STAIR

1. Introduction

Version followed: STAIR Narrative Therapy (SNT) as set out in Cloitre, Cohen, Ortigo, Jackson & Koenen (2020), Treating Survivors of Childhood Abuse and Interpersonal Trauma, 2nd ed. (10 STAIR sessions + 8 Narrative Therapy sessions), as taught in the 2024–2025 STAIR-Well implementation trainings (Pacific Lutheran University). Older and alternative versions are named where they differ: the original 8 + 8 "STAIR/MPE" (STAIR plus Modified Prolonged Exposure) of the 2002 and 2010 trials and the 2006 1st edition; STAIR + standard PE (Dutch trial); Group STAIR (12 sessions); Brief STAIR (5 sessions); webSTAIR (10 online modules with 5–6 coaching sessions). [source: Guilford contents and description pages; PLU STAIR-Well Day 1/Day 2 slides 2024–2025; CEBC STAIR/MPE profile; Cloitre et al. 2010]

STAIR (Skills Training in Affective and Interpersonal Regulation), developed by Marylene Cloitre and colleagues (originally at the NYU Child Study Center's Institute for Trauma and Stress), is a structured, cognitive-behavioural skills programme for adults with interpersonal and chronic trauma, especially childhood abuse. It is described by its trainers as neutral about the source of trauma and aimed at PTSD, Complex PTSD, depression, dissociation and the emotion-regulation and relationship problems that impair functioning. It can be delivered alone or as the first module of SNT, in which it is followed by Narrative Therapy: repeated, recorded telling of trauma memories plus a "meaning analysis" of the beliefs about self and others inside each narrative. [source: PLU Day 1 slides Jan 2025; CEBC; Guilford description]

Core idea of change: chronic interpersonal trauma, especially in childhood, leaves people short of two resources, the ability to feel and manage emotions and the ability to connect with others (the book frames this as a "resource loss" model [uncertain on detail]). STAIR rebuilds these resources in the present, using a strong alliance as a working model in which the self is competent and worthy and others are available and responsive. Narrative Therapy then organises trauma memories through repeated telling (habituation and a sense of control) and revises the trauma-derived relationship models, so that the client can accept the past while living in the present ("continuity of self"). Trial data indicated that the Phase 1 alliance and gains in negative-mood regulation predicted how much clients gained from the exposure phase. [source: PLU Day 1 and Day 2 slides; CEBC summary of Cloitre et al. 2002 and 2004]

2. Framework

Overall structure (2nd edition SNT). Module I, STAIR (about 10 weekly sessions), builds resources; Module II, Narrative Therapy (8 sessions; the client handout says 8–10), processes the past. The STAIR sessions are grouped under three "resources": Hope (session 1), Feelings (sessions 2–5) and Connection (sessions 6–10). [source: Guilford contents; PLU handouts 10.1; PLU Day 1 slides]

[source: Guilford contents; PLU Day 1 and Day 2 slides Jan 2025 and Aug 2024; PLU handouts]

Session format. Individual, weekly. Within skills sessions the trainers give a four-step sequence: identify a problem, introduce the skill, practise it in session, client chooses a skill and commits to practise it. Between-session practice is required (daily FMF, worksheets, breathing at least twice daily for about 5 minutes). Session length is not stated in the training slides; in published trials STAIR sessions were 60 minutes and narrative sessions 90 minutes [source: PLU slides; PLU handouts 10.2, 11.3; Oprel et al. 2021; Eur J Psychotraumatol 2024 STAIR+EMDR vs STAIR+NT trial]. The book's exact recommended lengths are not drawn on [uncertain].

Version differences.

• STAIR/MPE (2002, 2010; 1st ed. 2006): 8 weekly STAIR sessions (4 emotion regulation: labelling feelings, emotion management, distress tolerance, accepting feelings and experiencing positive emotion; 4 interpersonal: revising schemas, assertiveness, awareness of social context, flexibility) then 8 exposure sessions based on prolonged exposure, with in vivo exposure replaced by interpersonal skills practice and a meaning analysis after each exposure; narratives ordered by distress rating and importance. [source: Cloitre et al. 2010 AJP; CEBC]
• STAIR + PE (Oprel et al. 2021): 8 × 60-min STAIR sessions then 8 × 90-min standard PE including in vivo exposure. [source: Oprel et al. 2021]
• STAIR + NT vs STAIR + EMDR (Eur J Psychotraumatol 2024): 8 × 60-min STAIR, then 8–12 × 90-min NT. [source: that trial]
• Group STAIR: one facilitator, 5–8 members, 12 sessions in two 6-session cycles (emotion regulation cycle; interpersonal cycle), with the STAIR Coach app as support. [source: PLU Day 2 slides]
• Brief STAIR (5 sessions): (1) introduction, three goals, focused breathing; (2) body tools, feelings awareness, soothing the senses; (3) thought tools: positive imagery, alternative thoughts, emotion surfing; (4) behaviour and communication: pleasurable activities, taking a break, using support (Jan 2025 slides add "I" messages here); (5) relationships and compassion: basic rights, ("I" messages in Aug 2024 slides), compassion, summary. Requires a committed client, matching of skills to the client, and the STAIR Coach app. [source: PLU Day 2 slides Jan 2025 and Aug 2024; the two decks place "I" messages differently]
• webSTAIR: Welcome + 10 online modules taken in order (1–5 emotion management; 6–9 relationship skills; 10 conclusion). Coaching: 5 sessions each covering two modules (training deck) or six 45–60-min biweekly sessions over 10–12 weeks (Day 2 deck); a group-supported format also exists. [source: PLU webSTAIR booster slides; PLU Day 2 slides; the two decks give different coaching counts]

Who it is for and who not (selection). Good match: trauma history; PTSD, depression, dissociation, emotion-regulation or relationship problems; wants structured, skills-focused sessions; willing to practise between sessions. Poor match: uncontrolled bipolar disorder, psychotic symptoms, recent suicidal behaviour or non-suicidal self-injury, wanting unstructured conversation, no interest in between-session work. The trainers position DBT for clients whose focus is suicidality/self-injury (longer, multimodal), and STAIR for functional impairment (single modality, 6–24 weeks, digital option). Trial exclusions (2010): substance dependence not in remission for 3 months, current psychosis, significant cognitive impairment, untreated bipolar disorder, acute suicidality needing hospitalisation or emergency referral in the past 3 months. webSTAIR adds significant borderline personality disorder as an exclusion. [source: PLU Day 2 slides; Cloitre et al. 2010; PLU webSTAIR slides]

Moving between phases.

