By Lynn Mollick & Milton Spett

“Without preparation, only 20% of PTSD patients can participate in exposure treatment,” asserted Dr. Marylene Cloitre, addressing NJ-ACT on Sunday, June 5. “When you push most patients to do exposure too soon, their symptoms get worse or they drop out of treatment.”

Cloitre cited data indicating that 60% of PTSD patients have experienced repeated traumas during childhood. She believes that these individuals never develop the affect regulation and social skills that would enable them to resolve their traumatic experiences. “You need a lot of resources, both internal and external, to resolve traumatic experiences,” said Cloitre.

To enable more patients to experience the enormous cognitive, behavioral, and physiological benefits of exposure, Cloitre has developed a two-stage program for PTSD. Stage One is called Skill Training in Affect Regulation (STAIR). Tailored to individual patients, STAIR consists of the following components:

1) Psychoeducation. Describe the symptoms of PTSD and explain the treatment rationale.

2) Training in experiencing and identifying feelings, triggers, thoughts, and mood regulation strategies.

3) Learning History. How did the patient deal with traumas past and present? How did the patient’s family deal with feelings? How did the patient’s family life impact on his or her present difficulty experiencing and identifying feeling?

4) Emotion Regulation Skills. Identify the cognitive, behavioral and social support modalities for coping. Use data gathered with self-monitoring forms to identify strengths and weaknesses in each coping modality. Teach skills such as: breathing re-training, self-statements to reduce fear, and social skill training to improve social support.

5) Acceptance and Tolerance of Negative Affect. Motivate patients to face distressing situations related to the trauma that are important to them. Review negative repercussions of avoidance. Discuss tolerating negative affect in order to achieve specific goals.

6) Schema Therapy for Improved Relationships. Identify relevant schemas learned in childhood. Suggest alternate ways of viewing self and others in current relationships. Use role playing to teach assertiveness, emphasizing response flexibility based on relative power in each relationship.

Each step of the STAIR program is based on the one before, and Cloitre recommends proceeding through the components in this order. After completing the STAIR program, patients experience improvement in their presenting problems and daily functioning. (Few patients enter treatment to relieve the nightmares, flashbacks, and florid symptoms of PTSD. More frequently, therapists uncover PTSD in the course of treating presenting problems.)

Once STAIR is well learned, patients can move on to exposure therapy. Cloitre’s approach to exposure – called Narrative Story Telling or NST -- differs somewhat from Foa’s (1988). In NST, patients are asked repeatedly to imagine and then retell the details of their traumatic experiences. Post-exposure, patients are asked to identify emotions elicited by exposure, to use emotion regulation skills to stabilize themselves, and to identify negative interpersonal schemas embedded in the trauma narrative. Cloitre has found that teaching these coping skills obviates the need for in vivo exposure to the traumatic cues.

In the end exposure creates distance from the traumatic memories. Patients stop reliving the trauma over and over, and can remember the trauma without intense, disruptive memories. Patients’ sense of self-control and personal competence increases, and they feel safe in a present that is more benign than the past.

To conform with NIMH research guidelines, STAIR-NST is necessarily only 16 sessions long. In clinical practice, Cloitre recommends addressing shame and guilt. Use psychoeducation and cognitive techniques for relieving shame, and narrative techniques with loss.

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