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\begin{document}

\title{STAIR Narrative Therapy for Complex Posttraumatic Stress Disorder:
Treating Sexual and Gender Minority Trauma}



\author[1]{Marylene Cloitre}%
\affil[1]{VA Palo Alto Health Care System}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\selectlanguage{english}
\begin{abstract}
Complex PTSD (CPTSD) is a new diagnosis in the World Health Organization
(WHO)'s International Classification of Diseases (ICD-11). This case
study describes the delivery of Skills Training in Affective and
Interpersonal Regulation and Narrative Therapy (SNT), a flexible,
multi-component therapy that addresses the symptoms of CPTSD. SNT
balances interventions that address current day stressors with those
that reappraise the meaning of traumatic past events. This paper
outlines 16 sessions of SNT with a 55-year-old gay man. The treatment
introduces client tailored coping skills for current minority stress,
discrimination and micro-aggressions as well as trauma-focused
interventions regarding events from his childhood and the death of his
partner and many members of his community due to the AIDS epidemic.
Qualitative and quantitative outcomes are summarized. Implications
regarding the relevance of SNT for sexual and gender minority (SGM)
individuals is discussed.%
\end{abstract}%



\sloppy


ABSTRACT

Complex PTSD (CPTSD) is a new diagnosis in the World Health Organization
(WHO)'s International Classification of Diseases (ICD-11). This case
study describes the delivery of Skills Training in Affective and
Interpersonal Regulation and Narrative Therapy (SNT), a flexible,
multi-component therapy that addresses the symptoms of CPTSD. SNT
balances interventions that address current day stressors with those
that reappraise the meaning of traumatic past events. This paper
outlines 16 sessions of SNT with a 55-year-old gay man. The treatment
introduces client tailored coping skills for current minority stress,
discrimination and micro-aggressions as well as trauma-focused
interventions regarding events from his childhood and the death of his
partner and many members of his community due to the AIDS epidemic.
Qualitative and quantitative outcomes are summarized. Implications
regarding the relevance of SNT for sexual and gender minority (SGM)
individuals is discussed.

KEY WORDS: Complex PTSD, Sexual and Gender Minorities (SGM), STAIR
Narrative Therapy, PTSD, Minority Stress

\textbf{1. INTRODUCTION}

\textbf{1.1 Complex PTSD}

Complex posttraumatic stress disorder (CPTSD) is a new diagnosis in the
11th revision of the International Classification of Diseases (ICD-11).
CPTSD is a sibling to posttraumatic stress disorder (PTSD) under the
general parent category of ``disorders specifically associated with
stress'' (Maercker et al., 2013). The diagnosis of Complex PTSD was
introduced to address the kinds of problems that clinicians reported
observing related predominately to multiple and chronic forms of trauma
exposure as distinct from those related to single event trauma (Keeley
et al. 2016). However, research has shown that individuals can develop
PTSD rather than CPTSD after multiple and chronic traumas and,
conversely, that individuals with single event traumas can develop CPTSD
(Cloitre et al., 2013), likely depending on vulnerability and protective
factors. For these reasons, the presence of chronic or repeated traumas
is considered a risk factor rather than a requirement for the diagnosis
of CPTSD.

ICD-11 PTSD consists of three core symptom clusters: re-experiencing
trauma, avoidance of trauma reminders, and a heightened sense of threat.
CPTSD consists of the three PTSD clusters as well as three additional
clusters described as ``disturbances in self-organization'' (DSO)
symptoms: affect dysregulation, negative self-concept, and disturbances
in relationships with the latter symptoms representing the effects of
chronic trauma on these three critical psychological and social domains
of functioning (Maercker et al., 2013).The presence of childhood trauma
(such as sexual or physical abuse) can disrupt socio-emotional
development and generate problems in emotion regulation and relational
capacities represented in CPTSD. Individuals who experience repeated or
chronic trauma beginning in adulthood may have had good emotion
regulation, self-concept and relational capacities but these can
deteriorate in the context of severe sustained or multiple forms of
trauma as is experienced, for example, by refugees (Nickerson et al.
2016). Reviews of current evidence regarding ICD-11 PTSD and CPTSD
support the construct validity of these diagnoses and clarify their
clinical characteristics (Brewin et al., 2017; Redican et al., 2021).

Individuals with CPTSD will report re-experiencing of traumatic
experiences in either nightmares or flashbacks; avoidance of
trauma-related reminders (thoughts, feelings or places) and a chronic
sense of threat. Affect dysregulation is broadly represented by
emotional reactivity in which affected individuals are quick to
experience emotions such as anger or sadness and/or report overall
emotional numbing. Individuals view themselves in extremely and
persistently negative ways, including as worthless or a failure, often
associated with feelings of shame and guilt. There are difficulties in
managing relationships with a tendency to avoid or withdraw from
relationships particularly under conditions of stress or conflict.

The diagnosis of CPTSD as well as PTSD can be assessed via a reliable
and valid 18-item self-report measure, the International Trauma
Questionnaire (ITQ; Cloitre et al., 2018). It has been translated into
over 30 languages and is freely available (see
globaltraumameasures.com). A clinician assessed version of the ITQ has
been developed and is in the final stages of validation (Roberts et al.,
2019).

\textbf{1.2 STAIR Narrative Therapy Overview}

Skills Training in Affective and Interpersonal Regulation (STAIR)
Narrative Therapy (SNT), is a phase-based intervention which was
initially developed for individuals with PTSD related to childhood abuse
but now is applied to treat the effects of various types of
interpersonal trauma (see Cloitre et al, 2020). The treatment was
developed to address not only the symptoms of PTSD but also the commonly
observed problems of emotion regulation and interpersonal problems among
those with chronic abuse (Cloitre et al., 2002). The first module
(STAIR) includes skill training to develop emotional and interpersonal
resources that have been compromised by long-term complex trauma. The
second module (Narrative Therapy) employs exposure and cognitive
restructuring techniques to alleviate PTSD symptoms. Three RCTs have
demonstrate the clinical efficacy of SNT for PTSD symptoms, and problems
related to emotion regulation and interpersonal functioning among
individuals with childhood abuse and interpersonal trauma (Cloitre et
al., 2002, 2010; Oprel et al., 2021). Given the problem domains it was
developed to resolve, the treatment appears transparently appropriate
for the treatment for CPTSD. A pilot study has indicated substantial
positive benefits for individuals with CPTSD (Niwa et al., 2022) and
other studies are under way.

