Integrative · 2002
Skills Training in Affective and Interpersonal Regulation (STAIR / ESTAIR)
Recovery from complex trauma advances when the person rebuilds the emotional, relational and autobiographical resources that stop the past from continuing to govern the present.
Skills Training in Affective and Interpersonal Regulation, known as STAIR, is a treatment developed by Marylene Cloitre for people with PTSD linked to childhood abuse and other forms of chronic interpersonal trauma who present, alongside traumatic symptoms, persistent disturbances in affect regulation, relationships, self-concept and everyday functioning. The original 2002 protocol organised the intervention into two phases: eight weekly sessions of training in affective and interpersonal regulation, followed by modified prolonged imaginal exposure to the traumatic memories. The later evolution, called STAIR Narrative Therapy, retained the training of resources for the present and extended the second module into a narrative therapy that processes fear, shame, betrayal, loss and grief, integrating traumatic memories into a coherent life story. In 2023, ESTAIR, Enhanced Skills Training in Affective and Interpersonal Regulation, reformulated the treatment as a person-centred modular architecture for ICD-11 complex PTSD, with four equivalent modules of emotional regulation, relational patterns, self-concept and narrative reprocessing, selected and sequenced according to the clinical formulation, safety, the phase of recovery and each person's preferences.
Theory of change
Change occurs when the person recovers the resources to regulate themselves, to relate and to treat themselves with respect, and can integrate the traumatic memories into a story that no longer organises the present as a threat.
Core ideas
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Interpersonal trauma can interrupt the development of resources for living
STAIR Narrative Therapy formulates chronic trauma as an experience that can damage or prevent the development of the emotional, social and identity resources needed to live with safety and agency. Recovery requires processing what happened and also rehabilitating capacities that were denied, interrupted or eroded during the adaptation to traumatic contexts. (Cloitre et al., 2020).
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Affective dysregulation and relational difficulties are clinical targets in their own right
The model arose because many people with PTSD related to childhood abuse presented disturbances of affective and interpersonal regulation that were as frequent and as disabling as the classic traumatic symptoms. STAIR addresses these difficulties directly instead of expecting them to disappear automatically once intrusions or avoidance are reduced. (Cloitre et al., 2002; Cloitre et al., 2010).
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Original STAIR is a skills phase, not the whole treatment
In the founding formulation, STAIR is the first component of a sequential architecture: eight sessions of training in affective and interpersonal regulation precede a phase of modified prolonged imaginal exposure. The later evolution extended the second component into Narrative Therapy, but retained the distinction between generating resources for the present and processing traumatic memories. (Cloitre et al., 2002; Cloitre et al., 2020).
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The skills-before-traumatic-memory sequence has a specific clinical function
The initial phase makes it possible to develop affect regulation, to practise resources in daily life and to establish a sufficiently safe alliance before asking for a sustained approach to traumatic memories. In the 2002 study, improvement in mood regulation and the strength of the alliance during STAIR predicted a better subsequent reduction of PTSD during the exposure. (Cloitre et al., 2002).
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Traumatic relationship patterns are learned adaptations, not personal defects
The model understands that expectations of abandonment, control, danger or exploitation may have formed in relationships where closeness coexisted with harm, neglect or unpredictability. These expectations can be maintained in current relationships through responses of submission, withdrawal, control or mistrust, and are transformed through the analysis of patterns, corrective experiences and a widening of the interpersonal repertoire. (Cloitre et al., 2020).
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Narrative Therapy goes beyond exposure to fear memories
The narrative module uses imaginal exposure to work with fear memories, but adds strategies of autobiographical contextualisation and the processing of shame, betrayal, loss and grief. Its purpose includes reducing PTSD symptoms and restoring a continuity of self in which the person can recognise the trauma as part of their history without being exhaustively defined by it. (Cloitre et al., 2020).
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Post-narrative stabilisation is part of the processing
The modification of prolonged exposure in STAIR includes an active check of stabilisation and orientation to the present, together with the identification of fear, anxiety, sadness, dissociation and relational schemas activated during the narration. This phase prevents regulation from being treated as a peripheral addition and integrates it within the work on traumatic memory. (Cloitre et al., 2002).
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Recovery combines reducing threat and increasing agency
The treatment is not limited to decreasing intrusions, fear or avoidance. Practising skills, revising relationships, building boundaries, recognising strengths and integrating autobiography allow the person to move from reacting to the trauma towards making decisions more coherent with current needs, values and projects. (Cloitre et al., 2020).
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ESTAIR reorganises the model for complex PTSD without abandoning its principles
ESTAIR preserves the clinical principles of STAIR Narrative Therapy and organises the treatment into emotional regulation, relational patterns, self-concept and narrative reprocessing. The extension responds to the ICD-11 profile of complex PTSD and makes it possible to choose objectives according to priority symptoms, available resources, phase of recovery and the person's preferences. (Karatzias et al., 2023).
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Modular flexibility requires rigorous formulation and monitoring
ESTAIR does not propose an arbitrary sequence of modules, but a collaborative selection based on safety, risk of destabilisation, predominant symptoms, functioning, response to previous interventions and preferences. Its authors note that the comparative efficacy of different sequences and of ESTAIR against other treatments for complex PTSD still requires specific research. (Karatzias et al., 2023).
Influences
- Cognitive behavioural therapy
- Dialectical behaviour therapy
- Prolonged exposure
- Attachment theory
- The interpersonal and object relations tradition
- The conservation and recovery of resources model
- Complex trauma formulation
- ICD-11 complex PTSD
Key references
- 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, 70(5), 1067–1074. [https://doi.org/10.1037/0022-006X.70.5.1067](https://doi.org/10.1037/0022-006X.70.5.1067).
- Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L., Gan, W., & Petkova, E. (2010). Treatment for PTSD Related to Childhood Abuse: A Randomized Controlled Trial. American Journal of Psychiatry, 167(8), 915–924.
- 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.
- Karatzias, T., Mc Glanaghy, E., & Cloitre, M. (2023). Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR): A New Modular Treatment for ICD-11 Complex Posttraumatic Stress Disorder (CPTSD). Brain Sciences, 13(9), 1300. [https://doi.org/10.3390/brainsci13091300](https://doi.org/10.3390/brainsci13091300).
- Foa, E. B., & Rothbaum, B. O. (1998). Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. Guilford Press.