• Within STAIR: sessions run in order; the client should leave each session with a chosen skill and a practice commitment. [source: PLU Day 1 slides]
• STAIR to Narrative Therapy: the 2nd edition has a dedicated chapter ("How do you know your client is ready?") that is not drawn on [uncertain]. What the sources support: session 10 is framed as the transition either to NT or to independent growth; in trials, Phase 1 alliance strength and improved negative-mood regulation predicted exposure success. [source: PLU handouts Box 19.1; CEBC] Practical readiness checks I suggest [synthesis]: the client can name and rate emotions on the FMF; can bring distress down with at least two practised skills in each channel; has no recent suicidal behaviour, self-injury or substance misuse that would be triggered by exposure; current life is safe enough (no ongoing contact-abuse); the alliance is solid; and the client agrees to the narrative rationale.
• Ending: NT session 8 closes the programme; trials allowed a variable number of NT sessions (8–12) and early completion when symptoms remained low. [source: Eur J Psychotraumatol 2024 trial; Oprel et al. 2021]

3. Guiding principles

[source for all items unless marked: PLU STAIR-Well Day 1 and Day 2 slides, Jan 2025 and Aug 2024]

• Post-trauma behaviours are adaptations. Treat avoidance, people-pleasing, anger or distance as once-useful survival strategies, never as character flaws.
• Build on strengths. Start from what already works for the client and add to it.
• Skills serve aspirational goals. Tie every skill to something the client wants in life, not only to symptom relief.
• Present before past. STAIR works on current life; discussing trauma is optional during skills sessions and the narrative is kept for NT.
• Two resources: emotions and connection. Every session targets either feeling and regulating emotion or relating to others.
• Interpersonal interventions for interpersonal injuries. Relationship patterns are a core treatment target, not a side topic.
• The therapy relationship is a working model. Through the way you relate, let the client experience self as competent and worthy and others as available and responsive.
• Non-pathologising view of patterns. Everyone has relationship patterns; they were learned from real experience, they made sense, and they can be changed; keep those that work, change those that do not.
• Continuity of self. Aim for a client who accepts the past while being willing to live in the present; balance present-focused skills with past-focused processing.
• Practise before you need it. Rehearse skills when calm, the way one trains before a race, so that they are available under stress. [source: PLU webSTAIR slides; PLU handouts 10.2]
• Client choice and commitment. The client selects which tools to use and commits to practise; tools are matched to preferences and strengths. [source: PLU Day 1 slides]
• Collaboration in narrative work. The first memory is chosen together, need not be the worst one, and not every trauma has to be told; themes will emerge. [source: PLU Day 2 slides]
• Emotions as a pathway to patterns. In NT, emotions identified in a narrative are used to reach the relationship beliefs embedded in it. [source: PLU Day 2 slides]
• Bearing witness. In grief and loss narratives the therapist's role is to witness and honour what was lost. [source: PLU Day 2 slides]
• Respect is constant. Respect for self and other does not depend on who holds power. [source: PLU Day 1 slides; PLU handouts 17.3]
• Self-compassion as the end point. Both modules close by helping the client hold painful and positive parts of self together without judgment. [source: PLU Day 2 slides]
• Structure with measurement. Track change with self-report scores (the webSTAIR dashboard and coaching agenda begin with score changes; trainings cite PCL-5, PHQ-9, DERS and IIP-32 outcomes). [source: PLU webSTAIR slides]

4. Intervention inventory

Order follows the 2nd-edition session sequence. Handout numbers refer to the 2nd-edition handouts as posted by STAIR-Well; they are described, not reproduced. All example language is illustrative unless quoted. [source for this section unless marked: PLU STAIR-Well Day 1/Day 2 slides Jan 2025 and Aug 2024; PLU STAIR handouts; PLU webSTAIR slides]

Module I, Resource of Hope (session 1)

4.1 Orientation, motivation and goals

• Purpose: engage the client, give a roadmap, build the alliance. Use in session 1 of every format.
• Steps: (1) Ask about current problems and what brought them now. (2) Explore motivation and what the client hopes will be different. (3) Explain how chronic or early trauma can disrupt emotions and relationships. (4) Walk through the plan: skills module, then narrative module (or skills only). (5) Set goals (Brief STAIR asks for three). (6) Agree on between-session practice. (7) Teach focused breathing (4.2).
• Example language (illustrative): "What happened to you made sense of some ways of coping that may now be costing you. We'll first build skills for feelings and relationships in your life today, and only then, if you choose, look at the memories."
• Watch for: ambivalence about structure or homework (a poor-fit sign per the trainers); hopelessness. Working: the client names concrete goals and agrees to practise.

