Case Reports: STAIR for Strengthening Social Support and Relationships Among Veterans With Military Sexual Trauma and PTSD

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1 MILITARY MEDICINE, 181, 2:e183, 2016 Case Reports: STAIR for Strengthening Social Support and Relationships Among Veterans With Military Sexual Trauma and PTSD Marylene Cloitre, PhD*; Christie Jackson, PhD ; Janet A. Schmidt, PhD ABSTRACT Military sexual trauma (MST) is associated with high rates of post-traumatic stress disorder (PTSD) and multiple comorbid symptoms. In addition, women Veterans with MST report negative perceptions of social support, poor relationships, and difficulties in social and role functioning. Treatments for PTSD do not provide interventions to improve social or relationship functioning and do not consistently produce positive benefits regarding these outcomes. This article presents a series of case studies in which an intervention focused on building social support and relationship skills is delivered to Veterans with PTSD and MST. The intervention, Skills Training in Affective and Interpersonal Regulation (STAIR) promotes social engagement and skills that support greater role functioning. It can be used as a stand-alone treatment, as an adjunctive intervention to PTSD therapies or as part of a combination therapy in which skills precede trauma-focused work (STAIR Narrative Therapy). Further investigation is suggested to determine the added benefits of incorporating skills building to PTSD or other diagnosis-specific interventions. INTRODUCTION Military sexual trauma (MST) is defined as sexual assault or severe or threatening forms of sexual harassment during military service (see U.S. Code 1720D of Title 38). It is a prevalent duty-related stressor and is considered by some to be epidemic. 1 Nearly one in five (22%) women in Veterans Health Administration (VHA) report MST when screened. 2 Among women Veterans, risk for post-traumatic stress disorder (PTSD) is significantly greater when it results from MST as compared to other duty-related stressors or experiences of sexual assault in a civilian context. 3,4 In addition, women Veterans with PTSD who have experienced MST suffer from a greater number of comorbid symptoms and disorders. 5 The most persistent and severe difficulties reported by women Veterans with MST are problems in social and role functioning. 4 Veterans with MST fear stigmatization and do not discuss their military experience with friends or partners, leaving them feeling isolated, with fewer supports and coping resources 5 for dealing with emotional distress. Of note, MST is not an experience unique to women: among Veterans receiving VHA outpatient health care services in fiscal year 2013, 1.3% of men had disclosed to their health care provider that they had experienced MST. 2 We report on the use of an evidence-based intervention that builds emotion regulation and relationship skills intended to facilitate greater symptom management and improve social engagement and relationship functioning. The treatment can be used either as *National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road Building 334, Office 230, Menlo Park, CA VA New York Harbor Healthcare System-NY Campus, 423 East 23rd Street, New York, NY National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road Building 334, Office 269, Menlo Park, CA doi: /MILMED-D a stand-alone intervention or in combination with diagnosisspecific interventions for PTSD. MST has been associated with childhood abuse, entering the military at a younger age and being less likely to have completed college and more likely to be of enlisted rank. 6 Some data suggest that a reason why individuals enter the military at a younger age is to escape abusive or dysfunctional home environments. 6 However, younger age, dysfunctional families, and limited exposure to important skills-building life experiences may contribute to risk for MST as well as for PTSD and multiple comorbidities, to difficulties in recovery, and to complaints about social and role functioning. Social support and positive relationships are critical resources that facilitate adjustment after military service. Women Veterans report less social support and more relationship problems than men 7 and this is particularly true of women Veterans with MST. 5 In addition, social support plays an important role as both a risk and resilience factor in mental health. Social support and relationship difficulties contribute to risk for PTSD and severity of PTSD symptoms while the presence of positive support not only protects against PTSD but also can facilitate recovery. 8 Trauma-focused cognitive behavioral therapies are effective in reducing PTSD. However, they were not intended to nor do they consistently provide significant improvement in social support or relationship functioning. Skills Training for Affective and Interpersonal Regulation (STAIR) is a cognitive behavioral therapy that focuses on building emotion management and interpersonal skills necessary to both give and received social support and to maintain healthy relationships. STAIR was initially developed as part of a two-component treatment called STAIR Narrative Therapy, in which skills training preceded trauma-focused work to help individuals with childhood or multiple forms of trauma who suffered from highly comorbid PTSD and often were at risk for compromised skills development related to sustained e183

