What Researchers are Saying About the Subject of Traumatic Incident Reduction (TIR)
& Related Techniques:
- “We are very impressed with the power and simplicity of TIR in helping trauma sufferers work through their frightening experiences and find great relief.” ~Charles R. Figley, PhD, editor of TRAUMATOLOGY
- “Being able to watch someone go from confusion to certainty, from sadness to happiness in a single session is a wonderful privilege. It is invigorating. I get the same satisfaction and joy from teaching Metapsychology techniques to others.” ~Lori Beth Bisbey, PhD, Chartered Counselling Psychologist
- “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.” ~Wendy Coughlin, PhD
- “In many cases, TIR results in the complete and permanent elimination of PTSD symptomatology. [My] dissertation suggests the use of TIR as an effective technique in the treatment of child and adolescent Post Traumatic Stress Disorder with the identified population.”~Francine Odio, PhD
- “In TIR you do no interpretation for the client. You do not say to your client: ‘That’s probably related to something that happened in your childhood.’ You would not presume to know what happened; you would not in fact interpret those things for the person.”~Joyce Carbonell, PhD., Florida State University
- “The comments given by female inmates [in this study] 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.”~Pamela Vest Valentine, PhD
- “This process may activate memories of important details of the recent trauma that heretofore have been omitted or forgotten. In this way, TIR makes use of verbally mediated generalization gradients, which will broaden the exposure treatment stimuli and thus reduce the likelihood of renewal.” ~Phillip M. Massad PhD and Timothy L. Hulsey, PhD
The following material is taken with permission from the Applied Metapsychology International (AMI) website. For complete information on these studies and more please visit: Applied Metapsychology site
Brief Treatment of Trauma-Related Symptoms in Incarcerated Females with TIR
By: Pamela Vest Valentine, PhD Pamela Vest Valentine, obtained her PhD from Florida State University in 1997. The following abstract is based on materials presented at the Proceedings of the Tenth National Symposium on Doctoral Research in Social Work (1998).
The comments given by inmates in this study 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 in this population 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.
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.
At both the posttest and the three month follow-up, the experimental condition showed a statistically significant decrease in symptoms of post traumatic 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.
A Review of Alternative Approaches to the Treatment of Post Traumatic Sequelae
An abstract from the published results appears below:
Anne M. Dietrich, PhD candidate, – University of British Columbia, Anna B. Barranowskky, PhD – Private Practive, Toronto (Canada), Mona Devich-Navarro – University of Southern California, J. Eric Gentry, PhD candidate – Florida State University, Chrys J. Harris, PhD – Private Practice, Boone, North Carolina (USA), Charles R. Figley, PhD – Florida State University Volume VI, Issue 4, Article 1 (December, 2000) Traumatology
Approaches to the treatment of posttraumatic sequelae are reviewed in terms of criteria for evaluating inferential validity with case studies, and where applicable, effect sizes are provided where there are data from group comparisons. The approaches covered in this paper include the Trauma Recovery Institute (TRI) Method, Traumatic Incident Reduction (TIR), Visual/Kinesthetic Disassociation (V/KD), and Thought Field Therapy (TFT). Internal validity of case studies on the TRI Method and V/KD appear controlled for, whereas reports on TFT do not meet internal validity criteria. Effect sizes are reported on one study that compared TIR to waitlist control and Direct Therapeutic Exposure (DTE), suggesting that TIR is superior to waitlist control, and shows more modest gains over DTE. The available evidence suggests TIR, the TRI Method, and V/KD are effective treatments for posttraumatic sequelae.
Bisbey (1995) studied 57 participants diagnosed with PTSD, who were randomly assigned to one of three separate conditions: Direct Therapeutic Exposure (DTE), which is an exposure treatment that has clients revisit the trauma without strict facilitator directives, TIR, and a control group. Clients in the two treatment groups evidenced significant reductions in trauma symptoms as per the Penn Inventory for Posttraumatic Stress (PENN) (Hammerberg,), the Impact of Event Scale (IES) (Horowitz, et al, 1979), and the Crime-Related PTSD scale (CR-PTSD) (Saunders, Arata, & Kilpatrick, 1990). Effect sizes using Hedge’s unbiased g statistic are calculated for the groups and are reported in table 2.
Table 2. Hedge’s unbiased g effect sizes for TIR compared to DTE and Controls on the PENN, IES, and the CR-PTSD MEASURE TIR/DTE TIR/CONTROL PENN 0.89 2.01 IES 0.95 2.08 CR-PTSD 0.56 1.40
The results from Bisbey’s randomized, controlled study provide preliminary evidence for the efficacy of TIR. Effect sizes for TIR show that it results in considerable improvement over wait list control, and modest improvement over DTE. Further studies are needed to determine whether these effects are robust.