4.2 Focused breathing

• Purpose: first body-channel skill; a portable way to lower arousal; practised from session 1.
• Steps: (1) Explain that fast, shallow breathing feeds dizziness, racing heart, tension and poor concentration. (2) Client sits comfortably, feet on the floor, one hand on chest and one on stomach. (3) Breathe so the belly rises and the chest stays fairly still; lengthen the out-breath, nasal breathing helps, small pause. (4) Add a calming image (e.g. a wave) and optionally count breaths to ten, pairing each exhale with a calming word. (5) Debrief: normalise difficulty, problem-solve. (6) Homework: at least 5 minutes twice daily, first when calm, later when distressed.
• Example language (illustrative): "Let the breath drop down to your hand on your belly... make the out-breath a little longer than the in-breath."
• Watch for: breath focus increasing panic or triggering trauma reminders [synthesis: offer eyes open, shorter practice, or switch to soothing the senses]. Working: the client reports using it outside session and a drop in 0–10 intensity.

Module I, Resource of Feelings (sessions 2–5)

4.3 Emotional learning history (social influences on emotions)

• Purpose: show how the client learned which emotions were allowed and how to express and cope with them; reduces self-blame for current difficulties.
• Steps: (1) Using a three-column grid (growing up / current relationships / community or society), ask which emotions were permitted or forbidden, how one was expected to cope, and how to express feelings. (2) Note messages that still operate today. (3) Link to the idea that these were learned and can be relearned.
• Example language (illustrative): "In your family, what happened when someone cried or got angry? What did you learn to do with those feelings?"
• Watch for: the exercise opening trauma detail; keep it at the level of rules and messages (trauma discussion is optional in STAIR).

4.4 Emotions as messengers; feelings list, feelings wheel and intensity scale

• Purpose: build emotion vocabulary and the idea that emotions have functions (guide action, communicate needs, show preferences).
• Steps: (1) Review how fear, anger, sadness, guilt, happiness, pride and love each protect or inform. (2) Use a feelings list or wheel to move from vague ("bad") to precise labels. (3) Introduce 0–10 intensity ratings.
• Example language (illustrative): "If your anger were a messenger, what might it be telling you you need right now?"
• Watch for: numbness or alexithymia [synthesis: start with body sensations and use the wheel's broad categories first]. Working: more differentiated labels on the FMF.

4.5 Feelings Monitoring Form (FMF)

• Purpose: the core self-monitoring tool across Module I: builds "online" awareness and tests which skills work.
• Steps: (1) Introduce in session 2; complete one example in session from a recent event. (2) Fields: triggering situation, feeling, intensity at start (0–10), duration, thoughts, behaviour/coping used, intensity after, whether it was effective. (3) Daily homework; review at the start of each session. (4) From session 3, use the coping column to record channel skills tried.
• Example language (illustrative): "Let's take the argument with your sister on Tuesday and fill in the form together: what happened, what you felt and how strongly, what went through your mind, what you did."
• Watch for: blank forms (see Section 5). Working: entries become more frequent and specific; after-strategy ratings drop.

4.6 Three-channel model and tool selection

• Purpose: organise regulation skills into body, thought and behaviour channels so that the client builds a personal toolkit.
• Steps: (1) Define emotion regulation and its benefits (session 3). (2) Present the three channels. (3) Review common trauma-related habits in each channel (e.g. poor sleep or substance use; assuming danger, black-and-white or "what's the use" thinking; isolation, outbursts, caretaking to avoid one's own problems). (4) Teach and try skills. (5) In session 4 the client selects two tools per channel based on preference and strengths. (6) Track use on the FMF.
• Example language (illustrative): "Which two of these body skills fit you best? We'll make those your go-to tools this week."

4.7 Self-care basics plan (body)

• Purpose: restore foundations (sleep, eating, exercise, environment, substances) that make emotions harder to manage when neglected.
• Steps: (1) Checklist of unhealthy and healthy body-channel habits. (2) Pick one concrete self-care commitment. (3) Track it on the FMF.
• Watch for: self-harm or substance use appearing on the unhealthy list [synthesis: assess risk and agree a safety plan]. Do not set weight, calorie or exercise targets.

4.8 Soothing the senses (body)

• Purpose: calm arousal through pleasant sensory input.
• Steps: (1) Choose at least two senses. (2) Write specific, vivid examples the client can actually do or imagine (a scent, a texture, music). (3) Use several senses at once. (4) Try one in session.
• Example language (illustrative): "Name one smell and one sound that calm you, as specifically as you can."

4.9 Progressive muscle relaxation (body)

• Purpose: reduce tension through the contrast of tensing and releasing.
• Steps: (1) Work through about 13 muscle groups from hands to toes. (2) Tense each about 10 seconds, release 10–15 seconds, notice the difference. (3) Practise one full sequence daily.
• Watch for: the handout's cautions: check with a doctor if there are injuries or medical problems, skip painful areas, do not hold breath or clench hard.

4.10 Reminders and reframes about feelings (thought)

• Purpose: counter trauma-based beliefs about emotions.
• Steps: Teach and rehearse reminders: feelings are not facts and need not dictate action; feelings pass; pushing them down makes things harder; approach feelings with curiosity, without judging them. The client picks one to write down.
• Example language (illustrative): "This feeling is strong, and it will pass. I don't have to act on it."

4.11 Evidence technique (checking beliefs) (thought)

• Purpose: loosen trauma-driven assumptions (danger, rejection, criticism).
• Steps: (1) Identify the belief. (2) What's the proof? (3) How strong is it? (4) What else could it be? (5) Let go of the old belief and "try on" an alternative. (6) Test the alternative in a real situation.
• Example language (illustrative): "What tells you she was judging you? How solid is that? What else could her silence mean? Can you try out 'maybe she's distracted' at the next meeting?"
• Watch for: the client experiencing this as being told they are wrong; validate the origin of the belief first.

