By Wendy Coughlin, PhD
No outcome evaluation studies of Traumatic Incident Reduction (TIR) had yet been done in 1992. Its efficacy had not been established except through anecdotal evidence offered by proponents of the methodology. As I began doctoral study, I was intent on finding tools to remove blocks to therapeutic progress. After attending a seminar introducing TIR, it became clear that Traumatic Incident Reduction worked to resolve these barriers. It seemed logical to develop a research project to evaluate its therapeutic utility. Only one other study had begun, a comparison of TIR and DTE (Direct Therapeutic Exposure) being conducted by Lori Beth Bisbey in England.
The premise for the study of TIR included several initial assumptions. First, it was clear that therapeutic barriers often occur when an individual attempts to avoid addressing sensitive material. Second, the sensitive material frequently has a traumatic content.1 Third, the barrier needs to be resolved so that the individual can deal with the traumatic material. This allows the person to desensitize to it, and cognitively restructure its meaning so that it is no longer aversive material. Traumatic Incident Reduction satisfied the three major known components required to address therapeutic impasses.
In 1992, I lacked the resources for mounting a full-scale study. Anyone familiar with the requirements of outcome evaluation research can attest to the complexity of conducting a fully replicable investigation. There were few mental health clinicians certified to conduct TIR. No preliminary data was available to guide further research. And, the Institute for Research in Metapsychology (IRM) was anxious to publish data to substantiate the utility of the procedure. In order to bring supporting evidence to the professional community as quickly as possible, a pilot study was developed using a quasi-experimental pre-test/post-test design. Anxiety was chosen as the most clearly measurable component of both therapeutic avoidance and traumatic response. A subgroup of individuals with panic symptoms was also assessed.
Efficacy studies measure the impact of treatment. To best measure that impact in the most realistic setting available, the research was conducted in private practice settings of established facilitators of Traumatic Incident Reduction 2. A list of qualified facilitators was provided by The Institute for Research in Metapsychology. TIR is a standardized procedure. Therefore, delivery of service does not vary among practitioners. This feature made it possible to compare the outcomes of service provided by different individuals. All participating facilitators signed an affidavit to attest to their adherence to the official TIR protocol. Due to the simplicity of the procedure, it is not necessary to have clinical background in order to administer it. TIR also includes ground rules (See Appendix A), which generate both empathy and a safe therapeutic space. It not only does not require therapist insight, but it prohibits interference from, or customization by, the facilitator.
When taught and supervised by a certified TIR trainer, any adult with average intellect can execute the procedure. According to TIR developers Gerbode and French (1992):
“We have found that anyone of good will and reasonable intelligence who wants to be able to help people who are unhappy can become a competent facilitator.”
Although some of those providing data for this research did possess substantial mental health background, some did not. The initial experimental design had to be modified to accommodate facilitators who did not have a background in mental health.
Originally, we hoped to pre-select our study participants to include only those suffering from anxiety or panic disorders. This was only possible if there was an initial diagnosis, but not all participating facilitators were qualified to diagnose. Thus, we were not able to screen participants. In the end this proved more valuable than problematic. Our data indicate efficacy for a broad range of anxiety levels including those customarily experienced by normal people in normal environments. In short, because of this seeming limitation, the results are more validly applicable to a general population.
Two instruments were used to assess clients. A standardized and well validated test of anxiety, The State-Trait Anxiety Inventory (STAI) (Spielberger, 1983) was used to evaluate State and Trait Anxiety levels. State Anxiety represents immediate feelings of apprehension and tension, the anxiety a person feels “at the moment.” Trait Anxiety reflects the individual’s tendency to respond to the world in an anxious fashion. State Anxiety is generally amenable to short-term therapeutic interventions whereas Trait Anxiety tends to be an enduring characteristic of the individual. I specifically designed the second scale for this study. It was The Symptom Checklist, intended to elicit the symptoms of panic as defined by the diagnostic criteria set down in the DSM-IV (APA, 2000). Symptom checklists allow individuals to directly rate the presence or absence of specific symptoms. There is a high degree of reliability as they represent a direct report from the client and are free from researcher bias. Neither instrument required facilitator interpretation.
Method
Six facilitators trained in TIR provided data from their private practice. A total of twenty-five participants commenced, but five withdrew for reasons not related to this study. Each participant completed both the STAI and The Symptom Checklist on three occasions: on intake, and on one and three month follow-ups. The efficacy of Traumatic Incident Reduction as a treatment tool for managing anxiety and panic was assessed by a change in the reported symptom levels before and after treatment.
