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Comparing Traumatic Incident Reduction & Prolonged Exposure Therapy

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The article below was written by ATSS member Nancy Day. Nancy became a member of ATSS and a Certified Trauma Specialist in 1996. She is also certified with Applied Metapsychology International as a facilitator and trainer for Traumatic Incident Reduction and related techniques developed by Frank A. Gerbode, M.D. and colleagues. 

Nancy provides trauma resolution and life stress reduction professional skills training for mental health professionals and others involved with helping individuals overcome the negative effects of traumatic experiences and excessive life stress. 

Program developer Edna B. Foa, Ph.D. summarizes Prolonged Exposure (PE) therapy as a cognitive-behavioral treatment program for individuals suffering from Post-Traumatic Stress Disorder (PTSD). The program consists of a course of individual therapy designed to help clients process traumatic events and thus reduce trauma-induced psychological disturbance. The standard treatment program consists of nine to twelve 90-minute sessions. (SAMHSA, 2003)

Frank A. Gerbode, M.D., psychiatrist, and one of the principal developers of Traumatic Incident Reduction (TIR) summarizes TIR as a procedure that involves tracing back sequences of traumatic incidents to their roots while completing the incomplete receptive cycles that have accumulated in the sequences. What must be assimilated and accommodated from a traumatic incident are one’s reactions to the incident — including one’s thoughts, sensations, feelings, and perceptions. (Gerbode, 1995)

Although there are some remarkable similarities between PE and TIR, there are also some very distinct differences. I have listed the major differences in a table, which is followed by a brief summary of these differences.

Traumatic Incident Reduction (TIR) Prolonged Exposure (PE) Therapy
A.    100% Person-Centered  Therapist evaluates client’s progress
B.     Client is not interrupted when viewing trauma  Therapist takes a SUDs[1] rating every 5 minutes
C.    Sessions have no fixed length  Sessions are terminated in 45-60 minutes
D.    TIR sessions are complete Homework is required
E.     TIR produces rapid resolution of trauma, often in a single session or in a few sessions. In 10-15 sessions, chronic PTSD symptoms reduced 58%

 

 A. TIR: The Rules of Facilitation ensure that there are no interpretations, evaluations or other judgments made during the TIR session. (French and Harris, 1998; AMI/TIRA, 2007)

A. PE: During the session when the client is reviewing the trauma with eyes closed, the therapist lets the client know that he is there by offering brief but encouraging comments once in awhile, for example: “You’re doing very well. Hang in there,” “Great job, stay with your feelings,” “Remember, memories are not dangerous like the trauma was.”(Foa, et al, Prolonged Exposure Therapy for PTSD, 2007)

B. TIR: In basic TIR training, the facilitator enhances her skill in managing communication during session through a series of eight Communication Exercises. The facilitator’s job is to help the viewer move from his existing scene to as close as he can get to his ideal scene. She does this by following the specific steps of the TIR technique; no unnecessary extraneous verbiage is allowed, as it would be unproductive in helping the client reach his goals. (AMI/TIRA, 2007)

B. PE: The therapist probes for thoughts, feelings, and physical reactions by asking brief, specific questions while the client is recounting the trauma. She also asks the client for a SUDs rating every 5 minutes and makes notes about things the client says or does that seem important to discuss later. (Foa, et al, Prolonged Exposure Therapy for PTSD, 2007)

C. TIR: Taking a TIR session to a point of resolution is a key factor in the success a client has in viewing a past traumatic incident. Therefore, TIR sessions must be open ended. When the TIR technique has taken the requisite amount of emotional charge out of a traumatic incident, a certain set of phenomena will typically appear, indicating that the client has reached a valid end point. These end point indicators are: Positive indicators (examples: expression of relief, a smile, the elimination of negative affect earlier present in the session); Extroversion of attention; Realization, insight, or expressed decision or intention made at the time of the incident or because of the incident. (French and Harris, 1998)

C. PE: After about 45-60 minutes of imaginal exposure, the therapist terminates the exercise by asking the client to open his eyes and end the imaginal experience by saying “OK, let’s stop here. Great job⎯now let’s talk about how this was for you.” (Foa, et al, Prolonged Exposure Therapy for PTSD, 2007)

D. TIR: When the client reaches an end point of a TIR session and his attention is more in the here and now and he feels a sense of relief or resolution, his work is done until the next session. His success with TIR is acknowledged by ending the session when the end point has been reached. (AMI/TIRA, 2007)

