1.3 STAIR Narrative Therapy Process
SNT is a cognitive behavioral therapy that is based in interpersonal and attachment principles. The treatment was developed following both theory and evidence that early life trauma disrupts attachment and related capacities for emotion regulation, positive self-regard and healthy relationships (see Cloitre et al., 2006). Accumulating research in the trauma field has strongly indicated that trauma which is the result of human design (e.g., war, community violence, genocide and other forms of organized violence), regardless of whether in happened in childhood or adulthood, is particularly pernicious. Compared to non-interpersonal traumas, it is associated with higher rates of PTSD and other adverse effects (e.g., deterioration in social networks) that relate to the capacity to maintain social bonds at an individual and community level (Charuvastra & Cloitre, 2008).
As described in the case illustration, the therapeutic allianceis key to recovery as is repeated psychoeducation on the nature of trauma . The therapist’s feedback and explanations help the client begin to reframe the nature of their experience from one in which they are to blame (“How did you let this happen? ”), to something that happened to them and from which they can recover (“I’m sorry this happened to you. How can I help ?”) The first two sessions of STAIR highlight the negative impact of trauma on emotions, self-identity and relationships. The selection of emotion regulation skills is based on client preferences, needs and strengths. Research on depression indicates that the selection of skills that strengthen existing competencies rather than fill a gap (compensatory) result in greater decrease in symptoms (Cheavens et al., 2012). This may be because emphasizing strengths may enhance of mastery and positive self-regard, both of which are low among trauma-exposed individuals. There are at least 15 emotion regulation skills available in the protocol (Cloitre et al., 2020) and typically clients comfortably and effectively adopt from 3 to 6.
The sessions on relationships models borrows directly from Bowlby (see Cloitre et al., 2020). The relationship models are viewed in a nonpathological manner. They are described as strategies intended to maintain connections and ensure survival in particular social or interpersonal circumstances. Thus, models like “If I don’t share my feelings, I will be taken care of ” works well for a child with a distant mother or “Trusting others can get you killed ” ensures survival in a combat zone. Consistent with attachment theory, SNT recommends that a client diversify their attachment models for different relationships and circumstances. It is not necessary to reject or invalidate old models; they may still be useful if the client returns to a trauma-genic environment e.g., (an abusive family, combat zones). The client is encouraged to develop new and alternative schemas that are relevant to their current environment or even as related to an aspirational goal (e.g., “I would like to make friends.” ). As supported in the SNT protocol, several themes can be discussed in the treatment including, for example, power dynamics, shame, and grief. Therapist and client can choose to settle in on one or more of these themes as appropriate.
Last and most importantly, the therapist and client prepare to conduct narratives of the trauma memories. These sessions can number from 4 to 10 depending on the number of events that the client wants to discuss. The sessions also include continued use of the emotion regulation and interpersonal skills learnt during the STAIR phase of the treatment. This can highlight difference between the “old” traumatized self represented in the narratives, and the new evolving self emerging from the STAIR work which is respectful of but different from the person in the stories.