Symptom Course during IRRT and STAIR/IRRT for
individuals suffering from PTSD, due to childhood
sexual and -or physical abuse
Master thesis
A.B. Hendriks 10003700 Supervisor: Sandra Raabe University of Amsterdam
Contents Abstract 3 Introduction 4 Method 6 1.0 Participants 1.1 Procedure 1.2 Measures 1.3 Treatments 1.4 Statistical analysis Results 9 2.0 Participants
2.1 Efficacy of STAIR treatment 2.2 Symptom course of IRRT treatment
Discussion 13 References 14
Abstract
This study investigated the symptom course for Imagery Rescripting and Reprocessing therapy (IRRT, 16 sessions) and a phased-based treatment, Skills Training in Affective Interpersonal Regulation (STAIR, 8 sessions) followed by IRRT (16 sessions) for individuals suffering from PTSD, due to childhood sexual and or physical abuse. In this non-randomized pilot study, twenty two patients diagnosed with PTSD were allocated to two conditions; STAIR/IRRT and IRRT. At pre- and post- treatment assessment the Clinician-Administered PTSD Scale (CAPS) and the Impact of Events Scale (IES) were administered. During treatment the IES was filled out at the beginning of every session. Expectations were (1) at the beginning of IRRT treatment, participants in the STAIR/IRRT condition reported significantly lower PTSD symptom severity scores on the CAPS and IES compared to participants in the IRRT only condition who reported significantly higher PTSD symptom severity scores on the CAPS and IES, and (2) for symptom course during IRRT, participants in the
STAIR/IRRT condition reported significantly lower PTSD symptom severity scores on the IES at mid- treatment compared to begin-treatment, and significantly lower scores on the IES at post- treatment compared to mid-treatment. Participants in the IRRT only condition reported significantly higher PTSD symptom severity scores on the IES at mid- treatment compared to begin-treatment, and significantly lower scores at post- treatment compared to mid-treatment. The results of the first hypothesis indicated that STAIR/IRRT and IRRT only treatments were equally efficacious and the second hypothesis showed that for IRRT only treatment, PTSD symptoms were significantly lower at post-treatment assessment. Although more research is needed about the treatment effects of STAIR and IRRT, the findings are shown to be clinically meaningful.
Introduction
In recent years, there has been increased discussion regarding the effectiveness and adequate treatment for people suffering from Post-Traumatic Stress Disorder (PTSD), as a result of childhood sexual and or physical abuse (Minnen & Verbraak, 2002). Cognitive Behavioral Therapy (CBT), and specifically Trauma Focused Therapy (TFT) being a renowned and effective method, is widely used for treating PTSD (Bradley, Greene, Russ, Dutra, & Westen, 2005; Seidler & Wagner, 2006 cited in Arntz & Kindt, 2007). Nevertheless, the implementation of TFT in clinical practice is controversial.
According to a meta-analysis of Powers, Halpern, Ferenschak, Gillihan and Foa (2010), diverse studies have shown the efficacy of Prolonged Exposure (PE) (Foa, Hembree & Rothbaum, 2007) and recommended it in world-wide treatment procedures for PTSD (Foa, Keane, Friedman & Cohen, 2009). Besides the efficacy of PE, researchers have also paid attention to the symptom course pattern during treatment. For instance, symptom course for PTSD in rape victims has been
investigated using PE or cognitive processing therapy (CPT) (Nishith, Resick & Griffin, 2002). Findings indicate that overall PTSD symptoms seem to increase during the first three sessions of therapy, which is a critical drop-out period for patients during CPT or PE. An explanation for this increase appears to be a result of overwhelming fear and anxiety due to exposure and confrontation with the traumatic event at the beginning of treatment. Nevertheless, when patients continue treatment, PTSD symptoms appear to decline drastically. This can probably be explained due to trauma
processing during subsequent sessions. In other words, actively being engaged with traumatic feelings, thoughts and events for a prolonged period of time reduces PTSD symptoms (Nishith, Resick & Griffin, 2002). PE not only accomplishes short-term reduction in PTSD symptoms as it also shows long-term effects up to ten years (Resick, Williams, Suvak, Monson & Gradus, 2012).