\textbf{1.3 STAIR Narrative Therapy Process}

SNT is a cognitive behavioral therapy that is based in interpersonal and
attachment principles. The treatment was developed following both theory
and evidence that early life trauma disrupts attachment and related
capacities for emotion regulation, positive self-regard and healthy
relationships (see Cloitre et al., 2006). Accumulating research in the
trauma field has strongly indicated that trauma which is the result of
human design (e.g., war, community violence, genocide and other forms of
organized violence), regardless of whether in happened in childhood or
adulthood, is particularly pernicious. Compared to non-interpersonal
traumas, it is associated with higher rates of PTSD and other adverse
effects (e.g., deterioration in social networks) that relate to the
capacity to maintain social bonds at an individual and community level
(Charuvastra \& Cloitre, 2008).

As described in the case illustration, the \emph{therapeutic alliance}is
key to recovery as is repeated \emph{psychoeducation on the nature of
trauma} . The therapist's feedback and explanations help the client
begin to reframe the nature of their experience from one in which they
are to blame \emph{(``How did you let this happen?} ''), to something
that happened to them and from which they can recover (``\emph{I'm sorry
this happened to you. How can I help} ?'') The first two sessions of
STAIR highlight the negative impact of trauma on emotions, self-identity
and relationships. The selection of \emph{emotion regulation skills} is
based on client preferences, needs and strengths. Research on depression
indicates that the selection of skills that strengthen existing
competencies rather than fill a gap (compensatory) result in greater
decrease in symptoms (Cheavens et al., 2012). This may be because
emphasizing strengths may enhance of mastery and positive self-regard,
both of which are low among trauma-exposed individuals. There are at
least 15 emotion regulation skills available in the protocol (Cloitre et
al., 2020) and typically clients comfortably and effectively adopt from
3 to 6.

The sessions on relationships models borrows directly from Bowlby (see
Cloitre et al., 2020). The relationship models are viewed in a
nonpathological manner. They are described as strategies intended to
maintain connections and ensure survival in particular social or
interpersonal circumstances. Thus, models like ``\emph{If I don't share
my feelings, I will be taken care of} '' works well for a child with a
distant mother or ``\emph{Trusting others can get you killed} '' ensures
survival in a combat zone. Consistent with attachment theory, SNT
recommends that a client diversify their attachment models for different
relationships and circumstances. It is not necessary to reject or
invalidate old models; they may still be useful if the client returns to
a trauma-genic environment e.g., (an abusive family, combat zones). The
client is encouraged to develop new and alternative schemas that are
relevant to their current environment or even as related to an
aspirational goal (e.g., \emph{``I would like to make friends.''} ). As
supported in the SNT protocol, several themes can be discussed in the
treatment including, for example, power dynamics, shame, and grief.
Therapist and client can choose to settle in on one or more of these
themes as appropriate.

Last and most importantly, the therapist and client prepare to conduct
narratives of the trauma memories. These sessions can number from 4 to
10 depending on the number of events that the client wants to discuss.
The sessions also include continued use of the emotion regulation and
interpersonal skills learnt during the STAIR phase of the treatment.
This can highlight difference between the ``old'' traumatized self
represented in the narratives, and the new evolving self emerging from
the STAIR work which is respectful of but different from the person in
the stories.

\textbf{1.4 Application of the treatment to Sexual and Gender Minority
(SGM) Clients}

Sexual and gender minority (SGM) people are at higher risk for exposure
to trauma events compared to their heterosexual and/or cisgender
counterparts (Roberts et al., 2010). This is, in part, the result of
experiencing trauma earlier in life and experiencing traumas generated
by SGM status (e.g., physical assaults) (Roberts et al, 2010). SGM
status is associated with minority stress (anticipated discrimination
and victimization, internalized stigma, and concealment of stigmatized
identity) which is often derive from experiences of discrimination
(e.g., denial of equal employment and healthcare) and micro-aggressions
(e.g., insults, assumed pathology) (Livingston, 2019; Meyer, 2003).
Minority stress has been identified as contributing to adverse mental
health effects including DSM-5 PTSD (Solomon et al., 2021) and higher
rates of Complex PTSD than other trauma-exposed populations (see Charak
et al., in press).

SNT may be a particularly relevant trauma-focused treatment for SGM
clients as it addresses traumatic events that have occurred in the past
and also supports the individual in managing ongoing minority stress,
discrimination and micro-aggressions.

\textbf{2. CASE ILLUSTRATION}

\textbf{2.1 Presenting Problem and Client Description}

Michael is a 55-year-old gay man who has lived in the San Francisco Bay
area his entire life. Michael has a history of chronic low-grade
depression, with occasional periods of severe depression. He also is
HIV+ which is medically well managed. He has been receiving supportive
psychotherapy for the last couple of years at an LGBTQ+ serving
outpatient mental health service for his depression. The treatment was
helpful. He felt part of a community of sexual and gender minority (SGM)
people and, for the very first time in his life, shared something about
his past. He described his childhood experiences of family rejection,
the euphoria of finding a gay community in late adolescence, that joy
being demolished by the onset of the AIDS epidemic and the fear, grief
and loss he experienced in the many years since. An ongoing problem is
Michael's relentless anger about minor and major ways in which he was
degraded, shamed and rejected due to his gay identify. His basic needs
such as health care services can be denied him and civility in routine
social exchanges cannot be assured. Seeing heterosexual couples holding
hands can fill him with rage and depression as he feels he cannot have
the experience of showing his affection in a free and easy way.

His first years on his own in his late teens in the gay community were
thrilling. He felt accepted and that he was coming into his own. He was
experiencing emerging pride in his identity and mastery in his work in
the publishing industry. The AIDS crisis increased stigma, criticism and
even hatred of the gay community. Michael's ``first love'' and partner
had died during the AIDS epidemic as well as many friends. He saw many
men his age with physical wasting and dementia. Worse, he saw his
friend's families ignore their deaths, not attend funerals nor make
efforts to mark their passing. This period of life defined him. Everyone
he loved died. Moreover, the homophobic reaction of families who did not
attend funerals sent the message: you are trash, you will never be
lovable.

