TIRA

Traumatic Incident Reduction Association

Research on TIR and Related Technique

The views and opinions expressed in these articles and interviews are those of the individuals speaking, and do not necessarily represent those of Applied Metapsychology International or the TIR Association.

Brief Treatment of Trauma-Related Symptoms in Incarcerated Females with TIR

By: Pamela Vest Valentine, Ph.D.
Pamela Vest Valentine, obtained her Ph.D. from Florida State University in 1997. The following article is based on materials presented at the Proceedings of the Tenth National Symposium on Doctoral Research in Social Work (1998).
Statement of the Research Problem

Conducted in the Tallahassee Federal Correction Institute (FCI) in Florida, this experimental outcome study examined the effectiveness of Traumatic Incident Reduction (TIR) (Gerbode, 1989) in treating trauma-related symptoms of female inmates who were victims of interpersonal violence. TIR is a brief (in this case, one session), straightforward, memory-based, therapeutic intervention most similar to imaginal flooding. A memory-based intervention implies that the symptoms currently experienced by a client are related to a past event and that lasting resolution of those symptoms involves focusing on the memory rather than focusing on symptom management. TIR is straightforward in that the roles of both the client and therapist are very clearly defined and strictly followed.

TIR is both a client-respectful and therapist-directed intervention. TIR is client-respectful in that the client's perception of the traumatic incident takes precedent over the therapist's perception of the incident. For example, should the client have multiple traumatic events in her past, she would decide on which event to focus in the one-session TIR intervention, and her version of the event would be undisputed by the therapist. Additionally, an event is considered traumatic if the client so deems it. In other words, the client, not the therapist, is considered the expert regarding the client's life and the impact of the traumatic event on her life. TIR is a therapist-direct technique in that the therapist acts as a guide, not an interpreter, evaluator, or problem solver. Both the non-intrusive stance of the therapist and the client's work of confronting the painful incident combine to empower the client (Valentine & Smith, 1996).

The study specifically examined the effectiveness of TIR on symptoms of Post-Traumatic Stress Disorder (PTSD), depression, anxiety, and low expectancy of success (i.e., low self-efficacy). Symptoms of PTSD include intrusion, avoidance, and arousal (American Psychological Association, 1994; Waldinger, 1990). Intrusion involves nightmares, recurring thoughts, and flashbacks. Avoidance speaks of numbing of feelings, avoiding places associated with the event, and attempts to refrain from thinking about the event. Arousal, among other things, pertains to an exaggerated startle response and hypervigilance. The diagnosis of PTSD means that the symptoms are more present after the traumatic event than they were before the event, and that the symptoms have existed for at least four weeks. Other symptoms associated with trauma are low self-esteem and a reduced sense of being in control.

The theoretical underpinnings of TIR are considerable and are closely related to the etiology of trauma-related symptoms. Psychodynamic theorists explain trauma-related symptoms as consequences of unresolved emotional processing that occurred during a traumatic episode (Gerbode, 1989). Behaviorists write of classical conditioning and seek treatment that reveals the stimuli associated with a particular traumatic event (Resnick, Kilpatrick, & Lipovsky, 1991). Cognitive theorists speculate that one's basic beliefs about the world were shattered during the traumatic event and that the shattered beliefs cry out to be restored (Janoff-Bulman, 1992). Cathartic theory, on which TIR is primarily based, agrees with each of the above theories. It also asserts that a heightened physiological state (much like the state experienced in the original incident) must be recreated to finish the emotional processing and to reveal the associated stimuli and/or the distorted cognitive schema (Straton, 1990). TIR is structured so that the incident is viewed repetitively, non-intrusively, and in an open-ended time frame. The structure is designed to elicit a heightened physiological state so that the client can process the event to its completion (Gerbode, 1989). Key to that structure is the open-ended time frame that allows the client to emotionally engage in the memory without fear of being cut off.

The reasons for studying the influence of TIR on previously traumatized female inmates are several. Since 1980, the rate of family homicide has increased fivefold (Joffe, Wilson, & Wolfe, 1986). Women are the target of much violence, as illustrated by the following: 75% of adult women have been victims of at least one sexual assault, robbery, or burglary (Resnick, et al., 1991); and 53.7% are victims of more than one crime. Abundant data exist that suggest that PTSD can result from having been a victim of crime or having witnessed a violent crime (Astin, Lawrence, & Foy, 1993; Breslau, Davis, Andreski & Peterson, 1991; Resnick, et al., 1991). Therefore, the number of women affected by PTSD is growing as violence and sexual abuse increase in society as a whole (Ursano & Fullerton, 1990). There is a lack of empirical research on the traumatic effects of interpersonal violence (e.g. robbery, rape, incest, physical assault). Since inmates are typically victims of interpersonal violence (Gabel, Johnston, Baker, & Cannon, 1993), the inmate population studied was particularly suitable for TIR.

