EMDR, NET, or CPT, matching client preference and context.
Adaptive Information Processing: Combine exposure with active techniques for cognitive restructuring (“hot spots,” automatic thoughts).
Prolonged vs. Brief Intensive: Adjust format (once per week vs. daily intensives) based on client stability, resources, and presentation (e.g., cPTSD might require more gradual pacing).
Posttraumatic Growth and Integration
Consolidation: Emphasize ongoing skill use, relapse prevention, and meaning-making.
Social and Cultural Context: Address community reintegration, cultural identity, and spiritual/existential growth, highlighting expanded sense of self and possibility.
New Modalities: If clinically indicated and available, incorporate peer-support networks, telehealth booster sessions, or novel adjuncts (e.g., MDMA-assisted therapy trials).

Conclusion

Since 2017, extensive research, updated clinical guidelines, and evolving technologies have sharpened the field’s understanding of PTSD treatment. The active ingredients framework—cognitive restructuring/psychoeducation, robust therapeutic alliance, self-regulation, and trauma-focused exposure—remains firmly supported by data. Additionally, greater recognition of cPTSD, posttraumatic growth, cultural humility, and telehealth innovations enrich how clinicians implement these core components.

While new tools (e.g., MDMA-assisted therapies, telehealth platforms, smartphone apps) continue to emerge, they remain facilitators—rather than replacements—of the four fundamental principles. As the evidence base expands, trauma-focused counselors who develop competency in these common elements will be better positioned to tailor interventions, ensure cultural responsiveness, and optimize healing for the diverse individuals affected by trauma worldwide.

References

(Note: Below is a selective list incorporating both older key references and more recent works. All references are formatted in APA 7th edition.)

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