Despite these harrowing experiences, Michael never viewed them as
traumas. They were simply events that had shaped his life. His therapist
stated that what he had experienced was a trauma and that perhaps a
trauma-specific treatment might help move him out of the depression and
anger he was experiencing. Michael first rejected this option. The
depression felt monolithic and the anger a part of his personality. He
noted ``The past is the past. I can't change it, so why focus on it?''

The therapist described the process of talking about traumatic events
for the purpose of understanding their impact on his life and more
importantly critically re-evaluating their meaning in a more adaptive
way. The current supportive therapy was in a stable perhaps even
stagnant state. The therapist expressed curiosity about whether a
trauma-focused treatment might be helpful to him in a new way, different
from the work that had been accomplished thus far. Michael became more
interested in this option. Complex PTSD symptoms were assessed. Michael
was surprised to see that he endorsed all symptoms of CPTSD. The
assessment shifted problems that had been on the periphery of his
awareness to center view. He had intrusive thoughts and nightmares about
the AIDS-related deaths. He experienced reminders of his traumas
whenever he went out of his apartment or even when he shut himself away
in his apartment as he watched the news on COVID. In addition, the
assessment allowed him to consider that his emotional reactivity, some
of the negative views he had about himself and the often-negative ways
he interacted with people might be related to his traumatic experiences.
This made him hopeful that the treatment might work for him. He agreed
to the treatment.

\textbf{2.2. Case Formulation}

Michael's mother was angry and dominated the family through verbal
intimidation and unprovoked rages. He was physically abused by his
mother from his preschool to early adolescence for the slightest
infraction of house rules and inevitable behavioral slip-ups such as
spilling milk at the dinner table. His father was disengaged and distant
and did not protect him or his sister. He believed his mother intensely
disliked him but did not think this was necessarily related to his being
gay. He coped by ignoring the problems at home, avoiding his mother's
attention as much as possible and saying as little as possible. Michael
was careful to cover up his attraction to boys. He dated girls and kept
an emotional and physical distance from boys. He had superficial
friendships with schoolmates. He did not share anything about his home
life, his fears, or his sexual feelings. Being unseen and unheard
protected Michael in his early years but ultimately led to him feeling
like he did not really know who he was or worse, that he really did not
have a ``self.'' If asked, he could not have described who he was in any
authentic way. He had no ambitions other than a dedicated drive to leave
his family home as soon as he could.

Following high school, Michael obtained a job as a fact-checker at a San
Francisco newspaper and moved into the city. He was surprised and
energized by the presence of a gay community and unexpectedly found
himself falling in love with a mentor. They moved in together and
Michael began to blossom. Drew, his partner, was his first love and a
positive role model as a gay man: confident, gregarious and active in
the community. A couple of years into this ``perfect life'' the AIDS
epidemic came full-force and Drew died. Many others in the gay community
became sick and died as well. During his therapy, Michael stated that
this short period of happiness was also the source of all of his
unhappiness and anger. He was angry at this turn of fate, stating he'd
rather not have gone through this period than to know happiness and then
have it taken away from him.

Drew's death made him feel that he did not deserve to be loved.
Irrational though it was, he felt abandoned. He felt unloved and
unlovable, a belief that had been instilled in him during his childhood.
His losses left him with deep and enduring feelings of inferiority which
were expressed in his anger and his social isolation. He also developed
the belief that there was no point in having loving relationships: they
only led to loss.

Michael had initially been shocked by the hostility towards the gay
community at the height of the AIDS epidemic and the callous, dismissive
attitude towards the suffering and deaths of so many. Later, his
personal losses stoked an anger that was at first directed towards
social injustice but which eventually generalized to almost all social
interactions.

By the time that Michael had entered therapy, the many traumas of
Michael's adulthood had resulted in the reinforcement of the old coping
strategies from his childhood abuse, namely social withdrawal and
emotional numbing. Along with these came the addition of chronic anger
and expressions of hostility and disappointment towards everyone with
whom he interacted.

In treatment, he talked a lot about straight culture and straight people
with a strong focus on negative dynamics between gay and straight
communities stating ``We are under attack, they are trying to
exterminate us.'' The emergence of the COVID epidemic heightened these
beliefs. He saw himself and all minortized people as without power,
ignored and dismissed by the dominant culture and consequently at
increased risk for illness and death. Michael would blow up at instances
of discrimination and micro-aggressions. While the anger was justified,
the intensity of his reactions left him feeling exhausted and bad about
himself. He wanted to be able to hand the chronic minority stressors he
experienced in a better way.

There were times when his anger biased his interpretation of neutral
situations or created barriers to his intended goals. For example, he'd
been at a clothing store and took some time considering his purchase.
When he paid for the item and the cashier concluded with ``Have a nice
day'' he could not help but reply: ``Oh, you must be happy to get rid of
me.'' He received feedback from his support group that he was so angry
that people were having difficulty supporting him.

Michael was motivated to try the STAIR Narrative Therapy program for
many reasons. He felt angry much of the time and bad all the time. He
wanted to feel better emotionally. He did not feel he had a purpose and
questioned why he had survived. He wanted to have a place in society. He
was lonely and wanted to have some social connections but at the same
time experienced other people as emotional triggers, who were
threatening him or putting him down. The social isolation had left him
profoundly unhappy. He wanted to have a relationship without pain.

\textbf{2.3 Treatment Goals and Plans}

One important goal of the treatment was to help Michael manage his anger
better. Part of this goal involved helping Michael identify the ways in
which his anger actually got in the way of efforts to re-engage
socially. In addition, Michael was not aware of emotions other than
anger (i.e., ``emotionally numb''). A second goal was to increase his
exploration and awareness of other feelings. This was intended to help
relieve his depression and also support communication and socialization.
As a gay man, Michael was subject to minority stressors which included
chronic discriminations and micro-aggressions. It was important for him
to learn how to handle them in a more adaptive way and with a less
negative impact on himself. It was also important for him to recognize
the powerful emotions that came from his traumatic past and determine
whether or not they were not helpful in managing day-to-day stressors.
Last, most importantly, Michael had not properly grieved the loss of
Drew, his friends and community. He had been left feeling unloved and
had become dismissive of the idea of ever developing a deep relationship
again.

