40 A Clinician's Guide to STAIR/MPE: Treatment for PTSD Related to Childhood Abuse Jill T. Levitt and Marylene Cloitre, New York University School of Medicine Women who have PTSD related to childhood abuse have significant deficits in the areas of emotion regulation and interpersonal skills. These probl~ms are associated with impaired functioning in social, work, and home life. In addition, there is substantial clin- ical concern that limited emotion-regulation skills puts this population at risk for early dropout and symptom exacerbation, in treat- ment focusing on emotional processing of traumatic memories. Skills Training in Affective and Interpersonal Regulation plus Modi- fied Prolonged Exposure (STAIR/MPE) is an evidence-based, 2-phase cognitive behavioral treatment designed to address these concerns. Specifically, this treatment targets PTSD symptoms, emotion-regulation deficits, and interpersonal difficulties. The purpose of this article is to describe the rationale for and clinical application of STAIR/MPE, detailing the essential clinical components and presenting relevant case examples. I T IS ESTIMATED that as many as one in two individuals in the general population will experience a trauma at some point in his or her life (Breslau et al., 1998; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). While the traumas experienced by men are relatively diverse and in- clude combat, accidents, natural disasters, and witnessing of violence, the trauma that women experience fall pre- dominantly into one category: childhood abuse (Kessler et al., 1995). More than twice as many women have expe- rienced childhood sexual abuse compared to adulthood rape, which occurs in approximately 10% of the general population (Breslau et al., 1998; Kessler et al., 1995). Im- portantly, among women, childhood abuse is associated with greater susceptibility to PTSD than traumas that occur later in life (Breslau, Davis, Andreski, Peterson, & Shultz, 1997). While there have been advancements in the devel- opment of treatments for PTSD related to rape, the de- velopment of empirically supported treatments for adult survivors of child abuse has lagged far behind. This ar- ticle will describe and outline an evidence-based cognitive behavioral treatment for PTSD specifically designed for female survivors of childhood physical and/or sexual abuse. There is substantial evidence that the needs of women with PTSD related to childhood trauma are more diverse than those of rape survivors and victims of single-incident traumas. Specifically, women who have been abused in childhood often have difficulty regulating emotions, such that they have high-intensity emotional reactions such as anger (Briere, 1988) or anxiety (Zlotnick et al., 1996). Childhood abuse survivors also commonly report prob- Cognitive and Behavioral Practice 12, 40-52, 2005 1077-7229/05/40-5251.00/0 Copyright © 2005 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved. lems in interpersonal functioning, such as marital or rela- tionship dissatisfaction, social isolation, and poor social adjustment (Briere, 1988; van der Kolk, Roth, Pelcovitz, & Mandel, 1993). Studies directly comparing individuals with childhood-onset trauma to those with adult-onset trauma have found that childhood abuse survivors have more problems in the domains of affect modulation, anger management, and interpersonal relationships (Cloitre, Scarvalone, & Difede, 1997; van der Kolk et al., 1993). It has been argued that these problems are a relatively dis- tinct feature of childhood trauma and derive from the trauma's disruptive impact on the achievement of social and emotional developmental goals (van der Kolk, 1996). Interestingly, individuals presenting for treatment re- lated to childhood abuse often identify interpersonal prob- lems as the main reason for which they are seeking help. Anecdotally, clinicians report that childhood abuse survi- vors frequently seek treatment after "another failed rela- tionship attempt." Empirically, we have data indicating that a significant number of patients seeking treatment related to childhood abuse do so because of interper- sonal difficulties. In a sample of 98 treatment-seeking women with histories of childhood abuse, the most fre- quently cited reason for seeking treatment was interper- sonal problems (see Table 1). Upon evaluation, 73% of this sample had scores above the psychiatric mean on the Inventory of Interpersonal Problems (Horowitz, Rosen- berg, Baer, Ureno, & Villasenor, 1988), indicating signifi- cant interpersonal dysfunction, while 33% had past sub- stance abuse diagnoses, and 45% had past suicide attempts, suggesting clear emotion-regulation deficits. In another study, Cloitre and colleagues found that among women with a history of childhood abuse, emotion regulation and interpersonal problems were strong predictors of func- tional impairment beyond the effects of PTSD symptom severity (Cloitre, Miranda, Hart, & Stovall-McClough,