Despite the efficacy of PE, therapists are reluctant to use it in clinical practice (Van Minnen, Hendriks & Olff, 2010). PE as a burdening form of therapy causes concern over its high drop-out rate and assumed aggravation of symptoms (Pitman et al., 1991). This burden on patients consists of increased nightmares, anxiety, intrusions, and feelings of guilt and impotence (Nishith, Resick & Griffin, 2002; Pitman et al., 1991). However, some clinicians argue that steep reductions in PTSD symptoms are found from the first exposure session onwards reporting no signs of increased anxiety. Neither did participants show worsening in PTSD symptoms post- PE treatment (Foa et al., 2002). Nevertheless, in a study wherein Cognitive Therapy (CT) and Imaginal Exposure (IE) were compared patients reported higher PTSD symptom severity post-treatment. At post-treatment a larger population of patients given PE reported exacerbation of PTSD symptoms (Tarrier et al., 1999). The use of PE in clinical practice remains controversial.
Due to the concerns about PE, an alternative form of treatment for which the maximum fear and tension experienced during PE is not reached such as, Imagery Rescripting Reprocessing Therapy (IRRT) (Smucker & Danku, 1995) is required. IRRT is a promising treatment stemming from schema therapy. Besides exposure, it focuses on altering maladaptive cognitions about the trauma that reduce
PTSD symptoms (Arntz, Dana & van Breukelen, 2013). The aim of IRRT is to give individuals a sense of empowerment and simultaneously reduce feelings of guilt and impotence (Holmes, Arntz and Smucker, 2007). Some clinicians argue that altering maladaptive cognitions alone is insufficient as stabilizing PTSD symptoms prior to exposure seems to be imperative for successful treatment outcome (Cloitre, Koenen, Cohen & Han, 2002; Cloitre et al., 2010). Nonetheless, there is limited evidence that stabilizing PTSD symptoms is a prerequisite for treatment as patients seems to improve with PE treatment as well (Foa et al., 2002). However, differences are found in symptom course patterns. In contrast to symptom course for PE in which PTSD symptoms initially increase and then drastically decrease, stabilizing PTSD symptoms and improving interpersonal skills can reduce PTSD symptoms initially and result in a gradual decrease in symptoms during treatment (Courtois & Ford, 2009; Cloitre, Koenen, Cohen & Han, 2002).
Stabilizing PTSD symptoms and interpersonal skills training is an integral part of Skills Training in Affective and Interpersonal regulation (STAIR) (Cloitre, Koenen, Cohen & Han, 2002). STAIR is a phase-based treatment that helps in stabilizing emotions and provides skills to deal with affective and interpersonal difficulties. Additionally, it seems to have a lower drop-out rate when compared to PE therapy as stand-alone treatment (Cloitre, Koenen, Cohen & Han, 2002). For instance, the efficacy of STAIR was shown for women with PTSD as a result of childhood abuse. In comparing STAIR to a waitlist treatment results showed that there were significant reductions in PTSD symptoms for STAIR treatment compared to waitlist treatment. Additionally, long-term gains were found in three and nine month follow-up assessments (Cloitre, Koenen, Cohen & Han, 2002).
Considering existing literature about promising treatments such as IRRT, for which maximum anxiety levels are not reached like during PE, and STAIR, which stabilizes PTSD symptoms, this study investigated (a) the efficacy of STAIR treatment on PTSD symptoms and (b) symptom course patterns during IRRT treatment. In this non-randomized pilot study, twenty two patients diagnosed with PTSD were allocated to two conditions; STAIR/IRRT and IRRT only. PTSD symptoms were examined at pre- and post- treatment assessment using the Clinician-Administered PTSD Scale (CAPS) and the Impact of Events Scale (IES). To track PTSD symptoms during treatment, the IES was filled out at the beginning of every session.