Results
There was a substantial and statistically significant reduction in State Anxiety for the entire sample. State Anxiety levels dropped by nearly one third of their original levels. Looking at the scoring on the STAI, the drop moved the group average from an anxiety level which would cause clinical concern and personal discomfort to a level that is considered normal for most people. The reduction in State Anxiety remained significant three months after treatment ended. Trait Anxiety levels also decreased by approximately twenty percent and held steady over the three month post-treatment period. These results indicate that Traumatic Incident Reduction is very effective in reducing anxiety. It is noteworthy that the reduction in anxiety levels occurred both for those in the normal pre-test range of anxiety as well as for those whose anxiety levels began at a higher, clinically significant level. This demonstrates that TIR is an effective tool for anyone. It will help those whose anxiety creates a problem in their life to bring that anxiety to tolerable levels. It will also help those who are only mildly anxious, perhaps only voicing reasonably normal concerns about their life, to reduce their discomfort and achieve a state of less worry and greater calm. Interestingly, there were no significant differences in the reduction of State or Trait Anxiety levels for individuals who also had panic disorder and those that did not suffer panic. There were, however, major differences in the level of panic symptoms. There were no additional follow-ups past three months.
Panic is defined as a discrete period of intense fear with symptoms of extreme anxiety such as pounding heart, shaking, shortness of breath, nausea, and fears of going crazy or dying 3. Seven members of the study reported having at least one panic attack in the previous month. The average length of treatment time for the panic group was 10.3 hours with a range between 3 hours and 24 hours of treatment contact. In that relatively brief period, the mean number of panic attacks decreased from 12.1 to 1.1. That represents a 91 % reduction in the number of panic attacks. Additionally, the number and severity of the symptoms decreased substantially. There was a 64% reduction in the number of usual symptoms. The number of severe symptoms decreased by 67%. For individuals who suffer from panic disorder, this results in a marked improvement in their quality of life. It is important to note that these results occurred without the need to use sedating, often addictive, medications which are commonly prescribed to manage panic disorder.
The sample group was subdivided, based on the presence or absence of panic and the levels of State and Trait Anxiety. The general trends and results were similar across groups with one important exception. The group that suffered from panic and had low State Anxiety scores reported an approximately 25% increase in State Anxiety and a 50% increase in Trait Anxiety following treatment.
Further research needs to be done to determine the cause of this aberrant response. One possible explanation relates to the function of the panic attack for some individuals. A panic attack may serve as a psychological mechanism to “hold” or release anxiety. Once the panic symptomatology has been dispersed, related anxieties manifest as both State and Trait anxiety symptoms. While this appears to be objectively problematic, it is subjectively more manageable. An individual with State or Trait Anxiety can manage those symptoms with cognitive behavioral tools. State and Trait anxiety are more amenable to control and management than panic. Any treatment intervention which returns conscious control to the individual is usually considered beneficial.
Discussion
Traumatic Incident Reduction is an effective technique for reducing many types and symptoms of anxiety. The most debilitating presentation of anxiety is the panic attack. TIR is highly effective in reducing the number of panic attacks, the number of symptoms experienced during a panic attack and the severity of the symptoms. The procedure of viewing used in TIR allows the individual to revisit his/her panic symptoms and begin to understand why they occur. Once an understanding is present, the individual is able to take conscious control over the symptoms. The most frightening aspect of most panic attacks is that the individual does not know what is happening. Frequently, panic originates with an earlier, fearful event that has been forgotten by the individual. Because TIR does not proceed in a logical, linear fashion, it may unlock the memory and reveal the significance of panic symptoms more readily than traditional therapeutic approaches.
State Anxiety, which is nervousness about an event or situation, is highly responsive to treatment using TIR. One might normally encounter this type of anxiety prior to an important event, during public speaking or when making a major life change. Anxiety can be defined as “anticipatory fear”. Based on past experience, we anticipate that the approaching event contains an element of danger. Traumatic Incident Reduction allows the individual to investigate the interconnecting cognitions which may link a past event with a current event and the belief that there is danger. In re-viewing the linked events, a clearer understanding may be achieved and, through cognitive rehearsal, the individual may come to feel less fear. In this way, TIR may facilitate the reduction in State Anxiety.
Once an individual begins to evaluate the origins of his/her anxiety, once he/she has gained control over overt symptoms, there is often an enhanced sense of competence in handling life. The reduction in Trait Anxiety may result from an overall sense of enhanced mastery that can be the outcome of using Traumatic Incident Reduction. Of those people who began with clinically significant levels of Trait Anxiety, 69% had this score reduced to within the normal range. “Cure” is often defined as eliminating the deviation from the norm. It can therefore be suggested that TIR cures pathological levels of Trait Anxiety approximately 70% of the time.
