Proposed Treatment Model Skills Training In Affect And Interpersonal Regulation Modified Prolonged Exposure

The treatment model recommended for retraumatized women is a two-phase model in which the first phase of treatment focuses on skills training in affect and interpersonal regulation (STAIR). Training includes skills development in (1) identifying and labeling feeling states (especially feelings of threat), (2) tolerating distress and modulating negative affect, and (3) identifying abuse-related interpersonal schemas that initiate and shape negative interpersonal situations and developing alternative, more adaptive schemas, (4) developing an expanded interpersonal behavioral repertoire, and (5) practicing and testing it in the "real world." Cognitive-behavioral techniques used to meet these goals include monitoring and rating feeling states, use of positive imagery and self-statements, identifying and challenging maladap-tive cognitions, and role plays that emphasize context-sensitive and flexible interpersonal responses. Treatment is organized into eight sessions, although the treatment can be lengthened depending on the client's needs.

The second phase of treatment is an eight-session modified prolonged exposure (MpE) treatment adapted from Foa's treatment for rape-related PTSD (Foa, Rothbaum, Riggs, & Murdock, 1991). The goal of this phase is to help the patient engage in exposure to the trauma memory in order to resolve posttraumatic stress symptoms such as fearfulness, nightmares, and irritability.

In the two-module approach, the STAIR phase takes place first. STAIR provides the client and therapist with a stabilization phase in which the therapeutic relationship can develop, and in which the client can acquire and practice skills that are intended to improve functioning in day-to-day life and, accordingly, that provide a sense of success and competence. Furthermore, skills training precedes exposure so that the increased ability to regulate feeling states obtained from phase 1 can be utilized to enhance the effectiveness of the PTSD-related exposure work of phase 2. However, the modules can be used separately. In particular, the STAIR module can be used alone as a skills training/prevention program for individuals at risk for assault who do not suffer from significant PTSD symptoms. Table 13.1 summarizes the sessions included in STAIR and MPE intervention approaches.

Sexual Revictimization TABLE 13.1. Summary of STAIR/MPE Sessions

Session

STAIR Session l

Session 2 Session 3

Session 4 Session 5

Session 6 Session 7

Session 8

MPE Session 9

Session l0

Sessions ll-l5

Session l6

Focus and content

Introduction to treatment: Psychoeducation on effects of childhood abuse on three problem domains: emotion regulation, interpersonal functioning, and PTSD symptoms; treatment overview and goals; psychoeducation and practice of focused breathing

Identification and labeling of feelings: Psychoeducation on impact of childhood abuse on experiencing emotions; introduction and practice of self-monitoring of feelings, triggers, intensity, and coping/reaction

Emotion regulation: Psychoeducation on connection between feelings, thoughts, and behaviors; identification of strengths and weaknesses in emotion regulation skill (cognitive, behavioral, social network domains); practicing new coping skills

Distress tolerance: Psychoeducation on acceptance of feelings/distress tolerance; assessment of pros and cons of tolerating distress; identification and practice of pleasurable activities Distinguishing between past trauma schemas and current goals: Psychoeducation on interpersonal schemas related to childhood traumatic events as self-fulfilling prophecies; distinguishing between trauma-related schemas and "here-and-now" interpersonal goals; identification of schemas in a current problematic situation Alternative interpersonal schemas: Psychoeducation on role playing; identification of relevant interpersonal situations and enactment via role plays; generation of alternative schemas

Assertivenesss and control schemas: Psychoeducation on assertiveness; discussion of alternative schemas and behavioral responses; implementation of role plays requiring assertiveness; generation of alternative schemas

Flexibility in schema application: Psychoeducation on flexibility in interpersonal relationships; implementation of role plays requiring flexibility; generation of alternative schemas; discussion of transition from phase 1 to phase 2 of treatment

Introduction to imaginal exposure: Psychoeducation on rationale and technique; development of a narrative; creation of trauma memory hierarchy

Imaginal exposure to first memory: Implementation of prolonged imaginal exposure; postexposure implementation of stabilization exercise; identification and labeling of feelings narratives identification of schemas embedded in narrative; contrast of trauma schemas with current developing schemas

Continued work on imaginal exposure: Working through memory hierarchy with probes, clarifications, and greater evocative details; continuation of feeling and schema analysis of narrative

Wrapping up: Identification of progress, risk for relapse, relapse prevention strategies

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