\textbf{2.4. Course of Treatment}

\textbf{2.4.1 Sessions 1- 5: Emotion Regulation Sessions~}

The Therapeutic Alliance and Psychoeducation

The first sessions of the treatment require special attention to the
therapeutic relationship. While Michael had been working with the SNT
therapist in supportive counseling, there was a shift in the emotional
and interpersonal dynamics in anticipation of embarking in a treatment
process that would focus on Michael's trauma. He was uncomfortable about
the prospect of exploring rather than distancing from his feelings. All
aspects of the treatment increased Michael's sense of vulnerability, and
in particular shame about his anger and social isolation. This initially
led to an exaggeration of Michael's tendency to engage in a dismissive
and demeaning interpersonal style. For example, Michael's therapist was
a lesbian and younger than him. Michael would sometimes chide the
therapist on her lack of lived experience regarding the AIDS epidemic,
what it meant to be a gay man during this time, and whether the
therapist could possibly be of any substantive help.

The therapist was sensitive to all of these issues. First, she quickly
highlighted that trauma impacts emotions and emotional well-being. The
problems that Michael experienced were common consequences of trauma
that many people experienced. A review of a worksheet listing the common
emotional consequences of trauma, which included anger, was affirming.
Michael's shame and confusion about ``Why am I this way?'' was replaced
by a quiet reflection about the relationship between the loss of his
partner and friends, and the onset of his anger problems. While details
of this history would come later in the treatment, Michael noted that
the connection ``felt true.'' His feelings of shame began to be replaced
by curiosity and greater openness to exploring his history.

The therapist also expressed respect for Michael's willingness to
explore painful experiences and feelings. Michael associated having
feelings with being feminine or weak. He took pride in his masculine
appearance and traditional masculine attitudes. It was one way he had
hidden his gay identity in his youth and had made him feel safe. The
therapist's interest and steadfast connection to Michael as he initiated
his emotional exploration provided an antidote to the rising feelings of
shame Michael experienced at the beginning of the process. The therapist
would make comments such as ``Thank you for sharing this with me.
Congratulations on these efforts. It takes strength to do this.'' The
therapist provided an alternative perspective about the task in which
Michael was engaging: it was not shameful but rather courageous to
explore feelings.

The therapist did not combat Michael about his views on her competence
in the work. She acknowledged that the LGBTQ+ community was very diverse
and that there were substantial life experience differences between
them. However, she hoped to be helpful to him and that shared
experiences related to living as a member of a minority group as well as
her knowledge about ongoing concerns of the LGBTQ+ people would support
their work together. She also invited Michael to let her know when she
misunderstood him so she could correct her understanding.

Lastly, the therapist did not rush Michael into the world of feelings
but followed him as far as he was willing to go and respected his limits
in exploration. The first two sessions focus predominantly on increasing
awareness of emotions through attention to daily interactions and
resulting bodily sensations, cognitions and behaviors. In the early
phase of the treatment, every example Michael reported focused on anger.
The therapist suggested that the anger might be a protective shield
against the emergence of other, more threatening emotions. While Michael
agreed in theory, the practice of identifying and experiencing other
emotions was a slow process in which small steps were counted as
victories.

Emotional Awareness

In the example below, Michael describes a situation to which the
therapist responds by suggesting that anger may be connected to feelings
of fear. Michael refuses to use the word ``fear'' but ultimately settles
for something similar but less threatening. The therapist uses several
tools to support the process including a Feelings Monitoring Form which
documented, organized and clarified his emotional experiences and a
Feelings Wheel, a figure which provided several feeling words and their
relationship to one another. This was used to help Michael recognize or
consider feelings that might be relevant to his experience.

Michael (M): Here is my Feelings Monitoring Form, I read an article
about COVID that reported very few people are wearing masks anymore. No
one taking it seriously makes me so f***ing mad! Therapist (T): I see
you rated your anger intensity a 10 out of 10. You must have been really
mad. M: This is mainstream society. No one cares that people are dying.
I've got a cold right now. And you know what? No one cares about that.
We are all going to die. T: This may be a good example for us to
identify other feelings you experienced. Let's use the Feelings Wheel as
a guide to other emotions you might have been feeling. M {[}looking at
wheel{]}: Angry, frustrated, annoyed, livid. T: Good, good. All this
language describes emotions that are very understandable. I am
considering your statement ``We are all going to die.'' I wonder if you
are feeling afraid? M: No, that's not really it. There is no point to
feeling afraid. T: Thank you. So, it sounds like you were not feeling
afraid. I am wondering if the report made you feel something
like\ldots{} apprehensive? M {[}Deep sigh{]}: You know yes, apprehensive
really does hit the mark. I just don't know what will happen with this
pandemic. It reminds me of everything I went through and thought I would
never have to face again.

Michael added the word ``apprehensive'' to his worksheet, which lent
strength to the reality of the feeling and also helped Michael
understand himself and his actions better. Michael noted that after
reading this report, he stayed in his apartment for several days. The
therapist reflected that if Michael was feeling apprehensive as well as
angry, it made sense that he should try to protect himself. The
elicitation of an emotion, apprehension, (an approximation of deeper but
not acceptable feelings of fear) allowed Michael to have a sensible
explanation for his behaviors and to make a connection between his
feelings and behavior.

Over time Michael was able to tolerate even more challenging emotions
which gave him greater insight into himself. For example, he felt an
increasing sense of purposelessness during the COVID pandemic. With
increasing attention to his emotions, he came to understand that these
new epidemic awakened feelings of survivor's guilt that he had not
previously acknowledged. Michael made the connection between survivor's
guilt and sense of purposelessness in this early phase of treatment.
This helped him feel less confused about his emotions and consequently
less depressed. However, it was only during the narrative work that he
was able to have compassion for his own survival and to see a path
forward for living his life with a sense of purpose.