4.12 Thought shifting (thought)

• Purpose: move attention away from rumination toward something neutral or absorbing.
• Steps: Agree in advance on what to shift to (a task, counting, a conversation); practise shifting deliberately when stuck. [source: named in slides and handout 13.2; detailed steps are not drawn on, so the steps here are [synthesis]]

4.13 Positive imagery (thought)

• Purpose: evoke calm or strength through a chosen image.
• Steps: The client builds a detailed, personally meaningful image (safe, calm or competent) and practises calling it up, alone or with breathing. [source: slides list it; step detail is [synthesis]]
• Watch for: imagery sliding into trauma material; keep images present-focused and client-chosen.

4.14 Positive self-statements (thought)

• Purpose: replace harsh self-talk with supportive statements.
• Steps: Review sample statements, have the client write a personal one, rehearse it aloud, and use it on the FMF.
• Example language (illustrative): "I've got through hard things before; I can take this one step at a time."

4.15 Emotion surfing (thought; also linked to body and behaviour)

• Purpose: tolerate an emotion without suppressing or amplifying it.
• Steps: The client notices the emotion, its body sensations, thoughts, urges and intensity, then watches it rise, crest and fall, like riding a wave, without acting on it (seven steps in handout 13.3).
• Example language (illustrative): "Notice where it sits in your body... give it a number... just watch it rise, and notice when it starts to come down."
• Watch for: intensity that keeps climbing; switch to a body or behaviour skill.

4.16 Time-out / taking a break (behaviour)

• Purpose: prevent escalation when overwhelmed, likely to make things worse, or unable to think clearly.
• Steps: (1) Stop. (2) Tell the other person what you are doing and when you will return. (3) Leave the situation. (4) Do not try to hold on to, intensify or suppress the emotion; notice it fade. (5) Do a calming activity. (6) Return as stated.
• Example language (illustrative, for the client): "I'm getting too heated to talk well. I'm going to take twenty minutes and then I'll come back."

4.17 Opposite action and replacement behaviours (behaviour)

• Purpose: act against the urge of an unhelpful emotion.
• Steps: Identify the emotion and its urge, then choose the opposite: anxiety, approach gradually and repeat; anger, practise empathy, do something kind, or disengage; sadness, get active with pleasant or competence-building tasks; guilt or shame, check whether it fits the facts, then repair or use self-compassion and commit to change; overwhelm, slow down, list, take small steps; hopelessness, act anyway in a small way.
• Watch for: opposite action used to push into real danger; it applies to unjustified fear.

4.18 Pleasurable and mastery activities (behaviour)

• Purpose: restore positive emotion and agency, moving from "being done to" to "being a doer".
• Steps: Use an activity checklist; schedule specific activities; record their effect on mood on the FMF.

4.19 Seeking support / asking for help (behaviour)

• Purpose: use other people as a regulation resource.
• Steps: Identify who could help with what; plan the exact request; rehearse it (links to assertiveness in session 7).

4.20 Distress tolerance in the service of goals (session 5)

• Purpose: tolerate discomfort without harming self or others when this serves a valued goal (e.g. finishing treatment, a work review, a hard conversation).
• Steps: (1) Define distress tolerance and its benefits. (2) Review past times the client tolerated distress successfully. (3) Choose a relevant goal (webSTAIR uses SMART goals). (4) List the pros of tolerating distress first, to build motivation, then the cons. (5) Rate expected distress and pick matched skills from all three channels. (6) Commit to a step.
• Example language (illustrative): "What would getting through this be worth to you? Let's write the reasons for doing it before the reasons against."
• Watch for: distress tolerance being used to stay in harmful situations [synthesis]; tolerance serves goals, not endurance of abuse.

Module I, Resource of Connection (sessions 6–10)

4.21 Relationship patterns psychoeducation (relationship models)

• Purpose: introduce the idea that early or significant relationships taught "instruction manuals" for relating that kept the client safe (staying connected meant staying safe) but may now be outdated or self-fulfilling.
• Steps: (1) Explain how models form in childhood, how trauma shapes them, how they turn into repeated patterns, and that they can change. (2) Give a self-fulfilling example (trainers use "Shelby", who keeps people at a distance and then takes her isolation as proof no one will love her, contrasted with "Maria", whose expectation of being liked brings warmth). (3) Client ticks common survivor beliefs in four areas: safety, trust/intimacy, power/control, self-esteem/needs.
• Example language (illustrative): "This pattern protected you back then. The question now is whether it still gets you what you need."
• Watch for: shame at "having patterns"; stress that everyone has them.

4.22 Relationship Patterns Worksheet 1 (RPW-1)

• Purpose: map one recent difficult interaction to reveal the underlying model.
• Steps: (1) Pick an uncomfortable interaction. (2) Record what happened. (3) Client's feelings and thoughts. (4) What the client expected the other person felt and thought. (5) What the client did. (6) Summarise the model as an "If..., then..." or "When..., then..." statement. (7) Check expectations against evidence, looking for mind-reading.
• Example language (illustrative): "So the rule seems to be: if I ask for something, then I'll be rejected. Does that rule show up elsewhere?"
• Watch for: working: the client starts spotting the same model across different relationships and between sessions.

4.23 Assertiveness styles and basic personal rights (session 7)

• Purpose: distinguish non-assertive, aggressive and assertive behaviour and give permission to assert.
• Steps: (1) Define the three styles and their usual emotional results, with pros and cons of each. (2) Review a list of basic rights (e.g. to ask, to say no, to make mistakes, to express feelings, to be treated with dignity, to say "I don't know", to negotiate change). (3) Ask which rights feel hardest to claim and why. (4) webSTAIR adds attention to non-verbal communication.
• Example language (illustrative): "Which of these rights did you never feel you had? What would it be like to act as if you had it?"

4.24 "I" messages

• Purpose: state a concern clearly and respectfully without blame or shame.
• Steps: (1) Three parts: the behaviour or situation, the feeling, the consequence or reason ("When..., I feel..., because..."). (2) Draft one for a real situation. (3) Role-play it (4.27). (4) Define success as saying it clearly and respectfully, not as getting agreement.
• Example language (illustrative, for the client): "When you snap at me about the keys, I feel hurt, because I'm trying to help."