2 adverse social environments and poor role modeling (e.g., neglect, alcoholic parents, and exposure to domestic violence). Based on both clinician and patient interest, STAIR without the trauma-focused module was tested and found to be effective in improving social and role functioning as a standalone treatment 9 as well as in combination with the narrative therapy 10 in civilian samples. In total, STAIR Narrative Therapy has been studied in four clinical trials of adults with PTSD including childhood abuse survivors, individuals with PTSD related to 9/11, and individuals with PTSD and multiple comorbidities with a range of traumatic exposures. 11 The characteristics of the population for which the treatment was developed are similar to those reported by Veterans with PTSD who have also experienced MST, including significant childhood adversities, multiple trauma exposures, and a range of comorbidities, suggesting the value of evaluating the treatment for this population. A recent web-based consultation program launched by the Women s Mental Health Program in , STAIR Webinar Consultation resulted in STAIR training being completed with clinicians at 77 VHA facilities and 101 sites including inpatient, outpatient, residential, community-based outpatient clinics, and Vet Centers. 12 This level of interest suggests that STAIR is meeting a perceived treatment need among VHA clinicians. Delivery of STAIR to those with PTSD is consistent with Veterans Affairs (VA)/Department of Defense Clinical Practice Guidelines. 13 Stress management or coping skills intervention is noted among the first-line options for the treatment of PTSD. In addition, the guidelines recommend adjunctive treatments for comorbid symptoms, problems dealing with daily living and with social support. Thus, STAIR represents a good option for individuals whose primary concerns are social and interpersonal functioning. STAIR may be used in conjunction with first-line traumafocused treatments for PTSD (e.g., prolonged exposure, or cognitive processing therapy). STAIR consists of 8 to 10 flexibly applied sessions with the same structure: psychoeducation, demonstration of skill, practice of skills, and assignment of between session exercises (Table I). The first half of the treatment focuses on emotion regulation interventions, the selection of that are tailored to the client s needs. The last 4 sessions focus on relationships, and in particular, the identification of traumagenerated interpersonal schemas or emotionally charged negative beliefs about relationships that can derail relationships. Alternative, more adaptive beliefs are proposed and role-plays are used to practice implementing behaviors consistent with alternative, healthier interpersonal expectations. When STAIR is followed by Narrative Therapy (Table I), the focus on interpersonal schemas remains. Following completion of a trauma narrative, therapist and client appraise the meaning of the story in terms of the interpersonal schemas embedded in it (e.g., When I reached out for help, I was told I was weak ). The trauma-generated schema is contrasted with the new alternative schemas that have been TABLE I. Session 1 Session 2 Session 3a* Session 3b* Session 3c* Session 4 Session 5 Session 6 Session 7 Session 8 Session 9 Session 10 Sessions Session 16 Session-by-Session Description of STAIR Narrative Therapy STAIR Module Treatment overview, identification of interventions mapped to symptoms, confirming commitment to treatment Emotional Awareness: Identifying and monitoring feelings Emotion regulation: Focus on the body Emotion regulation: Focus on thoughts Emotion regulation: Focus on behavior Emotionally engaged living: Acceptance of feelings/distress tolerance in the service of valued goals, identify and work towards a goal Identify relationship patterns: interpersonal schemas Changing relationship patterns: alternative interpersonal schemas and role play Building appropriate assertiveness skills: schemas and role play Increasing flexibility in interpersonal expectations: schemas and role play Narrative Therapy Module Motivating and planning for narrative work Practice building a narrative with neutral memory, first trauma narrative Continue to conduct narratives of different traumas, focus on different affective themes including fear, shame, guilt, and sadness. Closure: Identify gains, discuss future goals and relapse prevention plans *Can be done in one session or in three separate sessions, depending on client need or preference. developed during STAIR. Because clients with MST typically have experienced multiple traumas, the narratives of distinct trauma events are described as chapters in an autobiography to which the client can ascribe a value and meaning while the chapters about the present and future remain to be written, authored by the individual. Below we present three case studies of Veterans with MST and PTSD seen in VA outpatient mental health services. The first case describes the implementation of STAIR alone, the second describes a course of STAIR Narrative Therapy, and the third describes STAIR Narrative Therapy with a male Veteran who experienced MST. Diagnostic and Statistical Manual of Mental Disorders-IV PTSD symptoms were assessed immediately before and after treatment using the self-report PTSD Checklist (PCL); scores range from 17 to 85, and changes of 10 to 20 points are considered clinically meaningful. 14 CASE REPORTS CASE 1: STAIR With Female Veteran Kathy, a 28-year-old Caucasian woman, came to treatment because she was extremely anxious, depressed, lonely, and e184