Therefore, two hypotheses’ have been derived. The first hypothesis examines the efficacy of STAIR treatment on PTSD symptoms comparing STAIR/IRRT and IRRT only conditions. It is expected that at the beginning of IRRT treatment, participants in the STAIR/IRRT condition report significantly lower PTSD symptom severity scores on the CAPS and IES compared to participants in the IRRT only condition who report significantly higher PTSD symptom severity scores on the CAPS and IES. The second hypothesis investigates symptom course patterns during IRRT treatment for STAIR/IRRT versus IRRT only. It is expected that participants in the STAIR/IRRT condition reported significantly lower PTSD symptom severity scores on the IES at mid- treatment assessment compared to begin-treatment assessment, and significantly lower scores on the IES at post- treatment assessment
compared to mid-treatment assessment. Participants in the IRRT only condition reported significantly higher PTSD symptom severity scores on the IES at mid- treatment assessment compared to begin-treatment assessment, and significantly lower scores on the IES at post- begin-treatment assessment compared to mid-treatment assessment.
Method Participants
In this non-randomized pilot study, 47 participants were screened for PTSD by means of intake interviews at PuntP, a mental health institution. Certified health care psychologists conducting the interviews filled in screening forms indicating the suitability of the patients for the study. Once the researcher at the University of Amsterdam received these forms, participants were contacted for an interview in which the purpose of this study was explained. Questions were answered and participants were requested to give informed consent to participate in the study and to permit audio/visual
recordings during treatment and assessment. Included in this study were 22 participants (17 women and five men) with an average age of 38 years (SD =10). Participants were non-randomly allocated to one of the two conditions; STAIR/IRRT (24 sessions) and IRRT (16 sessions). The remaining 25 participants were excluded as they did not satisfy the inclusion criteria for this study.
Inclusion criteria were: (1) PTSD diagnosis due to childhood sexual and or physical abuse before the age of 15 years. Exclusion criteria were: (1) risk of suicide, (2) presence of alcohol and or drugs abuse, (3) benzodiazepines, (4) Body Mass Index (BMI) is below 18, (5) psychotic disorder, (6) bipolar disorder, (7) current trauma (eg. stalking or abuse by spouse), (8) unstable living conditions (eg. no income or being homeless) and (9) unable to comprehend the Dutch language adequately to answer questionnaires.
Procedure
After the interviews, 22 participants, having given informed consent for participation and permission for audio/visual recordings during treatment and assessment, were included in this study. At PsyPoli, a diagnostics based mental health institution of the University of Amsterdam, participants took part in pre- and post- treatment assessments. These were administered by trained psychologists blind for the experiment. The pre- treatment assessment comprised of two three-hour sessions. Participants were asked whether they had any questions regarding the study and were told that the assessor was blind for the study design, as it was important to be able to look at the complaints without prior knowledge of the patient or treatment. Moreover, the assessor briefly explained what patients could expect during the assessment; the use of audio and visual recordings, that patients could experience this session as stressful and anxiety provoking, and finally, that participation in this study is entirely voluntary. Subsequently, the assessment commenced. The Structured Clinical Interview for DSM Axis-I Disorders (SCID-I) and the Structured Clinical Interview for DSM Axis-II Personality
Disorders (SCID-II) were administered to assess disorder co-morbidity and to rule out exclusion criteria.
After completion of the assessment, participants were allocated to either STAIR/IRRT or IRRT treatment based on the availability of the certified health care psychologist at PuntP, who administered each treatment procedure once. IRRT treatment consisted of 16 sessions and was given two times a week at 90 minutes per session. STAIR/IRRT treatment comprised of 24 sessions, of which 8 STAIR sessions which was given once a week at 60 minutes per session, followed by 16 IRRT sessions that were given two times a week at 90 minutes per session. Total treatment duration of IRRT treatment was 8 weeks and total treatment duration of STAIR/IRRT treatment was 16 weeks.
Once treatment was completed, the post- treatment assessment which comprised of one three- hour session took place. The assessor explained that being blind for the experiment was essential for the assessment and that it was important not to give any personal information or disclose whether participants received STAIR/IRRT or IRRT treatment. After completion of the assessment, the participant was asked whether they were sufficiently informed about further treatment matters. Any questions were relayed to the researcher who would contact the participant. Finally, participants were told that if they suffered from any symptoms they should contact their therapist at PuntP.