In accord with a review by Shalev et al (1996) (see also van der Kolk, McFarlane, & van der Hart, 1996), although not sufficient per se as a cure for PTSD, exposure is one of the main active ingredients in treatments for post traumatic symptoms, particularly for intrusions. It has been long recognized (Wolpe, 1958) that a major element in cognitive-behavioral treatment approaches is that clients are assisted in gathering sufficient data about the conditioned stimulus to reduce its power in evoking conditioned reactions. Of the approaches covered in this paper, TIR is the best example of how exposure can be guided by clients, facilitate insight, and can facilitate tracking of shifts in trauma-based cognitions.
TIR is highly client-directed. Clients have control over the content, pacing, and degree of traumatic memory processing during sessions, and thereby have some control over the amount of affective arousal they experience. The presence of the therapist acts to provide support and encouragement, while also bearing witness in a non-judgmental manner. Attachment to the therapist can assist clients in modulating affective arousal, and the provision of safety by way of the therapeutic alliance may constitute discrepant information from the original, feared traumatic event to increase the effectiveness of desensitization (van der Kolk, et al, 1996).
The results of this review suggest that the Trauma Recovery Institute Method, Traumatic Incident Reduction, and Visual/Kinesthetic Disassociation are effective in the reduction of posttraumatic symptoms. The available case study data on the TRI Method and V/KD provide evidence that most internal validity criteria have been met, and that the treatment intervention per se results in improvement. The one controlled study on TIR suggests that it is more effective than no treatment in treating PTSD, and shows some improvement over DTE.
Reflections on Active Ingredients in Efficient Treatments of PTSD
Charles Figley and Joyce Carbonell ‘s “Active Ingredient” Series at Florida State University, 1994-95. The “Active Ingredient” project attempts to discover the actual means by which trauma may be released via a comparison of efficacy of TIR, TFT, EMDR, and TAT. An abstract from the published results appear below:
Four therapies for PTSD were presented at the Active Ingredients in Efficient Treatments of PTSD Conference, Florida State University, May 12-13, 1995. The conference was presided over by the principal investigators of the clinical demonstration study by the same title (Figley, C.R. and Carbonell, J., 1994). The methods included Eye Movement Desensitization and Reprocessing (Shapiro, 1995), Visual/Kinesthetic Disassociation (Bandler & Grinder, 1979), Traumatic Incident Reduction (Gerbode, 1995), and Thought Field Therapy (Callahan, 1985). Each method was summarized by the developers and/or representatives, preliminary results of the demonstration project were provided, workshops were presented and penetrating discussion ensued.
The four approaches were selected on the basis of nominations by traumatology professionals in response to the investigators’ request, the Internet facilitating the process. Over a dozen nominations were initially received; however, most did not fulfill criteria for inclusion in the study: verification of effectiveness by at least 300 licensed/certified clinicians who regularly treat PTSD clients; replicable under laboratory conditions at FSU; readily teachable to paraprofessionals; willingness of the principal developers to defend the approach to academic, clinical researchers at FSU; and willingness of the developers and/or principal practitioners to treat clients at FSU for a week under research conditions.
Four to six month follow-up’s revealed that all of the approaches yielded sustained reduction in subjective units of distress (SUD) relative to treated traumatic memories (although some rebound in SUDs was evident in many cases). The average pre-treatment SUD rating on a 10-point scale was between 8 and 9. Noting that the follow-up evaluation time frames and N’s [number of clients] varied considerably across treatment conditions, notably imposing variables, respective Mean Group Treatment Times and Post-Treatment follow-up SUD ratings were as follows: TFT (N14) 63 minutess [average session time], 3.60; V/K D (N11) 113 mins, 3.30; EMDR (N6) 172 minutess, 2.64; TIR (N9) 254 minutess, 5.67. (A variety of psychometric and physiologic measures not discussed in this article were also obtained.) While strict comparisons among the methods would not be valid due to varying client selection criteria across methods as well as other variables, preliminary results nonetheless support the contention of the nominating professionals that the methods are effective in reducing distress associated with traumatic memories.
Exposure has been a primary method for treating trauma, clinical experience and research supporting the position that in vivo and imaginal exposure to relevant stimuli over an extended period of time can result in the extinguishing of negative affective responses. So, too, some degree of ‘exposure’ appears to be an ingredient in the methods reviewed. Each requires the subject to ‘think about’ the trauma, this being necessary toward later desensitization or extinguishing of associated symptoms. While the developers of the methods proffer varying theoretical positions, not always favoring terms such as ‘extinguish’ or ‘desensitization,’ this is understandable and permissible in light of the rapidity of treatment effects and the significant departure of these methods from traditional procedures. In this respect it is evident that exposure alone cannot adequately account for the efficacy of these therapies; otherwise, flooding would prove equally efficient. Additionally the degree of exposure induced with some of the methods is so minimal that ‘attunement’, a term preferred by Callahan (1994), should perhaps be substituted. This term does not indicate intense vivification that is generally implied by ‘exposure’. In instances of exposure as generally understood, it should be borne in mind that the subject willingly maintain an unwavering level of attention to the trauma. This is entirely distinct from traumatic material emerging spontaneously, the subject being the victim of such events. Conscious choice in this manner may frequently serve to create a sense of self-efficacy that further figures into the resolution formula.