Emotion Regulation

The remaining sessions in this phase of treatment focused on identifying
skills that Michael could learn to help better manage his emotions.
STAIR typically provides 5 interventions associated with each channel of
experiencing (i.e., body, thoughts, and behavior). The selection of
interventions is based on the client's preferences and those which will
support a growing sense of mastery and satisfaction.

\emph{Body Interventions.} Michael responded well to focused breathing.
He liked body-based interventions because they helped him ``get out of
his head.'' He liked the idea of having an exercise that could be
integrated into his fitness plan and that helped calm his mind. Michael
was open to this intervention as a source of change. It did not require
buying into a new ethos. The exercise was consistent with his values as
a gay man: keeping fit and attractive was important. He viewed his body
as armor against the world as well as a source of pride. In addition, he
developed a routine before bedtime that included a nice warm shower and
a cycle of focused breathing as a way to down-regulate his physical and
mental energies to help him transition to sleep.

\emph{Cognitive Interventions} . Michael rejected cognitive
interventions that focused on critical evaluation and reappraisal of his
beliefs. He found them invalidating. The therapist agreed that many of
the negative beliefs Michael held resulting from his childhood trauma
and the AIDS epidemic were supported by substantial evidence. Michael
effectively used Emotion Surfing, a meta-cognitive strategy in which one
maintains awareness of the intensity, and ebb and flow of one's
feelings. The exercise reinforces a connection to emotions, like a
surfer riding a wave, in which being aware of the emotions but not being
overwhelmed or ``brought under'' by them reduces fear and confidence in
maintaining a connection to them. In this exercise Michael was asked
simply to observe his feelings which he found easier than digging
through and analyzing his thoughts. He also reported that through
watching his emotions, he was able to more easily change his thoughts
(e.g., ``Anger is manageable.''). Michael recognized that while he had
experienced and might continue to experience many traumatic and other
stressors, he could better manage his reactions to them. Later, Emotion
Surfing proved to be very valuable as Michael addressed sadness and
grief related to the loss of his partner and friends.

\emph{Behavioral Interventions.} Michael had ambivalent reactions to
engaging in positive or pleasurable activities. He took on what he
viewed as a ``masculine'' value that you engage in activities to meet a
goal rather than to ``have fun.'' However, he was persuaded by the
scientific literature on behavioral activation as effective for reducing
depression. The therapist needed to be careful about reviewing the
options for positive activities because some were not relevant to him
(e.g., bowling) or beyond his resources (e.g., taking photos) which
generated annoyance and risked disengagement. Michael was familiar with
Time-Out and in the context of his growing ability to track his
emotional state, He made a genuine effort to use the intervention in
situations at the clinic. He was strongly motivated to get along with
people there (e.g., case worker and reception staff) because he
recognized the value of having a space where he felt at home and
accepted. Despite his routine irritations, he felt a sense of belonging
at the clinic and decided to make an effort to appreciate it more by
interacting in a more positive manner with staff and other clients.

Dealing with Minority Stress

As Michael was learning new emotion regulation skills, their application
often focused on managing his distress and anger at micro-aggressions
and discrimination. The therapist became aware of these experiences
through the Feelings Monitoring Forms that Michael completed between
sessions to practice identifying his emotional and cognitive responses
to stressors, as well as which coping strategies he employed.

First, he spent some time disentangling the anger he felt arising from
his childhood family rejection from the ongoing social rejection he
experienced as a gay man. The anger was justified on both counts but
might be dealt with in different ways. Michael's therapist modeled
compassion for what felt like the inevitable burden and ongoing nature
of minority stressors, which, over time, helped Michael experience more
self-compassion. With his therapist's guidance and encouragement,
Michael practiced using new emotion regulation skills when confronted
with microaggressions. A key insight Michael reported was that, unlike
his childhood, he now had more choices about how to respond to these
situations and more influence in shaping their outcomes. He used emotion
surfing to reduce the intensity of his anger so he could respond to the
other person more skillfully or choose to invest his energy elsewhere.
He understood there were times when he could just walk away from a
situation when he could not respond effectively. He began relying on a
growing sense of community from the clinic and became more aware and
appreciative of a sense of acceptance and safety, which he had not
experienced in a very long time.

\textbf{2.4.2 Sessions 6-10: Relationship Patterns}

Michael was apprehensive about starting the interpersonal work. In part
this was because he was concerned that the therapist would challenge his
relationship beliefs in an invalidating way. More importantly, Michael
felt vulnerable. He worried that his therapist would come to see the
true and vast extent of his social isolation and think less of him for
it. Instead, the therapist simply acknowledged his social isolation, and
referenced that they would find practical strategies for working on that
later. Most importantly, the therapist took steps to identify Michael's
relationship models by exploring their own relationship.