Measures
CAPS. The Clinician-Administered PTSD Scale (CAPS) (Blake et al., 1990) is a clinician rated semi-structured interview that assesses the PTSD diagnosis and severity of PTSD symptoms during the last month. The CAPS comprises of 17 PTSD symptoms that are subdivided into two aspects per symptom; measuring the frequency and intensity per symptom respectively. Consisting of 34 items in total, each item is scored on a five point scale from zero to four. For frequency items, the five point scale ranges from zero (never) to four (daily). An item example is; ‘Do you have unpleasant dreams about the abuse you have experienced?’. For intensity items the five point scale ranges from zero (none) to four (extreme). An item example is; ‘How much discomfort do these dreams about the abuse give you?’. The symptom severity score is attained on basis of the sum score of all items. The minimum score on the test is zero (0) when all items are not applicable to the participant and the maximum score on the test is 170 when all items are applicable to the participant. For a minimum score of one (> 1) for frequency items and a minimum score of two (> 2) for intensity items, a PTSD symptom is identified. For a total score (< 45) participants report mild PTSD symptoms and for a total score (> 65) participants report severe PTSD symptoms. With respect to psychometric properties of the CAPS, a high validity (coefficient alpha = .88) and a high reliability (kappa = .87) are found (Blake et al., 1990). For this study the CAPS was used to assess PTSD diagnosis and severity of PTSD symptoms for pre- and post- treatment assessments.
IES. The Impact of Events Scale (IES) (Vassar, Knaup, Hale & Hale, 2011) is a self-report instrument that comprises of 22 items which assess the presence and severity of PTSD symptoms.
Items are scored on a five point scale from zero (not at all) to four (very much). An item example is; ‘I thought about it when I didn't mean to’. The symptom severity score is attained on basis of the sum score of all items excluding items 18 to 21. The minimum score on the test is zero (0) when all items are not applicable to the participant and the maximum score on the test is 110 when all items are applicable to the participant. The severity of PTSD symptoms is based on the following scores; a zero score indicates no symptoms (0 = no symptoms), scores zero – ten indicate mild symptoms (0-10 = mild), scores eleven – 20 suggest moderate symptoms (11- 20 = moderate), scores 21 – 35 suggest moderate to severe symptoms (21 – 35 = moderate – severe) and scores of 36 and above indicate severe symptoms (> 36 = severe). The IES reports a high validity (coefficient alpha= .87) and a high reliability (kappa= .70). The IES was used at pre- and post- treatment assessment and during
treatment. For pre- and post- treatment assessments the IES was conducted to track the presence and severity of PTSD symptoms during the last month. During treatment, the IES was administered at the beginning of every session to track the presence and severity of PTSD symptoms during the last week.
Treatments
IRRT.IRRT treatment consisted of 16 sessions and its procedure was conducted according to the protocol of Arntz and Weertman (1999). The participant underwent three IRRT treatment phases under guidance of the therapist. The first phase began with the participant imagining and
re-experiencing the traumatic event, preferably with their eyes closed, from the child’s viewpoint. If the traumatic event was too severe, it was not obligatory for the participant to close their eyes and to imagine the event entirely. Phase two consisted of, the participant being guided into imagining entering the event from an adult’s viewpoint, seeing the abuse take place and intervening the way the adult feels is right; saving the child and confronting the accused. In the third and final phase, the participant returned to the event from the child’s viewpoint, seeing and experiencing the interventions undertaken by the adult in phase two and asking the adult for anything the child needs at that moment; protecting and comforting of the child. During the session audio recordings were made for the patient to take home and listen to as homework between sessions.
STAIR. The STAIR/IRRT treatment comprised of 24 sessions, of which 8 STAIR sessions followed by 16 IRRT sessions. The STAIR (Cloitre, Koenen, Cohen & Han, 2002; Levitt & Cloitre, 2005) procedure commenced with psycho-education about PTSD symptoms. The second session focused on identifying, dealing and accepting emotions related to the trauma. Session three comprised of emotion regulation with respect to identifying effective and ineffective coping mechanisms in interpersonal relationships. The fourth session included distress tolerance related to the trauma. From the fifth to the eighth session, the focus was placed on identifying schemas, goals, and conflicts in interpersonal relations. Participants’ role played their interpersonal conflicts and examined their experiences. Additionally, alternative schemas and behavioral actions were discussed and integrated in
these role plays. Between STAIR sessions participants were given homework to apply their skills in current interpersonal conflicts.