4.25 Relationship Patterns Worksheet 2 (RPW-2)

• Purpose: generate a new model and new actions; used in sessions 7, 8 and 9 and in NT meaning analysis.
• Steps: (1) Complete the RPW-1 fields (old model). (2) Set an interpersonal goal for the situation. (3) Generate alternative beliefs and feelings about self. (4) Generate alternative beliefs about the other. (5) Plan alternative actions. (6) Write the new model. (7) Try it out and adjust. Handout 16.6 adds imagining a supportive response and practising in low-stakes situations first (e.g. asking a pharmacist a question).
• Example language (illustrative): "What do you want from this conversation? What would you need to believe about yourself to ask for it?"

4.26 Additional assertiveness skills: requests, saying no, broken record

• Purpose: concrete scripts for frequent situations.
• Steps: Requests: be specific, use "I", delay if the other person is aggressive. Saying no: adjust the style to whether the relationship should be kept. Broken record: calmly repeat the core message without being drawn into argument. [source: PLU handouts 16.5]

4.27 Role-play

• Purpose: rehearse new interaction styles with immediate feedback; used in sessions 7–9.
• Steps: (1) Client plays self, therapist plays the other person. (2) Swap: client plays the other, therapist models the client's new response. (3) Client plays self again. (4) Give specific feedback, model phrasing, rehearse until fluent.
• Example language (illustrative): "Let's try it. I'll be your manager. Go ahead whenever you're ready... Now swap, and you'll hear how it sounds from the other side."
• Watch for: freezing or shame [synthesis: lower the stakes, start with a less loaded person, rehearse a single sentence].

4.28 Power balances analysis (session 8)

• Purpose: identify how trauma distorts behaviour in equal, lower-power and higher-power relationships.
• Steps: (1) Client lists people in each category. (2) Review typical trauma effects: with peers, suspicion and vigilance; with lower power, over-eagerness, difficulty saying no, or accusing others of exploitation; with higher power, discomfort, avoiding authority, or acting abusively. (3) Identify trauma beliefs such as "having power means being abusive" or "having low power means having no worth". (4) Introduce the alternative belief that respect stays constant regardless of power. (5) Complete RPW-2 for a power situation.
• Example language (illustrative): "When you became team lead, what did you fear you'd turn into?"

4.29 Respect bookends

• Purpose: make requests or criticism to anyone, including those with more or less power, while keeping respect.
• Steps: (1) Open by acknowledging the other's view or strengths. (2) State the request or point clearly. (3) Close by restating the other's strengths or view. (4) Practise aloud; therapist repeats it back; client imagines being the receiver; rehearse and adjust.
• Example language (illustrative, for the client): "I know you work hard to keep this team going. I need the schedule a week ahead. I really value how you handle the busy weeks."

4.30 Self-respect work

• Purpose: address overly defensive or self-critical patterns; reframe the trauma journey as a source of strength and compassion.
• Steps: Identify self-critical or defensive reactions in power situations; generate alternatives on RPW-2; invite the client to name strengths gained through survival. [source: PLU Day 1 slides; step detail [synthesis]]

4.31 Boundaries: too distant, too close, balanced (session 9)

• Purpose: locate the client's typical closeness pattern.
• Steps: (1) Describe distant boundaries (pros: protection, little conflict; cons: loneliness, not always safer), too close or co-dependent (pros: connection, feeling in sync; cons: loss of own identity, priorities, needs and self-reliance) and balanced boundaries (connected, supported despite differences, safe). (2) Identify drivers of distance: fear of being overwhelmed or bullied, shame about being defective, distrust, belief that people are not worth it. (3) Identify distancing behaviours (not calling or texting, not showing up, outbursts or insults).
• Example language (illustrative): "Where does your relationship with your brother sit, too far, too close, or about right?"

4.32 Increasing closeness skills

• Purpose: build connection at a pace that fits the client.
• Steps: Choose from guideline areas: increasing social engagement, starting new relationships (webSTAIR includes small-talk practice), increasing intimacy and reducing distance (e.g. expressing a feeling), repairing relationships. Complete RPW-2 and role-play the chosen step. [source: PLU handouts 18.3 (titles of areas only); webSTAIR slides]

4.33 Repairing after conflict

• Purpose: restore a relationship after a rupture.
• Steps (trainers' sequence): (1) Ask if the person is willing to talk. (2) Acknowledge the last contact went badly. (3) Convey respect and caring. (4) Acknowledge your own part. (5) Share feelings respectfully. (6) Ask how they felt. (7) Ask for clarification. (8) Discuss amends both ways. (9) Plan how to avoid a repeat.
• Example language (illustrative, for the client): "Would you be willing to talk about Saturday? I know it didn't go well and I'd like to understand how it was for you."
• Watch for: repair attempts with an unsafe or abusive person [synthesis: assess safety first; repair is for relationships worth keeping].

4.34 Summary of achievements and skill commitments (session 10)

• Purpose: consolidate gains and plan the next step (NT or independent practice).
• Steps: (1) Review how emotions were handled before STAIR and now. (2) Same for relationships. (3) Client commits to specific skills in each channel. (4) webSTAIR adds a final self-assessment compared with baseline and a support and self-care plan. (5) Decide on NT or ending.
• Example language (illustrative): "When you think back to our first session, what's different in how you handle anger now?"

