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Stress inoculation training for PTSD

Another frequently reported behavioral approach to treating PTSD involves teaching patients specific coping skills for reducing or managing PTSD symptoms and/or alternative responses to fear and anxiety. Specific interventions applicable to PTSD include relaxation training, anger management training, thought stopping, assertiveness training, self-dialogue, problem-solving skills training, and relapse prevention. An example of this approach is Kilpatrick and Veronen’s  stress inoculation training (SIT) procedure for treating rape victims. Directed at the acquisition and application of coping skills, the SIT package includes Jacobsonian relaxation, diaphragmatic breathing, role playing, cognitive modeling, thought stopping, and guided selfdialogue. Patients are given homework assignments that require them to practice each coping skill.

The effectiveness of SIT was examined in four controlled studies. In one of these studies, Foa et al. reported findings of the comparative efficacy of SIT and PE for treating rape-related PTSD from a randomized trial. Specifically, these investigators compared the effectiveness of a wait-less control group and three interventions—prolonged exposure (PE), SIT, and supportive counseling (SC). PE consisted of both in vivo exposure exercises and imaginal exposure, SIT consisted of a modified version of Kilpatrick and Veronen’s multi-intervention package, and SC consisted of a form of problem-oriented counseling where the counselors played a supportive role in the patients recovery; no instructions for exposure or stress management were included in the SC regimen. Wait-list clients were randomly assigned to one of the three treatments following a 5-week period. Treatment consisted of nine twice-weekly individual sessions conducted by a female therapist. Indicators of general psychological distress and PTSD reexperiencing, avoidance, and arousal symptoms were collected at intake, at completion of treatment, and at follow-up (mean = 3.5 months posttreatment).

Only SIT produced significantly more improvement than wait list in PTSD symptoms at termination, but PE produced superior outcome at follow-up. Patients in the SIT and supportive counseling conditions showed little improvement of symptoms between termination and follow-up, whereas patients in the PE group that received in vivo and imaginal exposure continued to improve. The authors interpreted these findings as suggesting that (1) SIT procedures produce immediate relief in PTSD symptoms because they are aimed at the acquisition of anxiety management skills but show decreased effectiveness over time as performance compliance erodes and (2) PE shows less of an effect than SIT in the short term (a function of temporary increased levels of arousal induced by repetitive exposure to traumatic memories) but greater effectiveness over the long term, because therapeutic exposure is thought to lead to permanent change in the rape memory, thus producing durable gains.

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