Another reason for studying the influence of TIR on previously traumatized female inmates is the increased number of female prisoners in the last decade (Gabel, et al., 1993; "As Inmates Pay, so do Kids," 1995). This increase is due to a boost in drug-related arrests and sentencing. Between 1980 and 1989, 25% of women arrested were arrested for buying drugs; whereas among men, drug purchases accounted for only 10% of the arrests. More arrested females regularly use drugs than do their male counterparts. Among women incarcerated for violent crimes, a 1991 study (US Department of Justice, 1991) found that 61% of female inmates had victimized a male and that 36% had close relationships with their victims (Gabel, et al.). Violent offenders with a history of physical or sexual abuse are more likely to have killed relatives or intimates than strangers. Female inmates with no prior history of abuse were more likely to have victimized a stranger while committing a robbery. These statistics suggest a connection between female victimization and women who victimize. The impact of unresolved trauma needs to be explored.

The traditional treatment of inmates seldom incorporates the influence of prior traumatic events on current behavior (A. McNeece, personal communication, 4/18/1995). Furthermore, most trauma treatment is lengthy and nonspecific, making it difficult to reach conclusions about treatment efficacy. The above reasons mandated the need for this study.

Finally, while both clients and therapists throughout the United States report that TIR alleviates trauma-related symptoms (Valentine & Smith, 1996), little experimental research has been conducted to substantiate such claims (see next section). By conducting an experimental outcome study on the effects of TIR on traumatized, female inmates, knowledge is built pertaining to (1) the effectiveness of TIR, and to (2) the treatment of victims of interpersonal violence.

Prior Research on TIR

Although advocates of TIR suggest that it is a highly effective and cost-efficient brief treatment modality, there is little research to justify such claims. Most of what is written about TIR is anecdotal. A case study (Valentine, 1995), a multisite clinical debriefing study (Valentine & Smith, 1998), a dissertation based on a quasi-experimental design (Coughlin, 1995), and another dissertation, a true experimental study based on victims of crime in England (Bisbey, 1995), comprise the body of TIR studies.

The studies by Valentine (1995) and Valentine and Smith (1998) used ethnographic methods and were qualitative and discovery oriented. The client perspectives gathered in these studies expanded and clarified the existing theory base of TIR. The former study provided a vivid case study of the application of TIR in an outpatient setting. The latter study employed extensive phone interviews of the experiences of four clients living in three states who were treated by three certified TIR practitioners. Although the research designers did not allow conclusions about the efficacy of the intervention protocol, clients' and clinicians' enthusiasm about their experiences led the authors to conduct a controlled clinical trial of TIR. [As of 1998.]

The current study employed a credible design with a 3-month follow-up and relied on multiple published measures of anxiety, depression, PTSD, and general satisfaction. Furthermore, the sample consisted of female inmates who represented different ethnic groups and diverse socioeconomic classes. Finally, it used an analytic strategy that allowed conclusions about whether the treatment and control conditions differed after treatment and at a follow-up interval. Although the study was not intended to be a definitive test of TIR, it provides a rigorous examination of its efficacy with women of color from varied socioeconomic classes.

Research Questions

The research questions that this study addressed are the following:

  • How does TIR influence PTSD-related symptoms in incarcerated females?
  • How does TIR influence intrusion?
  • How does TIR influence avoidance?
  • How does TIR influence arousal?
  • How does TIR influence anxiety?
  • How does TIR influence depression?
  • How does TIR influence sense of control?
Methodology - Clients

Subjects in the study were recruited from the Federal Correction institute (FCI), Tallahassee, Florida. The sample was drawn from the total number of inmates at the facility (N = 730). The population (N = 730) filled out a Participation Questionnaire to indicate interest in the study. This questionnaire was used to determine eligibility based on whether inmates (1) had experienced a prior trauma in their lives, and if so, the nature of the trauma; (2) had experienced one or more of the trauma-related symptoms; and (3) were willing to further discuss their traumatic experience with a mental health professional. 248 inmates met the initial criteria. The inmates were brought together, in groups of approximately 12, to have the study explained to them and to have them sign consent forms when they chose to participate. 148 agreed to participate and were randomly assigned to either treatment or control conditions. 25 subsequently withdrew from the study, leaving 123 subjects. The reasons for withdrawal varied and included work-assignment constraints, disinterest, self-reevaluation of their level of traumatization, and/or a change of heart.

