International Society for Traumatic Stress Studies

Clinician's Corner Skills Training in Affective and Interpersonal Regulation (STAIR)

Posted 31 March 2015 in StressPoints by Marylène Cloitre, PhD

Skills Training in Affective and Interpersonal Regulation (STAIR) is an evidence-based skills-focused treatment that was initially developed to provide basic social and emotion management skills for individuals with PTSD related to childhood abuse. The motivation for developing the treatment was prompted by the observation that individuals with childhood trauma frequently experience disruptions in social and emotional developmental processes due to trauma and poor parenting.

In clinical terms, the treatment provided an opportunity for accelerated learning of basic social engagement and emotion regulation skills that had taken a “back seat” while the individual had been busy just surviving his or her childhood and adolescent years. In addition, STAIR has frequently been used preceding trauma-focused work as a multi-purpose alliance-building, symptom-reducing and mastery-enhancing intervention that supports and facilitates the effectiveness of trauma-focused work (see Cloitre et al, 2002; Cloitre et al, 2004).

It has become apparent that problems with emotion regulation and social connection are pervasive in traumatized populations, not just childhood abuse survivors. In addition and perhaps somewhat paradoxically, emotion management and social support have been identified as important personal and environmental resources that facilitate PTSD recovery and protect against its development (Charuvastra & Cloitre, 2008). STAIR has been implemented as a free-standing treatment, without a trauma-focused component, and has been applied in both individual and group modalities.

Data thus far are encouraging, suggesting that STAIR may be a powerful alternative to trauma-focused work (Cloitre et al, 2010). Clinical trials on group STAIR have reported significant improvements in PTSD as well as in emotion regulation and social problems in inpatient adult PTSD populations with comorbid schizoaffective disorders (Trappler & Newville, 2007) as well as among inpatient and outpatient adolescents with a range of traumas (Gudiño et al, 2014; Gudiño et al, in press).

STAIR implemented as individual therapy is an 8-12 session intervention that is flexibly delivered depending on the individual’s needs and skill level. STAIR begins with psycho-education about the impact of trauma on emotions and relationships, emphasizing the link between trauma and specific types of disturbances in social and emotional functioning. This typically motivates clients for the work ahead and serves to de-stigmatize and normalize their problems, i.e., they are not suffering from a character defect, or were not “just born that way.”

The first 4 to 6 sessions focus on emotion regulation skills and take a flexible “toolkit” approach with a subset of basic, foundational interventions that are always taught and practiced. The foundational interventions are body-based self-soothing strategies, cognitive reappraisals that focus on building positive self-regard and self-efficacy, and a commitment to achieving a mastery-building or positive goal.  

The second half of treatment transitions to the experience of emotions in social and interpersonal contexts. Emotion regulation skills are identified and implemented in the service of the client’s social and interpersonal goals. This includes effective expression of negative emotions such as anger and disappointment as well as increased expression of positive emotions such as satisfaction, and desire for greater closeness and intimacy.

Sessions include attention to interpersonal skills related to appropriate assertiveness and most importantly, development of flexibility in regards to interpersonal expectations, actions and reactions. Treatment ends with a recognition of achievements during the course of treatment and exercises in self-compassion. Self-compassion seems especially useful in helping clients appreciate their achievements without discounting them, and in providing an important therapeutic attitude with which to approach the narrative work that comes next, if they so choose that as a next step in their recovery.      

The 12-session group STAIR differs from the individual work primarily in providing a greater number of sessions focused on emotion regulation skills training and practice. It also differs in that group members are an important therapeutic resource, providing examples of effective variations in the emotion regulation strategies, and contributing alternative, more adaptive appraisals and action plans for interpersonal scenarios that are troubling an individual member.

The application of the group STAIR for Adolescents (STAIR-A) has a similar structure with content adapted to the developmental level and salient problems of adolescence. For example, STAIR-A helps teens strengthen communication skills particularly under stressful circumstances such as peer pressure and management of sexual encounters. Emotion regulation strategies emphasize verbal communication rather than action, and attention to the basics of care for the body.

The “big picture” benefit of providing STAIR or other effective trauma-related interventions to adolescents is that they intervene, in a timely fashion, to reduce or reverse the effects of early life trauma on emotion regulation and social engagement, halting the dominoes-like impact that sadly leads to substance abuse, bullying, sexual assault, domestic violence, negative self-regard and self-hatred.

One of the reasons I like using STAIR is that the work process is buoyant, upbeat and optimistic. The tasks of treatment are essentially rehabilitation of resources that are life-enriching and help protect against future adversities. Trauma-focused therapies have targeted and contributed substantially to reduction in PTSD and related psychopathology. However, once symptoms resolve, substantial problems in functioning often still remain. STAIR provides a means to increase capacities for better engagement in the present and so another way by which the past can stay in the past.   
   

About the Author

Dr. Marylène Cloitre is the Associate Director of Research at the National Center for PTSD Division of Dissemination and Training at the U.S. Department of Veterans Affairs in Palo Alto VA, California. She is also Clinical Professor (affiliate) of Stanford University Department of Psychiatry and Behavioral Sciences and Research Professor of New York University Medical Center Department of Psychiatry and Department of Adolescent and Child Psychiatry. She is a past president of ISTSS.
 

References

Cloitre,M.,Stovall-McClough,K.C.,Nooner,K.,Zorbas,P.,Cherry,S.,Jackson, C.L.,etal.(2010). Treatment for PTSD related to childhood abuse: A randomizedcontrolledtrial. American Journal of Psychiatry, 167, 915–924.

Cloitre, M., Koenen K.C., Cohen L.R., & Han H. (2002). Skills Training in Affective and Interpersonal Regulation followed by Exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70, 1067-1074.

Cloitre, M.., Stovall-McClough, C.K., Miranda, R., & Chemtob, C.M. (2004). Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72, 411-416.

Charuvastra, A., & Cloitre, M. (2008). Social bonds and PTSD. Annual Review of Psychology, 59, 301-328.

Gudiño, O.G., Weis, R., Havens, J.F., Biggs, E.A., Diamond, U.N., Marr, M., Jackson, C., & Cloitre, M. (2014). Group trauma-informed treatment for adolescent psychiatric inpatients: A preliminary, uncontrolled trial. Journal of Traumatic Stress, 27, 496-500.

Gudiño,O.G., Leonard, S., & Cloitre, M. (in press). STAIR for girls: A pilot study of a skills-based group for traumatized youth in an urban school setting. Journal of Child and Adolescent Trauma.

Trappler, B., & Newville, H. (2007). Trauma healing via cognitive behavior therapy in chronically hospitalized patients. Psychiatric Quarterly, 78, 317-325.