T: So, Michael, today we are going to move into our interpersonal
relationship work, and I know that you have found the Feelings
Monitoring Forms to be really helpful. You mentioned that having things
written down gives you something to look back at, and it actually helps
to organize your experience. M: Yeah, it didn't seem like it would work.
But having an experience written down on a piece of paper, in black and
white, is powerful. The reality of the situation hits home. It motivates
my desire for change and helps identify how to begin that process. T:
You've done very well with the Feelings Monitoring Forms so far. We are
ready to move into a new worksheet today called the Relationship
Patterns Worksheet or the RPW which describes interpersonal situations
and problems. As we have discussed, trauma impacts our beliefs about
ourselves in the context of the relationships we share with others. M:
Well, I don't know how effective this is going to be because I don't
have that many people that I talk to. T: Yeah, I know that that's
something that you've mentioned before. One of our goals, if you agree,
would be to increase the amount of social connections that you have. But
for now, I wanted to take a moment and refer back to last week. I
thought it was a really important session because you were vulnerable
with me and shared how much I might not be able to help you deal with
the consequences of the AIDS epidemic because I did not experience it.
It is understandable that you have some concerns about that. This is
something we could discuss. What do you think? M: Well, I think you're
the person I've interacted with most, and you seem to be pretty honest
with me. So, I think that might be a good step to try. T: Let's do it
then. What specific situation comes to mind? M: You asked me about my
thoughts on the interaction that happened at the coffee shop, and I felt
like you had an ulterior motive with you wanting to know how I felt. T:
I see. Okay, so, the situation we have identified is ``The therapist
asked me about the interaction at the coffee shop'', and the thoughts
you had about me were, ``The therapist had ulterior motives toward me.''
I would like to know more about the ulterior motives. What kind of
ulterior motives did you think I had? M: Well, in my history, it seems
that people who show that they care about you do it because they have a
reason to. Since you're a therapist, I know you're getting paid to help
me out here, so I guess as long as I continue seeing you and I continue
to be happy and you're asking me about my life, I'm going to continue to
talk. So, I'm going to keep coming and you could keep making money. T:
Thank you for sharing that. And as you tell me that, what are you
feeling? M: I've had doctors that I felt the same way about. Every time
I go in they push for me to do STD tests even after I tell them I am not
sexually active. They are just trying to squeeze that extra fifty bucks
out of me. I think my feelings start with anger, and maybe some
resentment. T: Okay. And what do you think I was feeling toward you? M:
I think you were doing it because you had to do a job. You do seem to
care, but I don't know if you care about me anymore than you'd care
about anybody else who comes in here. So I can't understand why you'd
care about my problems. T: So, did you think I was feeling indifferent?
M: Yeah, I do think indifference is something that I felt. T: Alright.
You've done a great job identifying what you think I was feeling and
thinking, and also what you were feeling. It sounds like what you are
thinking is there's no way she actually cares about me, Right? M: Yeah.
T: Okay, and then what did you do in response to having those thoughts?
M: I realized I was closing up. I didn't want to tell you more. T: Good.
Okay. Let's see if we can distill this down to a relationship model or
pattern. We could try to take this example as illustrative of a belief
you have about other people. Let me help you get started. So maybe
something like, ``If someone acts like they care about me, then'' what?
M: If someone acts like they care about me, then I close myself off. T:
Alright, Good. Then what do you do? M: I feel my wall going up. T: Yeah,
and I felt that, too. I was so grateful that you allowed the opportunity
for me to keep talking, and for you to even be curious about how it
could potentially be different. Curiosity is really at the heart of
this: What could be different now in the present in my life? Because you
were curious, we were able to talk it through. I think another
trauma-based belief might be, ``If I feel close to someone, then'' what?
M: They are going to leave me. T: Okay. That is what has happened to you
in the past, so it makes sense that you have that belief. The good news
is that through time and work, these beliefs can be changed as they
might apply in the present. But, for now, let's stick with this. What
other beliefs about relationships emerge from this example? M: I've got
to look out for me. I'm the only person who's gonna look out for me and
I'm the only person who ever has looked out for me. That's something
that I really do believe is true. T: Right. Part of your old belief is
``She doesn't really care about me.'' Sometimes it's helpful to even
just say to yourself, ``Maybe she does care, or at least has my best
interests at heart.'' M: Yeah, I could do that. And I think there have
been times when I've noticed that people care, but it's so hard to
believe that I find that sometimes I push people away, maybe a little
too soon. T: Yeah, and again, it makes sense that you would do that,
given the things that have happened in your life. It does take
tolerating that fear to try something different, even just not putting
your walls up automatically. I am wondering what you might feel instead
if you thought, ``Maybe she does care about me.'' What other emotions
might you feel instead of suspicious or angry? M: Well, I think first
I'd probably feel intrigued. I'd want to know why you care. Even if I
assume it's for a positive reason, I'm still going to be intrigued by
why. Then I think I'd be thankful because whatever issue you are showing
care for, I wouldn't have to go through it alone. I am so used to being
alone, and it's so exhausting. T: Yeah, it really comes at a price. What
alternative thoughts could you have about me? Towards the end of our
session what did you think I was thinking and feeling? M: We got to talk
through some of the problem, so at the end of our session I thought I
could have been wrong, and maybe you really did want to know how that
interaction went because maybe you thought you might be able to help me.
T: Okay, good. So. an alternative thought could be, ``She really does
want to know how the interaction went.'' And the feeling I could be
having could be concern, maybe? M: Yeah, that feels right. When we
continued the conversation, I realized that it was probably not as bad
as I thought it was at the moment. T: That is incredible! Excellent!
Finally, let's get to the new relationship model. So the old belief is
``If I get close to someone, then they will leave me.'' What could it be
instead? M: If I get close to someone, then they might add something to
my life that I don't already have. T: Oh, wow, that's great. The second
old belief was, ``If someone cares about me, then they will leave me.''
What could it be instead? M: If someone cares about me, then it might
not mean that I'm as bad as I think I am.

The therapist anticipates that Michael's relationship models relate to
his trauma history. This will be explored during the narrative work. The
relationship models certainly guide his current interactions. If the
beliefs are a consequence of his trauma history, the therapist and
client can begin the task of determining to what extent and under what
conditions the trauma-generated beliefs are still applicable versus when
he might feel the freedom to try on some of the alternative models that
have been generated in the session.

As the above dialogue indicates, the presence of strong and ongoing
relationships is not necessary to identify relationship models. In this
case, the therapist used an interaction between the therapist and client
to distill the beliefs. Relationship models tend to be stable and highly
generalized. The SNT protocol provides guidance about how to work
through relationship models related to themes of assertiveness,
flexibility/power and intimacy. In this case, the treatment remained
focused on themes of abandonment and rejection, because they were so
central to Michael's anger and social isolation.

\textbf{2.4.3 Sessions 11-16: Narrative Therapy}

Michael and the therapist created a memory hierarchy of specific
instances of various traumas that had occurred during his childhood and
adulthood and ordered them by how much distress he felt for each memory.
The death of Drew was the most distressing. This memory was chosen as
the first to review because thoughts of Drew had been strong during
COVID and Michael wanted an opportunity to talk about Drew. The
therapist agreed because she felt that Michael's beliefs about himself
and others, his feelings of abandonment and continuing rejection of and
hostility towards others were rooted in Drew's death.