Average age of inmates in the treatment condition was 32.8 years (SD = 9.1), and the average age of those in the control condition was 34.9 (SD = 9.8). The means did not differ significantly across conditions, suggesting that age would not threaten internal validity. The majority of the participants were Black (50%), 38.5% of the participants were White, and 24% of the participants identified themselves as Hispanic. The racial distribution did not differ significantly between the treatment and control groups. 32% of participants had never been married, and the treatment and control conditions did not differ significantly on marital status. 35% of the participants had no high school diploma whereas another 35% had some college or vocational training. The treatment and control conditions did not different significantly on this variable.

The following exclusion criteria were used: inmates who were on antipsychotic medication; inmates who had been hospitalized within the last 3 years with a diagnosis of bipolar disorder or schizophrenic disorder; inmates experiencing a severe depressive episode that required immediate psychiatric hospitalization; inmates experiencing hallucinations, delusions, or bizarre behavior; inmates with an alcohol or drug abuse disorder; or inmates who were victimized within 3 months prior to participation in the study. These criteria were in part modeled after the Foa study (Foa, Rothbaum, Riggs, & Murdock, 1991) and the recommendations of clinicians in the correctional facility. In general, the exclusion criteria represented acute situations that would be counterproductive to the process of TIR.

Methodology - Practitioners

All TIR practitioners were female; had graduate degrees in social work, marital and family therapy, or psychology. They had a mean age of 35 with 7.2 years clinical experience on average. Practitioners were given 16 hours of training in TIR by a certified TIR instructor. Practitioners delivered TIR using a standardized protocol in 3- to 4-hour blocks to every client in the treatment condition. To control for differing practitioner skills, a comprehensive treatment manual was created. Random sessions were audio taped, and an independent observer who was well versed in the TIR protocol reviewed sections of the tapes to ensure treatment integrity. Alpha was set a .05, beta was set at .20 , and the effect size was estimated at .50.

An experimental control group design was used to evaluate the efficacy of TIR on 123 female federal inmates. The primary hypothesis of the study follows: Those inmates receiving TIR will experience significant reduction in one or more of their self-reported PTSD-related symptoms, while those in the control conditions will not.

While all subjects completed pretest, posttest, and follow-up tests, additional steps were required of those in the experimental condition. Those steps were: (1) have a one-on-one orientation to learn the nature of TIR and the roles that the inmates and the mental health practitioners would play, (2) receiving a session of TIR, and (3) completing a debriefing session.

Results

The instruments used to determine the efficacy of TIR on trauma-related symptoms were the PTSD Symptom Scale (PSS), the Beck Depression Inventory (BDI), the Clinical Anxiety Scale (CAS) and the Generalized Expectancy of Success Scale (GESS). These instruments were administered in a pretest, posttest, and three-month follow-up format.

To analyze the data, an ANCOVA [analysis of covariance] (with the pretest as the covariate) was conducted on each of the above measures, as well as on the three subscales of the PSS: intrusion, avoidance, and hyper-arousal. Analysis revealed that TIR shows significant differences at the .05 level on the PSS, the BDI, the CASE, and the GESS at both posttest and the three-month follow-up. In other words, at both the posttest and the three month follow-up, the experimental condition showed a statistically significant decrease in symptoms of posttraumatic stress disorder (and its related subscales) and of depression and anxiety, while those in the control condition remained approximately the same. Subjects assigned to the experimental condition improved on the measure of self-efficacy at a statistically significant level, while subjects assigned to the control condition did not. The null hypothesis was rejected, and the research hypothesis confirmed.

Although the results of this study were promising, care should be taken in generalizing to larger populations. For example, while this study demonstrated TIR's effectiveness in treating trauma-related symptoms in female inmates, it would be a mistake to assume that TIR is effective with male inmates, or with female inmates in different institutional settings, or with persons outside a prison setting. Additional studies should be undertaken with those populations before definitive conclusions are drawn about TIR's efficacy with those populations. Besides testing TIR's effectiveness on different populations, TIR should be compared against other brief trauma treatments. Finally, research implications involve testing TIR's effectiveness on different ethnic groups and discovering the variables associated with training therapists to deliver TIR to a variety of ethnic groups.