4.35 Self-compassion exercise (session 10; repeated in NT session 8)

• Purpose: help the client hold positive and painful parts of self together without judgment.
• Steps: Guide the client to (1) picture all parts of self, positive (joy, loving memories, strengths) and painful (distressing feelings, fears, negative beliefs, painful experiences); (2) notice how these parts have struggled against each other; (3) let them coexist rather than fight; (4) hold all of them with compassion, as a whole person with strengths and weaknesses who deserves love and respect; (5) notice how this feels. Debrief.
• Example language (illustrative): "Instead of pushing the painful parts away, see if you can let them sit next to the parts you like... and look at the whole of you kindly."
• Watch for: strong grief or shame; some clients find compassion aversive at first [synthesis: shorten, keep eyes open, process the reaction]. In webSTAIR coaching the client's reaction to compassion is explicitly discussed.

4.36 webSTAIR coaching session agenda

• Purpose: support accountability and motivation for clients doing the online modules.
• Steps (sessions 1–4): (1) Review changes in scores. (2) Ask which exercises were useful. (3) Ask which were problematic or hard. (4) Practise one key skill from the modules (e.g. FMF, distress-tolerance worksheet, RPW). (5) Preview the coming work. (6) Assign the next modules, tailored to the client. (7) Schedule the next session. Session 5: review scores and changes in emotion regulation and relationships, discuss compassion, congratulate. Coaching is future- and present-focused and asks "how" rather than "why". [source: PLU webSTAIR slides]

Module II, Narrative Therapy (NT sessions 1–8; book sessions 11–18)

Safety and consent for all NT work: NT is an exposure method. Begin only with an informed client who has completed STAIR (or equivalent skills), with the exclusions in Section 2 checked, and with the client's explicit agreement to the rationale. Memories are treated as the client's experience, to be organised and understood, not as facts to be uncovered or verified; never use suggestion, imagery or hypnosis to "recover" memories. [source: PLU Day 2 slides; Cloitre et al. 2010 exclusions; framing of memories per brief and [synthesis]]

4.37 NT rationale and planning (NT session 1)

• Purpose: explain why telling the story helps and set up the practical plan.
• Steps: (1) Rationale: repeated telling organises the memory, allows habituation and a sense of control; the life narrative builds distance, safety, context and meaning, and hope; meaning analysis integrates the memory into the life story and revises beliefs about self and others. (2) Build the memory hierarchy (4.38). (3) Make the listening plan: when and where the client will listen to recordings, the top three skills to use, no alcohol or drugs for two hours before or after listening, test the recording technology. (4) Express optimism.
• Example language (illustrative): "Telling it here, with me, over and over, usually makes the memory less overwhelming and more like a story from the past."

4.38 Memory hierarchy

• Purpose: inventory and rank memories without yet telling them.
• Steps: (1) Client names each discrete traumatic memory in one sentence or a few words, without detail. (2) Rate each on SUDS (0–100 or as used). (3) Rank-order on a memory hierarchy sheet. Narratives can include childhood and adult events, ordered by distress and importance to the client.
• Watch for: the client starting to describe events; gently stop and keep to a title. [source: PLU Day 2 slides; Cloitre et al. 2010]

4.39 Choosing the first memory and optional practice narrative (NT session 2)

• Purpose: start at a manageable point.
• Steps: (1) Choose collaboratively using SUDS, how much the memory intrudes on daily life, the setting, the session time available and current life events; it need not be the worst. (2) Optionally first tell a neutral memory to practise a story with a beginning, middle and end and build confidence. (3) Remind the client that not every trauma needs to be told.

4.40 Narrative exposure (repeated, recorded telling)

• Purpose: the core exposure procedure.
• Steps: (1) Ask the client to recall the memory as vividly as possible, as if it were happening now, in touch with feelings, including sensations, thoughts and emotions. (2) First telling: do not interrupt. (3) Later tellings: audio-record and ask brief questions to bring out detail and guide the client through the hardest points. (4) Repeat one to two times in the session, either straight away or after debriefing and meaning analysis. (5) Take SUDS ratings during and after. (6) Give the recording for between-session listening according to the plan in 4.37.
• Published dosing: NT sessions in trials were 90 minutes; 8 sessions in the book, 8–12 in a 2024 trial; one to two repetitions of the narrative per session in the STAIR-Well training. The book's timing of each telling is not drawn on [uncertain]. Listening frequency between sessions is not stated in the sources [uncertain]; standard PE, from which NT derives, used daily listening (Oprel et al. 2021 PE arm).
• Example language (illustrative): "Close your eyes if that's comfortable and tell me what happened, in the present tense, as if it's happening now. Include what you see, feel and think." ... "Stay with it. What happens next?"
• Watch for: under-engagement (flat, summarised telling; prompt for feelings and sensations), over-engagement (flooding or dissociation; see 4.41 and Section 5). Working: SUDS falls across repetitions and sessions; the telling becomes more coherent.

4.41 Emotional grounding and SUDS check-ins

• Purpose: bring the client back to the present after each telling and before leaving.
• Steps: (1) Check emotional stability. (2) Orient to the present: the trainers' example begins "Look around the room. Breathe." and then names the year and the place (therapist's office). (3) Use STAIR skills as needed (breathing, senses). (4) Check SUDS several times and let it come down before moving on and before the client leaves.
• Example language (illustrative): "Open your eyes. Feel your feet on the floor. Tell me three things you can see in this room. What number are you at now?"

4.42 Emotion identification after the narrative

• Purpose: name and accept the emotions in the memory and use them as a route to the relationship patterns.
• Steps: Ask the client to rate anger, sadness, fear and shame (0–10 scales). Explore which was strongest and what it says about the client's needs and beliefs.
• Example language (illustrative): "Of anger, sadness, fear and shame, which was loudest just now, and what was it about?"