Statistical analysis
For all missing values the Last Observation Carried Forward (LOCF) method was used wherein missing items were substituted with values of the previous existing item. For the first hypothesis, descriptive analysis and a two way Mixed ANOVA were performed. For the second hypothesis, descriptive analysis, a two way Mixed ANOVA and post hoc t-test analysis were performed.
Results Participants
Twenty two participants were included of which five participants dropped out. One (n = 1) dropped out after the first STAIR/IRRT session, another (n = 1) seemed too suicidal after two sessions, two patients (n = 2) could not get their treatment appointments scheduled, and one ( n = 1) participant did not show up nor responded to e-mails or telephone calls. Therefore, data of 17 participants (nine women and eight men) with an average age of 37 years (SD = 7) were included for data analysis. Types of traumas in this sample were, psychological abuse (n = 1), sexual abuse (n = 1), physical and sexual abuse (n = 3), physical and psychological abuse (n = 2), and psychological, physical, and sexual abuse (n = 5). Besides PTSD, co-morbidity of two or more Axis-I and or Axis-II disorders were present for several participants; a Single Depressive episode (n =3), Depressive Disorder (n =5), Dysthymic Disorder (n =1), Obsessive-Compulsive Disorder (n = 1), Alcohol Dependence (n = 1), Cannabis Dependence (n =1), Social Phobia (n =4), Panic Disorder with Agoraphobia (n =1) and Avoidant Personality Disorder (n =1).
Efficacy of STAIR treatment.
Three assessment moments were used to track the efficacy of STAIR treatment on PTSD symptom severity; Time 1, Time 2, and Time 3. Time 1 evaluated PTSD symptoms before the STAIR treatment commenced for the STAIR/IRRT condition and Time 2 was the pre-IRRT treatment
assessment for both STAIR/IRRT and IRRT only conditions. Time 3 examined PTSD symptoms post IRRT treatment for both STAIR/IRRT and IRRT only conditions. Table 1. displays means and standard deviations at Time 1, Time 2, and Time 3 on the CAPS and IES. See Figure 1. for PTSD symptoms before and after IRRT treatment for both conditions at Time 2 and Time 3 on the CAPS and Figure 2. PTSD symptoms before and after IRRT treatment for both conditions at Time 2 and Time 3 on the IES. Preliminary analysis were conducted to investigate PTSD symptoms at Time 2. Results showed that PTSD symptoms did not differ at Time 2 for STAIR/IRRT and IRRT conditions on the CAPS, t(15) = -1.44, p = .17, and on the IES, t(15) = -0.67, p = .51.
Table 1.
Means and Standard deviations at Time 1, Time 2, and Time 3 on the CAPS and IES.
Condition n Time 1 Time 2 Time 3
CAPS IES CAPS IES CAPS IES M SD M SD M SD M SD M SD M SD STAIR/IRRT 9 80.44 26.18 57.11 13.73 67.78 20.47 47.56 14.58 62.44 31.95 38.33 18.89 IRRT 8 80.63 15.68 52.50 15.70 54.63 36.87 31.00 23.26
Note. Clinician Administered for PTSD Scale (CAPS), Impact of Events Scale (IES). Time 1= PTSD symptoms before the STAIR treatment for the STAIR/IRRT condition, Time 2= PTSD symptoms at pre-IRRT treatment for both STAIR/IRRT and IRRT only conditions and Time 3= PTSD symptoms post- IRRT treatment for both STAIR/IRRT and IRRT only conditions.
Figure 1. PTSD symptoms before and after IRRT treatment for both conditions at Time 2 and Time 3 on the CAPS.
To investigate the efficacy of STAIR on PTSD symptom severity, the STAIR/IRRT condition was compared to the IRRT only condition at Time 2. A 2 (Time: Time 2 & Time 3) x 2 (Treatment) Mixed ANOVA was performed. For the CAPS, the main effect of Time was not significant, F(1,15) 4.14, p =.06. The main effect of Treatment was not significant, F(1,15) 0.05, p =.82. Moreover, the Time x Treatment interaction was not significant, F(1,15) = 1.80, p =.20.
