A Comparison of Traumatic Incident Reduction (TIR) and Prolonged Exposure (PE) Therapy
Nancy L. Day, cts Metapsychology Monographs #3
A Comparison of Traumatic Incident Reduction (TIR) and Prolonged Exposure (PE) Therapy Copyright Š 2012 by Nancy L. Day, CTS Metapsychology Monographs #3 Learn more at www.TIRBook.com ISBN-13: 978-1-61599-081-8 Distributed by: Ingram Book Group Published by: Loving Healing Press 5145 Pontiac Trail Ann Arbor, MI 48105 USA http://www.LovingHealing.com or info@LovingHealing.com Fax +1 734 663 6861
A Comparison of TIR and Prolonged Exposure (PE) Therapy By Nancy L. Day, CTS Introduction 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 incidentincluding 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 SUDs1 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 jobnow 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. 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, 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 About the Author Nancy L. Day, CTS, CTM is a Certified Trauma Specialist with the Association of Traumatic Stress Specialists (ATSS), a Certified Traumatologist with the Academy of Traumatology, and a Certified Advanced Traumatic Incident Reduction (TIR) & Metapsychology Facilitator and Trainer with Applied Metapsychology International. Nancy is also an Advisory Board Member and the Assistant Director of Education for the Veterans National Resource Center. Never satisfied with mediocre, Nancy focuses on procedures that help individuals get results quickly, privately and without negative side effects. For additional information on Traumatic Incident Reduction (TIR) and TIR professional skills training contact E-Productivity-Services.Net, 13 NW Barry Road, PMB 214, Kansas City MO 64155-2728 USA, Phone 816-468-4945, E-Mail 21CE@MSN.COM. About the Cover U.S. Air Force Capt. (Dr.) Kieran Dhillon-Davis, a clinical psychologist and chief of mental health for the 380th Expeditionary Medical Group, talks with an Airman during operations at an undisclosed location in Southwest Asia Jan. 22, 2010. Dhillon-Davis is deployed from the 82nd Medical Operations Squadron at Sheppard Air Force Base, Texas. (U.S. Air Force photo by Tech. Sgt. Scott T. Sturkol/Released). Use of this DoD archive photo does not imply endorsement of this paper or the psychological methods described therein. Photographer's Name: TSgt. Scott T. Sturkol
Location: Undisclosed Southwest Asia
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. 1