4.43 Meaning analysis

• Purpose: identify the beliefs about self and others formed in the trauma and contrast them with present life.
• Steps: (1) Identify the interpersonal beliefs and patterns in the narrative (self and other). (2) Contrast them with present-day beliefs and relationships. (3) Use a pattern worksheet: situation, feelings and beliefs about self, about the other, resulting action, goals, alternatives. (4) Reinforce new patterns and plan "corrective emotional experiences" in daily life, which in the STAIR/MPE version replaced in vivo exposure (interpersonal skills practice). Schemas to look for include rejection, betrayal, shame, failure and loss.
• Example language (illustrative): "Back then, the lesson was 'if I speak up, I get hurt'. Who in your life now responds differently when you speak up? What could you try this week?" [source: PLU Day 2 slides; CEBC; Cloitre et al. 2010]

4.44 Thematic narratives: fear, anger, shame, grief and loss (NT sessions 3–7)

• Purpose: work through the main emotional themes in further narratives.
• Steps: Continue narrative + grounding + emotion rating + meaning analysis each session, organising by theme. Fear: standard narrative work. Anger: validate the right to be angry; review its pros (keeps others at a safe distance, avoids softer emotions) and cons (reduces intimacy, exhausting, alienating). Shame: explain why telling helps: it reduces alienation, loosens the bond to the perpetrator, builds self-compassion, lowers defensiveness, improves relationships. Grief and loss: the therapist bears witness; the narrative honours the past and what was lost; trainers use the kintsugi image of strength in visible repair.
• Example language (illustrative): "Your anger makes sense; it was protecting you. Let's look at what it costs you now, too." / "I'm here with you while you remember what you lost."
• Watch for: shame shutting down the telling; slow down, validate, and use self-compassion.

4.45 Final session (NT session 8)

• Purpose: consolidate and end.
• Steps: Review how the client sees self now versus before STAIR; refresh skill commitments; practise the compassion exercise together (4.35); plan for setbacks [synthesis].

4.46 Interpersonal skills practice in place of in vivo exposure

• Purpose: in the STAIR/MPE version, between-session real-life practice of new relationship patterns replaced in vivo exposure to trauma cues.
• Steps: Agree a concrete interpersonal experiment that follows from the meaning analysis (e.g. asking a trusted person for help), carry it out, review it next session. [source: Cloitre et al. 2010; CEBC; experiment format [synthesis]]

5. Handling problems

The sources say little about handling difficulties (the book's "Guidelines for Implementing Treatment" chapter is not drawn on [uncertain]). Items are tagged by source; most responses are [synthesis] built on STAIR's own tools.

Early dropout. In a 2024 trial most dropouts happened during the STAIR phase, mostly in the first five sessions; the authors suggested a treatment-feasibility interview before starting. Trainers note that commitment and attendance appear to drive group outcomes. [source: Eur J Psychotraumatol 2024 trial; PLU Day 2 slides] Response [synthesis]: before session 1, check that the client wants structured, skills-focused work and between-session practice (the trainers' match criteria); link each session to the client's own goals; after a missed session, contact the client promptly and use the distress-tolerance pros-and-cons format (4.20) about staying in treatment.

Homework (FMF, worksheets) not done. webSTAIR coaches check completion of FMF entries and worksheets at every session; the trainers list willingness to practise between sessions as a selection criterion; digital uptake is typically very low without coaching. [source: PLU webSTAIR slides; PLU Day 2 slides] Response [synthesis]: complete the form together in session from a recent event; shrink the task (one FMF entry a day, or only for one target emotion); explore the meaning of the task (being graded, fear of writing down feelings, literacy) using the RPW-1 format; use the STAIR Coach app or phone notes if paper fails; praise any partial attempt.

Client wants to tell the trauma story during STAIR. Trauma discussion is optional in STAIR; NT is where narratives are processed. [source: PLU Day 1 slides] Response [synthesis]: listen and validate briefly, then link the material to the session's skill (e.g. "Which feeling showed up as you said that? Let's put it on the FMF") and explain that the full story has a planned place in NT, with skills in place first. If the client has no wish for NT, respect that.

Overwhelm or flooding in session. STAIR tools: time-out, focused breathing, soothing the senses, emotion surfing; in NT, grounding and repeated SUDS checks until distress falls. [source: PLU slides and handouts] Response [synthesis]: stop the telling, orient to the present, use a practised body skill, and do not end the session until the client is regulated; next time use a less distressing memory or shorter tellings with the eyes open.

Dissociation during narrative. Not specifically addressed in the sources [uncertain]; trainers list dissociation as a target of STAIR and "dissociating or blanking out" as a trauma-related thinking pattern (handout 13.1). Response [synthesis]: signs include a fixed stare, slowed speech, numbness, losing track of time. Pause the narrative; use the grounding sequence (eyes open, name objects, feet on floor, date and place, a strong sensory cue); ask the client to rate how present they are; resume only when re-oriented, with eyes open and briefer segments; if dissociation is frequent, return to STAIR skills before continuing and consider specialist assessment for a dissociative disorder.

Under-engagement or avoidance in the narrative (summarising, skipping the worst part, refusing recordings). Trainers advise prompting questions on later tellings to bring out detail and guide through hard points. [source: PLU Day 2 slides] Response [synthesis]: review the rationale; ask what the client fears will happen; return to the hierarchy and pick a memory with lower SUDS; use the distress-tolerance pros and cons for the narrative goal.

Distress after listening to recordings at home. The listening plan specifies place, time, three chosen skills, no substances for two hours either side, and tested technology. [source: PLU Day 2 slides] Response [synthesis]: review where and when the client listened; schedule listening earlier in the day with a planned soothing activity afterwards; reduce listening frequency temporarily; make sure the client has a support person and crisis numbers.

Suicidal thoughts or self-harm emerging. Recent suicidal behaviour or self-injury is a poor-fit criterion; trial exclusions included acute suicidality in the past three months; one serious adverse event (a suicide attempt) occurred in the STAIR+PE arm of the Dutch trial. Trainers point clients with a primary suicidality/self-injury focus towards DBT. [source: PLU Day 2 slides; Cloitre et al. 2010; Oprel et al. 2021] Response [synthesis]: assess risk using your service's standard protocol at any sign of risk; agree a written safety plan including lethal-means counselling (safe storage or removal); pause NT until risk is stable; consider stepping up to DBT or a higher level of care.