Figures and efficacy of this magnitude are seldom found in traditional psychotherapeutic modalities, given that the average length of treatment was 13 hours which would on average have occurred in only 4-5 sessions. It can be postulated that the extraordinary treatment outcome was related to practitioner expertise. However, this would not be a valid assumption. Facilitator expertise was determined only to assure adherence to the protocol. Treatment administration does not deviate from one provider to another among those fully trained to provide TIR. The language and response patterns are specifically scripted so as not to vary among presentations. Unlike most forms of psychotherapy, TIR does not rely on practitioner talent to provide results. It requires only adherence to the protocol for administration.
Comparisons to Other Modalities
The parsimony in explaining why Traumatic Incident Reduction works lies in its incorporation of knowledge gleaned from the main schools of psychotherapy.
Psychodynamic theories approach symptoms as signals of unconscious material. Freud identified anxiety as originating in events that threatened the individual. Psychodynamic therapy focuses on uncovering the originating incidents and releasing the unconscious material leading to enhanced understanding which typically causes the symptoms to decrease or disappear. Traumatic Incident Reduction addresses incidents in an individual’s life which were ‘traumatic’. When the impact of those incidents is ‘reduced’ the symptoms decrease or disappear.
Behavioral theories view anxiety as a conditioned response. Behavioral treatments therefore focus on extinguishing the conditioned response through desensitization. A behavioral protocol would require the individual to repeatedly be exposed to anxiety-inducing stimuli without reinforcing (responding to) the anxiety. After repeated exposure, the individual becomes desensitized and no longer responds with anxiety. Treating anxiety with Traumatic Incident Reduction similarly requires the repeated viewing of incidents related to the symptom, releasing affect until the individual no longer responds with the symptom.
Cognitive theorists view the underlying belief systems of the individual as the foundation to healthy or unhealthy responses to the world. Foa and Kozak (1985) view pathological anxiety as originating in previously stored “fear programs” contained in the informational network of the memory. To resolve symptoms, the therapist assists the clients in uncovering their “fear programs” in order to reevaluate their validity. Typically, once the symptom producing “program” is uncovered, it is recognized as containing irrational beliefs. Once identified, the irrational beliefs can be reframed thus eliminating the symptom. Thematic TIR asks the viewer to identify “an incident that could have caused” the symptom and to chain back through events connected to the symptom. Once the salient events are re-viewed, the viewer is able to determine possibly erroneous decisions that were made at the time of the incident and re-evaluate their validity. Once that material is identified, the viewer is free to reframe the incident and resolve the symptom(s) connected to it.
The essential difference between traditional treatment modalities and Traumatic Incident Reduction lies in the role of the practitioner. Traditional treatments evolving from psychological theories rely on a therapist to conduct and interpret the treatment. TIR relies only on an individual to facilitate the procedure. The full implication of this difference is beyond the scope of this chapter. However, several benefits are clear: TIR does not require years of collegiate study to pre-qualify the provision of assistance to others. The efficacy of TIR is not contingent on the unique talents of a particular facilitator. The procedure is standardized and does not require continuous adjustments. It is universally applicable to anyone of average intellect who is able to focus sufficiently to follow the procedure. Most importantly, Traumatic Incident Reduction does not allow interference from the practitioner. I believe that it is precisely the prohibition against interpretation and discussion that frees the individual to investigate his/her cognitive content in order to uncover the specific cause of his/her specific symptoms without bias. This freedom allows for the efficient and precise resolution of symptoms using Traumatic Incident Reduction.
End Notes
1 The term “trauma” is used herein in the broadest sense of the term. Material is traumatic when it threatens the physical or psychological life of the individual.
2 At the time The Institute for Research in Metapsychology, headed by Frank A. Gerbode, the developer of TIR, credentialed all research facilitators.
3 For a full definition of panic disorder consult The Diagnostic and Statistical Manual of Mental Disorders (4th edition).
References
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: Author.
Foa, E.B. & Kozak, M.J. (1985) Treatment of anxiety disorders: Implications for psychopathology. In A.H. Tuma & J.D. Maser (Eds.) Anxiety and Anxiety Disorders (pp. 421-461). Hillsdale, NJ: Lawrence Erlbaum.
French, G.D. & Gerbode, F.A. (1992). The Traumatic Incident Reduction Workshop. Menlo Park, CA: IRM Press.
Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (STAI). PaloAlto, CA: Consulting Psychologists Press.
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