\textbf{Narrative of Death of Partner:}

T: Today we are going to move on to the highest memory on your
hierarchy, and that is Drew's death at the hospital. Are you ready? M:
Yes, I think it's time. T: I'm going to ask you to use the present tense
and incorporate as many details as possible: What you are seeing, what
you are hearing, what you are smelling, what you are feeling, all of
those things. I might ask you some questions along the way. You will
have a record of this story on your phone. Go ahead and press record,
when you are ready. Before we begin, what is your level of distress? M:
About a ninety-five. T: Very high, okay. If you feel comfortable, close
your eyes or you can just keep your eyes open looking down, and tell me
about the day that Drew died. M: Okay. I'm going to his hospital room. I
brought him flowers because once a week I bring him flowers to remind
him that his hospital room doesn't have to be this stinky, sterile
place; especially since he is spending more and more of his time here.
T: What do the flowers look like? M: The flowers are red. They are
tulips. I'm not able to afford much so they're in a small vase. I'm
thankful I have these flowers to carry with me. It always smells so bad
in here, like ammonia and death. The flowers cover up as much as they
can. When I bring them into his room, it's even worse. It smells like
urine and feces, and there are nurses in his room. One tells me I can't
be in here. They're taking care of him, and they've tried this s**t
before where they don't want us in the rooms caring for each other. I
know what they think of us. I usually argue with them, and they'll leave
us alone for a few minutes, so I can tell Drew ``Hi.'' But they don't
listen to me this time. They start pushing me out of the room. I tell
them, ``I have to at least give him his flowers today. If you're not
going to let me see him, I'm giving him his flowers.'' I scoot past the
nurse standing at the doorway, and I go to set the flowers on Drew's
windowsill. I turn and look at him and he already looks dead. His skin
has no color. He's emaciated. He always used to have abs. But now he is
just skin and bones. He has those sores all over his body now, too. They
started on his face, and I know that's gotta upset him because he had
such a pretty face. He just looks pitiful. He's just looking off at the
room. He doesn't even look up at me. It's like he's not even here. He's
brain dead or something. Even when I tell him, ``Drew, I brought your
flowers'', he didn't even move to look at me. It is so hard thinking
about all of the times we would go out. Everybody would be all over him
because Drew was the lively one. He could make friends with anybody, and
he's the reason I met so many people when I started to come out to the
scene. It's hard to see him this way. T: What's going through your mind
as you see him lying there? M: Well, first I feel very sorry for him,
because it's hard seeing somebody you love going through that. I
selfishly think about myself because I know that will be me one day. I
know I will be the one somebody will pity. As much as I want to be there
for him, part of me wants to run. T: What happens next? M: I am leaving
the room. I go to the pay phone and I call Thomas, our other friend. I
let him know that Drew's not doing good, and I wait in the waiting room
for him to swing by. I'm asking everybody what's happening with him. I
am sure the nurse is cussing me out because I must be going to the
Nurse's Station every five minutes. When Thomas gets to the hospital, I
go grab a bite to eat from the cafeteria. When I get back, Thomas tells
me that Drew passed. They didn't let me spend any time with him on his
last day. T: What's your level of distress right now? M: Eighty. T:
Okay. Is there anything else about this memory that would be important
to share? M: I feel angry. Angry at the nurses who didn't seem to care.
Angry at the world for blaming gay people for this virus. I've never
shared this with anyone, but I think as the years went by, I even felt
angry at Drew. For leaving me to deal with this mess, this homophobic
world by myself. And maybe just for leaving me alone. T: I see, okay.
Let's go ahead and stop the recording there. So, Michael, you did it.
You got through the worst memory on the hierarchy. I want you to take a
deep breath. Look around the room. Now see that you are safe. You're at
home. I'm here with you virtually. Let's look at this list of emotions.
You mentioned anger. I'm wondering right now, as you have just told me
this memory, how much anger are you feeling right now on a scale of zero
to ten. M: Well, in regard to Drew, I really don't know what to make of
that. Can we skip that for right now? T: Okay. What about the nurses? M:
About a two. They didn't have to treat us like they did when we were in
the hospital trying to be there for the people that we love that had
nobody else. But I know it was a time when I don't think any of us knew
what we were dealing with. So, everybody was more scared. T: Okay. That
brings us to another emotion, fear or feeling scared. What number would
you give that, zero to ten? M: I would say seven, especially with COVID.
If AIDS hasn't taken me out yet. Covid will. T: Okay, and what about
sadness? M: I would say nine or ten. That's the strongest. T: Tell me
more about that. M: I try not to think very much about the people that I
lost during that time. If I don't think about it, it's not happening
again. I feel like I just re-lived the situation, and I'm losing Drew
all over again. I wish he could have seen what's happened in the last
forty years in the world that he missed out on. T: You know, I'm so
proud of you for acknowledging those feelings. I know that doesn't come
easily to you. M: Yeah, I feel like I almost have a friend with me when
I'm talking about Drew, because he truly cared about me. He's one of the
only people I think I ever could be myself around. T: Yeah, and I know
you mentioned he really took you under his wing and helped you navigate
the scene. M: Yeah, I didn't know anything about anything. I didn't know
how to talk to a guy, he showed me that it wasn't as hard as I thought
it was. You know his parents didn't accept him, either, but he cared a
lot less than I did and he showed me how to be myself. T: You mentioned
that you even felt angry at Drew - for dying. M. I suppose what I really
feel is sad. I miss him. Whoah! I think I need to emotion surf for a
minute. T: Go ahead. M: It's so painful. I feel pain in my chest. Like
my heart is literally breaking. T: Take your time\ldots{} What do you
think he would want to say to you right now? M: He'd probably tell me
that he's glad I'm still alive, and that he still loves me. He didn't
abandon me. He just died. I think he would say that he wishes he could
be here with me. I wonder if he would have thought I would have turned
into this angry person or if he thought I'd have more of the friends
that we used to have. T: Sounds like he would want you to have a rich,
full life, whatever that would mean for you, just like he showed you how
to be free so many years ago. I suspect he'd want you to still be free
right now. This reminds me of one of those very important relationship
models that we had identified, which is, if I feel close to someone,
then they will leave me. That's exactly what happened here and happened
a lot in your life. I know you've been working on allowing yourself the
possibility to maybe feel closeness with someone. Maybe things can be
different now. M: Yeah, I think after Drew died, I realized that if I
never would have gotten close to him, I wouldn't have been hurt when he
died because I wouldn't have known him. I've missed out on so much of
life because I push people away. I want to have relationships with
people. I just don't want to lose them anymore. T: Of course. You just
said it: if you had never known him, it wouldn't have hurt you when he
died; but you would have never known him. What a terrible price to pay!
M: Absolutely. Yeah, I can't imagine what my life would be like if I
wouldn't have met him. T: I also am thinking about the fact that you
weren't allowed to be with him at the very end, and he was alone. I know
that's something that now, in the present, you feel safer being alone.
I'm wondering if it's also in the service of asking yourself, ``what
difference does it make, anyway? I'm gonna die alone, too.'' I am
curious if that's a thought that you have had. M: Yeah, and especially
the way I pitied him when he was laying in the bed. If I don't have
anybody to pity me, then I'm not going to be pitied when I eventually
die. T: Pity is one way of putting it. Compassion might be another. M: I
guess I do lose the opportunity for somebody to care for me when I die,
to bring me flowers. That's right. T: I imagine it brings you some
comfort to know that his last day you were there, and he had flowers and
some beauty in his life at the very end. M: I would like to think that
if he did know what was going on, the flowers might have been the last
thing he saw of the world in his final days. T: And what is your level
of distress now? M: 20