Substance use. Substance dependence not in remission for three months was an exclusion; no substances two hours around listening. [source: Cloitre et al. 2010; PLU Day 2 slides] Response [synthesis]: treat substance use as a body-channel coping habit on the FMF; agree sobriety around sessions; integrate or sequence substance-use treatment before NT.

Ongoing abuse or unsafe relationships. Not addressed in the sources. Response [synthesis]: assess current safety before assertiveness, repair or closeness homework; never coach confrontation or repair with someone who is currently abusive; safety planning and relevant reporting duties (child or vulnerable-adult protection) take priority; defer NT until the client is safe.

Alliance ruptures. The alliance is central: early alliance predicted PTSD improvement, mediated by better mood regulation. [source: CEBC summary of Cloitre et al. 2004] Response [synthesis]: treat ruptures as live examples of relationship patterns; name the moment, take your share (mirroring the repair steps in 4.33), and use RPW-1 together on the interaction ("When you looked at the clock, you expected I was bored with you..."); notice power dynamics in therapy (session 8's framework applies to therapist-client power too).

Distrust of the therapist or of others' motives. Trust/intimacy and power/control beliefs are expected (handout 15.2). Response [synthesis]: use the evidence technique on predictions about you; be predictable, transparent about the plan, and ask for feedback each session.

Reluctance to role-play. Response [synthesis]: start with the therapist modelling (step 2 of the role-play sequence), rehearse a single sentence, pick a low-stakes target first (as handout 16.6 suggests), or do it seated and talking "as if" rather than acting.

Distress tolerance or opposite action misused (to endure harm or push into real danger). Response [synthesis]: check that the fear or distress is out of proportion to present danger before prescribing approach; tolerance serves valued goals, not staying in abuse.

Little change after STAIR. In the 2024 trial most symptom change came in the trauma-focused phase, and STAIR alone produced only moderate PTSD and depression change. [source: Eur J Psychotraumatol 2024 trial] Response [synthesis]: if the client meets readiness criteria, move to NT rather than extending STAIR indefinitely; if not ready, identify the specific blocking problem (risk, substance use, dissociation) and target it.

Rapid improvement. One trial allowed early completion once PTSD scores stayed low for three consecutive weeks. [source: Oprel et al. 2021] Response [synthesis]: agree with the client whether to shorten NT; keep the final session (4.45).

Group-specific problems. Peers can name each other's avoidance, and attendance seems to matter. [source: PLU Day 2 slides] Response [synthesis]: set group norms that trauma details are not shared in group (unless running a narrative group with that structure); have a plan for members who become overwhelmed (a co-facilitator or a quiet space and grounding); follow up absences individually.

webSTAIR low engagement. Most users of digital programmes log in only once; coaching and gamification are the trainers' answers; select clients with good rapport who can commit. [source: PLU webSTAIR slides] Response [synthesis]: schedule the first coaching session within a week of enrolment; send reminder messages; switch to in-person or Brief STAIR if modules stall.

Therapist strain. Trainers include therapist self-care (compassion practice, two tools per channel, one professional boundary). [source: PLU Day 2 slides] Use consultation; STAIR-Well training uses biweekly consultation and credentialing after two completed cases.

Sources

Sources:

• Treating Survivors of Childhood Abuse and Interpersonal Trauma (2nd ed.): contents, Guilford Press
• Treating Survivors of Childhood Abuse and Interpersonal Trauma: book page and "new to this edition", Guilford Press
• January 2025 UCC STAIR training, Day 1 slides (PLU STAIR-Well)
• January 2025 UCC STAIR training, Day 2 slides (PLU STAIR-Well)
• August 2024 UCC STAIR training, Day 1 slides (PLU STAIR-Well)
• August 2024 UCC STAIR training, Day 2 slides (PLU STAIR-Well)
• STAIR handouts (PLU STAIR-Well), sessions 1–10
• webSTAIR booster workshop slides, Jan 2025 (PLU STAIR-Well)
• STAIR/MPE programme profile, California Evidence-Based Clearinghouse
• Cloitre et al. (2010), Treatment for PTSD related to childhood abuse: a randomized controlled trial, Am J Psychiatry
• Oprel, Hoeboer et al. (2021), PE, intensified PE and STAIR+PE for childhood-abuse-related PTSD, Eur J Psychotraumatol (Leiden repository)
• RCT of STAIR followed by EMDR vs STAIR followed by Narrative Therapy, Eur J Psychotraumatol 2024 (authors not visible in the text)
• Improving treatments for complex PTSD and survivors of child abuse (blog; secondary, little procedural content)

Books and papers cited (not drawn on in full):

• Cloitre, M., Cohen, L. R., Ortigo, K. M., Jackson, C., & Koenen, K. C. (2020). Treating Survivors of Childhood Abuse and Interpersonal Trauma: STAIR Narrative Therapy (2nd ed.). Guilford Press.
• Cloitre, M., Cohen, L. R., & Koenen, K. C. (2006). Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life. Guilford Press (1st ed.).
• Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology (known via CEBC summary).
• Cloitre, M., et al. (2004). Therapeutic alliance, negative mood regulation and treatment outcome in child abuse-related PTSD (known via CEBC summary).
• Levitt, J. T., & Cloitre, M. (2006). A clinician's guide to STAIR/MPE (cited by CEBC).

Not covered [uncertain]: the book's chapters on readiness for NT and implementation guidelines; exact session lengths in the 2nd edition; listening frequency for NT recordings; NT-specific procedures for dissociation and crisis.