0 10 20 30 40 50 60 70 80 Time 2 Time 3 IRRT Treatment S co res o n t h e I E S STAIR/IRRT IRRT 10
Figure 2. PTSD symptoms before and after IRRT treatment for both conditions at Time 2 and Time 3 on the IES.
For the IES, the main effect of Time was significant, F(1,15) 9.49, p =.01. Participants scored significantly lower PTSD symptoms on the IES at Time 3 compared to Time 2 for which participants scored significantly higher PTSD symptoms on the IES. The main effect of Treatment was not significant, F(1,15) 0.03, p =.87. Furthermore, the Time x Treatment interaction was not significant, F(1,15) = 1.52, p =.24.
Symptom Course of IRRT treatment.
Three assessment moments were used to track symptom course of IRRT treatment; begin-, mid-, and post-treatment assessments. For begin-treatment assessment, the mean PTSD symptom scores of sessions nine, 10 and 11 for STAIR/IRRT condition and for IRRT only condition the mean of sessions one, two, and three were included. For mid-treatment assessment the mean PTSD symptom scores of sessions 17, 18 and 19 for STAIR/IRRT condition and the mean of sessions seven, eight and nine for the IRRT only condition were taken. Finally, for post-treatment assessment the mean PTSD symptom scores of sessions 22, 23, and 24 for the STAIR/IRRT condition and the mean of sessions 14, 15 and 16 for the IRRT only condition were included. Table 2. displays means and standard deviations on the IES at begin-, mid- and post-treatment. See Figure 3. for symptom course on the IES for STAIR/IRRT and IRRT conditions at begin-, mid- and post- IRRT treatment. Preliminary analysis was conducted to investigate PTSD symptoms at the beginning of IRRT treatment. At pre- treatment PTSD symptoms on the IES did not differ for STAIR/IRRT and IRRT conditions, t(15) = -1.26, p =.23. 0 10 20 30 40 50 Time 2 Time 3 IRRT Treatment S co res o n t h e I E S STAIR/IRRT IRRT 11
Table 2.
Means and Standard deviation on the IES at begin- , mid- and post- IRRT treatment.
Condition n Begin Mid Post
IES IES IES
M SD M SD M SD
STAIR/IRRT 9 39.44 10.81 34.15 16.23 36.93 19.00 IRRT 8 46.96 13.73 45.25 19.24 28.08 21.02
Note. Impact of Events Scale (IES). Begin= for STAIR/IRRT condition the means of sessions nine, 10 and 11; for IRRT only condition the means of sessions one, two and three. Mid= for STAIR/IRRT condition the means of sessions 17,18 and 19; for IRRT only condition the means of sessions seven, eight and nine. Post=for STAIR/IRRT condition the means of sessions 22, 23 and 24; for IRRT only condition the means of sessions 14, 15 and 16.
Figure 3. Symptom course on the IES for STAIR/IRRT and IRRT conditions at begin-, mid- and post- IRRT treatment.
To investigate symptom course patterns of IRRT treatment comparing STAIR/IRRT and IRRT only conditions, a 3 (Time) x 2 (Treatment) Mixed ANOVA was performed. The main effect of Time was significant, F(2,30)= 6.19, p =.01. Participants scored significantly lower PTSD symptoms on the IES at post- IRRT treatment assessment compared to begin- IRRT treatment assessment for which participants scored significantly higher PTSD symptoms on the IES. The main effect of Treatment was not significant, F(1,15) = 0.19, p =.67. Nevertheless, the Time x Treatment interaction was significant, F(2,30) = 5.88, p =.01. Post-hoc analysis reported no difference in PTSD symptom severity scores for participants in the STAIR/IRRT condition at begin- and mid-IRRT treatment assessments on the IES, t(8) = 1.09, p =.31 and neither any difference in PTSD symptom severity scores at mid- and post-IRRT treatment assessments on the IES, t(8) = -1.06, p =.32. For participants
STAIR/IRRT; Begin; 39,44 STAIR/IRRT; Mid; 34,15 STAIR/IRRT; Post; 36,93 IRRT; Begin; 46,96 IRRT; Mid; 45,25 IRRT; Post; 28,08 S co res o n t h e IE S IRRT Treatment STAIR/IRRT IRRT 12
in the IRRT only condition, no difference in PTSD symptom severity scores were found at begin- and mid-IRRT treatment assessments on the IES, t(7) = 0.56, p =.59. However, between mid- and post- IRRT treatment assessments, participants in the IRRT condition scored significantly lower PTSD symptom severity scores on the IES at post-IRRT treatment assessment compared to mid-IRRT treatment assessment for which participants scored significantly higher PTSD symptom severity scores on the IES, t(7) = 3.54, p =.01.