Choosing to recall a trauma entails paradoxical elements that have been observed to be curative among a variety of therapeutic systems. Consider Victor Frankl’s paradoxical intention, Milton Erickson’s double binds, and the Zen Master’s koans. As the subject attends to the disturbing memory, perhaps there is a suspension of usual ways of experiencing, thus permanently altering the experience of the trauma. Bear in mind, however, that this may only be a side feature, since it does not appear that paradoxical procedures have generally been as rapidly effective as the methods presented.
PROMISING PTSD TREATMENT APPROACHES A Systematic Clinical Demonstration of Promising PTSD Treatment Approaches:
Joyce L. Carbonell, Charles Figley Florida State University Abstract from TRAUMATOLOGY 5:1, Article 4, 1999
[In the Figley/Carboneele study, practitioners from some of the methods being studied, selected which of the clients assigned to them they would accept, and some were rejected. The TIR practitioners accepted all clients assigned to them.]
Traumatic Incident Reduction, Visual-Kinesthetic Disassociation, Eye Movement Desensitization and Reprocessing, and Thought Field Therapy were investigated through a systematic clinical demonstration (SCD) methodology. This methodology guides the examination, but does not test the effectiveness of clinical approaches. Each approach was demonstrated by nationally recognized practitioners following a similar protocol, though their methods of treatment varied. A total of 39 research participants were treated and results showed that all four approaches had some immediate impact on clients and appear to also have some lasting impact.
Pre-testing: Each participant received the paper and pencil measures focusing on life stressors and stress reactions, demographic and psychosocial profile, and social support and other resources for managing. In addition, physiological recording was attempted but because of various equipment problems, few data were obtained. The measures to be discussed here are described briefly:
Demographic Information Form (used by the Psychosocial Stress Clinical Laboratory for all clients)- this form provided basic information on each participant.
The Traumagram Questionnaire (Figley, 1989)- this form was a description of each client’s individual “trauma history” and was reviewed by therapists before meeting with the clients.
The Brief Symptom Inventory (Derogatis & Spencer, 1982)- All participants received the Brief Symptom Inventory(BSI) before and six months after treatment. The BSI is a 53 item self-report inventory in which clients rated their distress of a five-point scale. Subjects are instructed to indicate how much a given problems has bothered them in the past seven days. It is described as a “measure of point in time, psychological symptoms status.” The BSI is highly sensitive to change and thus is useful as a tool for pre/post evaluation (Derogatis & Spencer, 1982). The BSI produces nine symptom dimensions and three global indices. The three global indices Global Severity Index (GSI) , Positive Symptom Total (PST) , and Positive Symptom Distress Index (PSDI)) were used in this study. These measures have higher test-retest reliability than any of the individual symptom dimensions available. Research has supported the validity of the BSI as a measure of psychological distress.
Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979) – The Impact of Events Scale is composed of two separate subscales, intrusion and avoidance. Participants rate each item on a scale of 0 ( not at all) to 5 (often) depending on how well the item describes the subject. The items contained in each subscale are summed to form a composite score for each subscale. There is no total score, which combines the subscales. The IES is noted to be useful as a screen for the presence of post-traumatic stress disorder, but does not include symptoms of hyper arousal (Briere, 1997).
Subjective Unit of Disturbance (SUD) rating (Wolpe, 1958): Participants were asked to provide a rating, on a ten-point scale, of their subjective unit of distress (SUD) in regard to their presenting problem before treatment began and immediately after treatment. The participants were also asked to keep a diary on a daily basis for the next six months. A notebook was provided for this purpose and the description of the ratings and instructions were on the inside cover of each notebook. A phone number and name of a member of the research team was also included so that the clients would call with any questions. In addition, a research team member called each research participant on a weekly basis to obtain a SUD rating for the week, to answer any questions and to encourage them to keep their diary.
Table 1: Presenting Problems, Untreated Treated, Subjects Subjects Problem N % N % Childhood Abuse 5 41.7 15 38.5 Death/Loss 3 25 9 23.1 Combat/Military 2 16.7 4 10.34 Domestic Violence 1 8.3 3 7.7 Other 1 8.3 3 7.7 Job Related 0 0 3 7.7 Sexual Assault 0 0 2 5.1 Table 2 Pre and Post SUD Ratings by Treatment Group Pre-Treatment Post-Treatment Treatment Group Mean Range Mean Range TIR
6.5 4-9 3.4 3-4 VK/D
4.75 0-9 5.25 1-9 EMDR
5.0 1-8 2.0 0-5 TFT
6.3 1-9 3.0 0-6 Table 3 Pre and Post BSI Scores by Group. Treatment Group Pre-Treatment Mean Post-Treatment Mean GSI TIR
57 48 VK/D
51 43 EMDR
52 43 TFT
44 39 PST TIR
52 49 VK/D
52 46 EMDR
55 42 TFT
41 39 PSDI TIR
57 48 VK/D
49 40 EMDR
54 42 TFT