D. PE: Session 2 begins with a homework assignment. The client is instructed to have an “in vivo” experience, that is, he is instructed to confront certain activities or situations that he has been avoiding, and to use a breathing technique when he feels anxious. The client’s imaginal exposures sessions are also recorded and the client is instructed to listen to the audiotape of his 45-60 minute sessions. The therapist and the client review the client’s homework assignments. (Foa, et al, Reclaiming Your Life From a Traumatic Experience Workbook, 2007)

E. TIR: It is not unusual for a single traumatic experience to resolve in one session of TIR. With long-term trauma or if there is an unknown source for negative feelings, emotions, sensations, attitudes or pains, an extensive intake interview is conducted with a customized case plan drawn up to address the client’s issues as efficiently as possible. A complete Life Stress Reduction program typically takes between 20 and 40 hours (10-20 sessions). The Life Stress Reduction program is judged to be complete when the client is no longer bothered by, or interested in, the issues he presented during the intake interview and any other issues that may have come up during the Life Stress Reduction sessions. (Volkman, 2005; Powell, 2006)

E. PE: It is reported that there is a large body of research supporting the effectiveness of PE. The PE treatment program gained a 2001 Exemplary Substance Abuse Prevention Program Award by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), and was designated as a Model Program for national dissemination. In Tel Hashomer Hospital, clients who had chronic PTSD related to combat reduced their symptoms by 58% with 10-15 sessions of PE. (Foa, et al, Prolonged Exposure Therapy for PTSD, 2007)

Conclusion

This paper outlines the main differences between TIR and PE. However, there are many similarities as well. Interested readers are encouraged to read the books listed in References below and engage in professional skills training in these methods for resolving trauma. Both TIR and PE have proven to be very effective tools in helping clients resolve traumatic stress and Post-Traumatic Stress Disorder.

(Footnote): 1 Subjective Units of Distress (SUDs): Wolpe’s scale measures intensity of subjective distress in response to a particular stimulus, such as a memory. It is widely used, and has been shown to correlate with several physiological measures of stress. Non-reactivity to a traumatic memory is considered an indicator of recovery (Horowitz, 1986). This 11 point scale uses 10 as the highest level of distress and 0 as the lowest level, or absence of distress.

References

AMI/TIRA (2007) Traumatic Incident Reduction Workshop Training Manual, Fifth Edition, AMI Press, Ann Arbor, MI

Foa, Edna B. (2003) Prolonged Exposure Therapy for Posttraumatic Stress, Substance Abuse and Mental Health Services Administration (SAMHSA) U.S. Dept. of Health and Human Services, http://www.samhsa.gov

Foa, Edna B., Hembree, Elizabeth A., Rothbaum, Barbara Olasov (2007) Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide, Oxford University Press

Foa, Edna B., Hembree, Elizabeth A., Rothbaum, Barbara Olasov (2007) Reclaiming Your Life From a Traumatic Experience, Workbook, Oxford University Press

French, G.D. and Harris, C.J. (1998), Traumatic Incident Reduction (TIR), CRC Press, Boca Raton, FL

Gerbode, Frank A. (1995) Beyond Psychology: An Introduction to Metapsychology, IRM Press, Menlo Park, CA

Horowitz, M. J. (1986). Stress Response Syndromes (2nd ed.). Northvale, NJ: Jason

Powell, David W. (2006) My Tour In Hell: A Marine’s Battle with Combat Trauma LovingHealing Press, Ann Arbor, MI

Volkman, Victor, Ed. (2005), Beyond Trauma: Conversations On Traumatic Incident Reduction, 2nd Ed. Loving Healing Press, Ann Arbor, MI

LIVE at ATSS’ 2010 Conference: Day 3

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It’s the third and final day of the 2010 conference. After this afternoon’s training sessions, it will be another two full years until the entire organization comes together for another ATSS conference. During our lunch break today, ATSS board members Diane Travers and Barbara Maurer led a presentation titled “Everything You Need to Know About ATSS Certification.”

The main reason individuals become members of ATSS, is for the certifications that the organization offers. ATSS offers three certifications: Certified Trauma Responder (CTR), Certified Trauma Service Specialist (CTSS) and Certified Trauma Specialist (CTS).

ATSS’ certifications have some of the most stringent and rigid set of standards in the trauma industry. Why? Once you attain one of our certifications, the incredibly-high educational and professional standard that you have been held to, will lend added credibility to the work you’re already doing.

How do I know which certification is right for me?