3 afraid to leave the house. Her stepmother had been mentally ill and had been physically and emotionally abusive. Kathy became a little mouse and silently hid under tables and in closets to avoid her mother s mistreatment. Her family moved frequently throughout her childhood. She had few friends and limited social activities. Kathy was drawn to the idea of a stable job with the Navy that would provide training. Unfortunately, during a brief medical hospitalization she was sexually assaulted by a hospital staff member during the night. Reporting the crime to the military authorities triggered a series of traumatizing inquiries and an eventual medical discharge because of a personality disorder. Kathy wanted to improve her self-esteem, manage her moods better, and start socializing. She was interested in STAIR because of its initial emphasis on improving life skills. As she explained it, the goal of her childhood was staying quiet and hiding to be safe. In contrast, her goal for life now was to have a happy time and a normal life, something no one in my family seems to know how to do. The therapist reassured Kathy that STAIR focused explicitly on building skills to improve mood and to increase social engagement, and that it had a good track record in these areas. Key aspects of STAIR therapy for Kathy included learning how to identify and express emotions, especially positive feelings, which would help promote her becoming more socially engaged. She learned she could manage her emotions better by using self-soothing skills for her negative feelings and generate awareness of positive feelings by engaging in activities she enjoyed such as making a meal for herself and dancing to music at home. The therapist next introduced practicing emotion regulation in social contexts by role-playing. Because of her fear of intimacy and social connections, roleplaying in session became a highly significant part of treatment. Assignments completed outside of therapy focused on the development of positive activities with varying degrees of social contact. Experiences such as asking for a book at the library were then discussed and role-played. Role-playing provided a safe space for Kathy to engage in emotionally charged interactions and to counteract the trauma-generated schema If I say how I feel, people will think I am crazy with the alternative If I can express myself, people might help me. As she ventured out more, Kathy was able to shift how she felt others perceived her and how she perceived herself. Even though her social activities were modest (i.e., volunteering at an animal shelter), she understood that she was not crazy and did not need to live as a little mouse any more. Her PTSD symptoms reduced significantly (from 77 to 46 on the PCL) at treatment s end. Kathy wanted to take a break from therapy after 10 sessions of STAIR. She knew she had more work to do but wanted to enjoy her new found skills. Kathy had a strong and trusting relationship with her therapist and they planned to meet again in 4 weeks to review the option of beginning trauma-focused work. Her positive relationship with the therapist and practice in social activities improved her confidence that she would develop friendships over time. CASE 2: STAIR Narrative Therapy With Female Veteran Barbara, a 35-year-old Hispanic Veteran, sought treatment for depression, irritability, and loss of interest in life including relationships with her husband and two children. Barbara had experienced childhood physical and emotional abuse by her mother and sexual abuse by an uncle. But her reason for entering treatment was her concerns about her deteriorating relationships with her family. The therapist described STAIR Narrative Therapy and how it might be a good match to her needs. The therapist noted that STAIR could help improve Barbara s emotional awareness and communication skills. The trauma work could help identify how her past history of trauma might be adversely affecting her current relationships. The therapist also invited her husband in for a session with Barbara where they discussed the connection between her childhood sexual abuse and intimacy issues in their own relationship. Among the interpersonal schemas that the therapist helped Barbara to identify which impacted day-to-day living were If I trust someone, I will be hurt, and I amso stupid and worthless, I deserve everything I get. Barbara was touched when her husband strongly countered these thoughts saying Barbara was a good parent and should be proud of her parenting skills given what a poor role model she had had with her mother. Kathy was ashamed of the MST and believed she deserved it and was helpless to change anything. This resulted in her staying with her military job for a full tour despite feeling isolated like a black sheep and never taking any official action about the MST. The therapist helped her link the childhood beliefs of deserving abuse, that there was no safe harbor in the world and feeling helpless, to the MST. The therapist proposed an alternative schema If I state an opinion or belief, people will listen. In conjunction with this new idea, Barbara learned how to be appropriately assertive and ask for what she wanted with her husband and with her adult children, from whom she received positive responses. Feeling better able to articulate her feelings and wants, having an improved family situation and strong alliance with her therapist enabled Barbara move into Narrative Therapy with confidence and some curiosity. She completed 10 sessions of narrative work about the trauma of her uncle s sexual abuse and mother s neglect. She liked the idea that each of the different narratives could be viewed as chapters in an autobiography of which she was now the author. Finally, she saw the importance of sharing the MST with her understanding husband. Barbara s PCL scores fell from 76 at pretreatment to 38 at the end treatment. She also finally acknowledged the MST to the VA and became involved with a MST advocacy group where she could help and continue to be helped by others with the same experiences. e185