\textbf{3. OUTCOMES AND PROGNOSIS}

A key outcome was that Michael was able to experience and accept many of
the feelings that resulted from Drew's death. During the narration, he
is able to experience the terrible grief and the anger he felt towards
Drew for abandoning him as a young gay man who was just learning to make
his way. Accepting the feelings allows him to explore their meaning and
with the therapist's guidance, have compassion for himself as the
confused and hurt young man he was at the time of Drew's death. Freed of
the burden of his grief and anger, he is able to understand that Drew
did not choose to leave or abandon him. The ``conversation'' with Drew
at the end of the narration reframes the relationship and points Michael
in the direction of becoming more socially engaged as Drew would have
wanted for him. Feelings of guilt for surviving are referenced but not
addressed in this narration (``I selfishly think about myself because I
know that will be me one day\ldots{}'') and that work may help him
understand his need to ``find a purpose'' and in fact succeed in this
task.

The first important intervention in the treatment identified that many
of Michael's problems were the result of his multiple traumas and not an
indication of a problematic personality, impaired character or being
gay. The diagnosis of CPTSD including his anger, social isolation,
emotional numbing his ``wordlessness'' in naming his feelings were
typical consequences of trauma. The presence of symptoms such as
nightmares, avoid and heightened fear, all of which confused him now
made sense and were organized under the diagnosis. The emotional
awareness and regulation exercises accelerated a process of connection
to his feelings in an accepting and mature way. They also provided him
with choices about how to effectively manage ongoing minority stressors
and helped him realize that his ability to manage these stressors
differed from those he experienced as a child.

Michael substantially benefited from the skills work included in SNT. He
had been living in an emotionally shut down manner and had become
literally de-skilled over time. This was also perhaps even more true for
his social skills. He had become effective in rejecting others. He felt
awkward and at a loss in appropriately engaging with others in both
social situations and in the task of developing deep and close
relationships. The therapist modelled healthy interactions with Michael
in which feelings of both vulnerability and safety were experienced.

Table 1 provides a summary of symptom measures which indicated
significant reductions in his Complex PTSD symptoms (ITQ; Cloitre et
al., 2018), reduction in depression (BDI-II; Beck et al, 1996) and
better emotion regulation (DERS; Gratz \& Roemer, 2004) and perceptions
and expectations about social support (ISEL; Cohen, 2008). The treatment
successfully met the goals of Michael feeling better and improving his
social connections. He began engaging with staff at the clinic and with
members in his support group in more open and friendly way. The
prognosis for Michael is good. He has experienced a radical revision in
his self-concept as an angry person with no friends to a person who is
struggling with loss, and with discrimination and aggression as a gay
man. The challenge is made easier by being in the process of
reconnecting with the LGBTQ+ community and recognizing he is accepted
there. Challenges that remain are effectively dealing with new traumas
and new societal discriminations as they may arise. He also is still
figuring out the steps to developing an intimate relationship.

\textbf{4. CLINICAL PRACTICES AND SUMMARY}

One of the benefits of STAIR Narrative Therapy is that it provides
intensive work in skills practice in emotional awareness and emotion
regulation. It also pairs up behavioral exercises in social skills with
changing relationship models so that intellectual understanding or
insight can be partnered with real and skilled changes in behavior. The
treatment is flexible so that therapist and client can work together in
the selection of skills that are tailored to the patient. While the SNT
protocol is organized into 16 sessions, the work from each `protocol
session' can be extended as needed over actual session time or therapist
and client can cycle back to old skills and exercises as needed. But, as
is hopefully demonstrated in this case presentation, the working through
of the meaning of the traumas is invaluable to revisions in sense of
self and in relational dynamics. For SGM individuals, SNT provides a
program that recognizes the importance of and helps manage ongoing
minority stressors as well past traumas, leading to increased resilience
and a more positive sense of self.

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Table 1. Michael's Symptom Scores at Pretreatment and Postreatment\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Measure\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Potential Score Range\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Pre- treatment\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Post-treatment\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Clinical Cut-Off\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
ITQ Total\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(0-48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
ITQ PTSD Symptoms\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(0-24)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
ITQ DSO Symptoms\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(0-24)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
BDI-II\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(0-63)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
25\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
10\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
DERS\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(36-180)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
118\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
90\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
100\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
ISEL-12\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(0-36)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Note: ITQ = International Trauma Questionnaire; PTSD = Post Traumatic
Stress; DSO = Disturbances in Self-Organization; BDI = Beck Depression
Inventory; DERS= Disturbances in Emotion Regulation Scale; ISEL =
Interpersonal Support Evaluation List. The Clinical Cut-Off represent
scores found in the general population and/or are estimated to represent
scores outside of a clinical or diagnostic range.

\selectlanguage{english}
\FloatBarrier
\end{document}