Discussion
This study investigated symptom course during IRRT and STAIR/IRRT for individuals suffering from PTSD due to childhood sexual and or physical abuse. In this study, two hypotheses were tested. The first hypothesis investigated the efficacy of STAIR on PTSD symptoms. Contrary to the hypothesis, the efficacy of STAIR on PTSD symptoms appeared to be minimal as STAIR/IRRT and IRRT treatments were equally efficacious for patients. This result could be attributed to the small sample size in this study.
The second hypothesis examined symptom course of IRRT treatment. Although it did not reach significance, there was a trend observed for participants in the STAIR/IRRT condition who reported an overall decrease in PTSD symptoms from begin- to post- IRRT treatment. For participants in the IRRT only condition, though an increase in PTSD symptoms at mid-IRRT treatment was expected, results showed no increase in PTSD symptoms. However, consistent with the hypothesis PTSD symptoms decreased significantly at post- IRRT treatment compared to mid-IRRT treatment.
In this study there were no drop-out’s found during treatment which suggests that IRRT appears to be well tolerated by patients. This is consistent with studies that found that IRRT is a promising treatment which focuses on altering maladaptive cognitions about the trauma that reduce PTSD symptoms (Arntz, Dana & van Breukelen, 2013).
Based on the findings, both STAIR/IRRT and IRRT are equally efficacious for treating PTSD. It seems fair to suggest that STAIR treatment does not appear to have an added benefit to IRRT treatment only. Results showed that IRRT treatment was well tolerated by patients since no significant differences in symptom course pattern of STAIR treatment were found. However, results of a study conducted by Cloitre, Koenen, Cohen and Han (2002) claim otherwise. They stated that altering maladaptive cognitions alone is insufficient as stabilizing PTSD symptoms prior to exposure seems to be imperative for successful treatment outcome.
Considering the results found, it is important to take several limitations into account. First, the small sample size of 17 participants requires careful interpretation of the results. Consequently, due to the low power in this study the expected treatment effects of STAIR treatment may not have been found. Second, with respect to the design of the study, there are no control conditions. To attribute a reduction in PTSD symptoms to STAIR and IRRT treatment effects a control condition is necessary. A control condition can indicate whether for example spontaneous recovery over time is
responsible for a reduction in PTSD symptoms rather than STAIR and IRRT treatments. Third, patients were non-randomly allocated to STAIR/IRRT or IRRT treatments, as treatments were given to patients based on the availability of the therapist who administered each treatment procedure once. There is a possibility that treatment effects of STAIR and IRRT treatments are associated with unintended therapist effects as perhaps, the therapist’s affinity with one of the two therapies and or previous experience with one of the two therapies could have influenced STAIR and IRRT treatment effects found in this study.
In order to get more insight into the treatment effects of STAIR and IRRT on the symptom course of PTSD, it is recommended for future studies to use a larger sample size with a randomized design and a control condition. Another suggestion for future research are follow-up assessments in the long term to investigate whether a reduction in PTSD symptoms will consolidate over time with IRRT and STAIR treatments.
This study was the first to investigate treatment effects of STAIR and IRRT for this complex form of PTSD. In conclusion, the results indicate that both STAIR/IRRT and IRRT are equally efficacious for treating PTSD as a result of childhood sexual and or physical abuse. However, taking aforementioned limitations into account the findings in this study should be interpreted carefully. This study contributes to present PTSD treatment literature. Although more research is needed to gain more knowledge about the treatment effects of STAIR and IRRT, the findings are shown to be clinically meaningful.
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