Implications for Social Work Practice

The implications for social work practice are multiple. Social work's knowledge base is increased in realizing an effective trauma intervention with female inmates. The knowledge base would be increased further by researching (1) TIR's effectiveness with other populations; (2) TIR as compared with other brief trauma interventions; (3) and the implementation of TIR with various ethnic groups.

One primary practice implication pertains to the accessibility of TIR to social workers in a variety of settings. TIR is an unfranchised therapeutic intervention. While social workers should be trained to deal with clients' traumatic memories, Gerbode (1989), the originator of TIR, does not require licensure nor certification to practice TIR, making TIR more accessible to a greater number of social workers. Furthermore, TIR training usually costs a fraction of the price of other trauma-focused interventions. Social work educators continually search for effective practice modalities that can be taught to students. Because TIR follows a detailed treatment protocol, it represents a practice model that can be easily taught to students within schools of social work. [Ed. Note: TIR Workshop attendees can now receive Continuing Education units approved by the National Association of Social Workers].

From a practice perspective, it is also noteworthy that addressing only one item from the list of traumatic events still brought about statistically and clinically significant results in the inmates. This underscores that assessing for traumatic events will not necessarily embroil practitioners in very lengthy treatment procedures. Instead, the results suggest that substantive issues can be addressed in a brief treatment procedure. Such results define a win-win situation for both clients and practitioners.

The comments given by inmates suggest that they were highly appreciative of the client-respectful nature of TIR. For many of them, this was their first experience with a treatment provider who was both effective and respectful. Given the histories of victimization cited by inmates, this feature represents one of the most important contributions of this intervention protocol.

Another practice implication is the applicability of this technique to the population with whom social workers are engaged. Many clients are oppressed and have likely been traumatized; yet, few psychosocial interview protocols exist that focus on having experienced prior traumatic events. Therefore, the demonstration of the effectiveness of TIR with previously traumatized female inmates should have several practice implications: (1) inclusion of a history of prior traumatic events in assessment of client problems; (2) inclusion of prior traumatic events in the treatment plan designed for the client; (3) encouragement of social workers to be trained to administer brief treatment to traumatized clients; and (4) practice of TIR by agency-based social workers, understanding that TIR has demonstrated effectiveness against trauma-related symptoms in incarcerated females. This study has shown TIR to be effective in the treatment of traumatized federally incarcerated females and renders TIR a promising intervention that begs further research.

References

American Psychiatric Association, (1994), Diagnostic and Statistical Manual of Mental Disorders (4th Ed.). Washington, DC; author.

"As Inmates Pay, so do Kids: More Mothers Jailed, Researchers Say." (1995 May). NASW News. 40(5), 7.

Astin, M. Lawrence, K., Foy, D. (1993) Posttraumatic Stress Disorder Among Battered Women: Risk and Resiliency Factors. Violence and Victims, (8), 17-28.

Gabel, K., Johnston, D., Baker, B., & Cameron, H. (1993) Female Offenders. Prepared for the Encyclopedia of the National Association of Social Workers.

Gerbode, F. (1989). Beyond Psychology: An Introduction to Metapsychology. Palo Alto: IRM Press.

Janoff-Bullman, B. (1992). Shattered Assumptions. New York: The Free Press.

Joffe, P., Wilson, S., & Wolfe, D. (1986). "Promoting Changes in Attitudes and Understanding of Conflict Resolution Among Child Witness of Family Violence." Canadian Journal of Behavioural Science, 18, 356-366.

Resnick, H.S., Kilpatrick, D.G., and Lipovsky, J.A. (1991) Profile of Jail Inmates, 1989. NDJ-9097. Washington, DC: Bureau of Justice Statistics.

Ursano, R. & Fullerton, C. (1990). "Cognitive and Behavioral Responses to Trauma." Journal of Applied Psychology, 20 (21), 1766-1775.

Valentine, P.V. & Smith, T.E. (1996, November). Brief Treatment of Traumatized Clients: An Ethnographic Study. Paper presented at the annual meeting of the National Association of Social Workers in Cleveland, OH.

Waldinger, R.J. (1990) Psychiatry for Medical students. (2nd Ed.). Washington, DC: American Psychiatric Press.

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