4 The treatment strengthened her relationships with her family and expanded her social support network. CASE 3: STAIR Narrative Therapy With a Male Veteran During a routine VA screening, Stephen, age 50, African- American, reported an episode of sexual trauma during Army basic training in his 20s. The MST as well as the significant anger problems Stephen was experiencing lead the physician to suggest STAIR treatment. His initial reluctance to participate in therapy was reinforced when he met the STAIR therapist. She was in her 20s, Caucasian and part of the military industrial complex as he described it, which had betrayed him. Despite these obvious differences, the therapist s warm, open manner, and acceptance of Stephen s skepticism toward her and the treatment gradually overcame Stephen s concerns. The therapist was supportive of Stephen s desire to learn to control his anger as the initial focus of treatment and stated that STAIR included several effective tools for managing anger. During their initial meeting, Stephen revealed that he had been sexually abused as a young child by his Veteran father with the knowledge of his mother. He stated that he had sought out the military after high school to get away from home as soon as possible and to find what he expected to be a less crazy environment. However, the MST was a shock to him. His PTSD was a result of his exposure to war casualties as well as his sexual assault and childhood abuse. The therapist introduced Stephen to emotion management strategies for his anger, including focused breathing and emotion surfing, which helped him on the job and also helped reduce his PTSD symptoms. Key to working with Stephen was linking the childhood abuse and MST with the explosive anger he was currently experiencing. In tracking his emotions, Stephen discovered that his intense rage was a cover emotion for more vulnerable feelings of fear, guilt, and shame. Anger had a protective feature it pushed others away, but at the cost of intimacy. The first schema identified was If I open up, I will be betrayed. Stephen realized that both his parents and the military failed to do their job and protect me. However, his experience with the STAIR therapist was different. She heard his story with empathy and in fact, helped protect him from his own intense rage. Role-playing with the therapist, Stephen learned to express negative feelings with appropriate intensity depending on the situation. The experiences with the therapist and the benefits of the new skills helped Stephen develop an alternative schema: If I ask for help, I can get better. Stephen agreed to begin Narrative Therapy. He had started treatment with a PCL score of 75 and at the transition to Narrative Therapy his score had dropped to 58. He and the therapist focused on a particularly hurtful memory: the denial by his mother that his father was abusing him. The therapist and Stephen listened to these tape-recorded narratives and Stephen understood, from the perspective of an adult, that he was not to blame for his abuse and felt sadness for the betrayals he had experienced by his parents. Stephen began to understand the reasons for his rage and forgive himself. At his request, he and the therapist processed one final trauma, the MST. With her help, he was able to view this brutal incident as specific to a particular set of individuals and contrast it with some new more positive experiences he recently had, including the work with his therapist. He was able to refrain from always assuming the old schema If I open up, I will be betrayed. After 16 sessions, Stephen ended with a PCL of 43, feeling significantly more able to successfully interact with his hospital coworkers and agreeable to the idea of joining a community-based support group for sexual abuse survivors. DISCUSSION These cases demonstrate the feasibility and potential value of STAIR for Veterans. STAIR systematically focuses on personal and interpersonal skills that contribute to good social and role functioning, resolving problems that are not usually addressed in traditional PSTD treatments. The treatment is likely to reduce burdens to both clients and their families by reducing the effects of MST and PTSD, which include social withdrawal, hostility, and aggression. STAIR may be attractive to service members because it is a treatment that focuses on building strengths. It may be more engaging and less stigmatizing than psychotherapy and is consonant with military values of goal setting and achievement. Currently, only 10% of Veterans diagnosed with PTSD are receiving evidencebased PTSD therapies, 15 which to date are exclusively trauma focused. The introduction of STAIR provides an alternative approach to reducing PTSD symptoms. It may also help Veterans engage in trauma-focused work, which can lead to even greater PTSD symptom reduction. Future research should include a randomized controlled trial among Veterans to determine the efficacy of STAIR compared to PTSD treatments in improving functioning as well as PTSD symptoms. STAIR training for VHA mental health service providers is available online ( STAIR), and the VHA Women s Mental Health Program typically provides a series of web- and phone-based consultation (contact M.C.). ACKNOWLEDGMENTS We thank the three Veterans with MST who allowed parts of their stories to be told. REFERENCES 1. Women Veterans Task Force: Strategies for Serving Our Women Veterans: Department of Veterans Affairs, Available at accessed July 29, e186

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