Since the three certifications aren’t built into a tiered system, “You should pick whichever certification describes your work the best,” explained Travers. Once you determine which certification is right for you, you need to get your documentation in order and submit it to ATSS. Let’s take a brief look at each certification individually:

Certified Trauma Responder:

The Certified Trauma Responder (CTR) is appropriate for those engaged in critical incident intervention, debriefing, or emergency response. The standards for experience and education are detailed in the Minimum Standards Training and Education Form. You should review the criteria with your sponsor to ensure you meet the minimum standards.

Documentation of Experience: Resume: A current resume indicating your current employment or volunteer position in a field or position which includes trauma-related/crisis intervention work. This information will usually include a position involving work with domestic violence, schools, crime victim’s services, rape crisis, crisis lines, hospice, chaplaincy, disaster services, child victims, combat veteran’s, police, fire personnel, emergency medical services, corrections, Red Cross, and trauma service ministries. Other trauma-related counseling and service positions may also qualify for experience. Consult your sponsor if you are unsure. The resume must clearly indicate a minimum of 40 hours of experience as a member of a crisis response team.

Certified Trauma Service Specialist:

The Certified Trauma Services Specialists (CTSS) is appropriate for those engaged in short term traumatic stress assistance, peer counseling, advocacy, and crisis support and response for victims, family members, co-victims, and survivors of trauma. The standards for experience and education are detailed in the application packet. You should review the criteria with your sponsor to ensure you meet the minimum standards.

Documentation of Experience: Resume: A current resume indicating your current employment or volunteer position in a field or position which includes trauma-related/crisis intervention work. This information will usually include a position involving work with domestic violence, schools, crime victim’s services, rape crisis, crisis lines, hospice, chaplaincy, disaster services, child victims, combat veteran’s, police, fire personnel, emergency medical services, corrections, Red Cross, and trauma service ministries. Other trauma-related counseling and service positions may also qualify for experience. Consult your sponsor if you are unsure. The resume must clearly indicate a minimum of one-year experience.

Certified Trauma Specialist:

The Certified Trauma Specialist (CTS) is appropriate for counselors and treatment specialists are facilitators of trauma recovery groups, hypnotherapists, art or drama therapists, individuals who provide Thought Field Therapy, Traumatic Incident Reduction, EMDR, meridian based therapy’s, individual, group, and/or family counseling to trauma survivors. The standards for education are detailed in the application. You should review the criteria with your sponsor to ensure you meet the minimum requirements.

Documentation of Experience: Experience Form application. Fill out the experience section on the first page of the CTS application. Be sure the information matches your resume. Resume: A current resume/vitae must be included which documents the above mentioned information and elaborates on trauma population.

There’s so much more to read and learn about the ATSS certifications. CLICK HERE to find out all the details.

Written by traumalines

October 2, 2010 at 2:06 pm

Have You Seen the Latest Trauma Lines Newsletter?

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Attention all members of the Association of Traumatic Stress Specialists (ATSS): a brand new issue of our Trauma Lines Newsletter has just been published.

The March issue of Trauma Lines covers a wide variety of information, yet focuses on the devastating earthquake in Haiti, the impact it has had on the Haitian children, and offers tips for parents on how to talk to their kids about trauma. The latest issue also highlights recent ATSS-member accomplishments and endeavors.

What Does a Model ATSS Member Look Like?” is an article contributed by ATSS President Kent Laidlaw, CTR which pays tribute to Dr. Anne Eyre, CTS. After years of dedication to ATSS and its members, Dr. Eyre is stepping aside, opening up the position for Secretary on the Board of Directors.

If you are interested in being considered for this position or have any questions, please email the ATSS office at: admin@atss.info. In your email, please indicate “Board Secretary” in the subject line. Deadline for submission of application is April 15th, 2010.

In addition to publishing various conference information, the March edition of Trauma Lines also features an article written by ATSS member Ron Hall, CTS. “Stranger in a Strange Land” is an original article by Mr. Hall in which he shares his experiences of living, working and gaining the trust of a people who at one time considered him a stranger.”

If you have any ideas or information (links, videos, articles, etc.) that you would like to appear in the next Trauma Lines Newsletter, don’t hesitate to leave us a comment on this blog or email us.

Click here to view the parameters for submitting articles or information to either the Trauma Lines Newsletter or the Trauma Lines blog.

READERS: Help us improve: what did you think of the latest issue of Trauma Lines — what did you like best, what would you like to see more or less of?

Written by traumalines

March 28, 2010 at 10:37 am