In the first session, the therapist took time to review more about Virginia’s relationships and early life. Typical of many patients who are referred for STAIR Narrative Therapy, Virginia suffered betrayals by both her primary caretakers: her stepfather abused her from age 5–11 with the knowledge of her mother. Virginia married at age 19 to a man fifteen years older and who had been married previously and had two teenage children. While they remained married for over 10 years, repeated infidelities by her husband and his drinking and financial difficulties within the family finally resulted in their divorce. The therapist and Virginia concluded that she had not had many people to confide in or to trust. Based on these experiences, there was little reason for Virginia to believe that she could disclose a difficult truth and expect a supportive or concerned response. The therapist used direct language to confirm that the doctor had told her about Virginia’s HIV status and expressed her sympathies about the status as a difficult situation. The therapist also mentioned she had worked with other HIV-positive individuals and was informed about medications and their actions. She also told Virginia she would follow up with the physician as needed with newer medications with which she might not be as familiar. They agreed that one practical goal of the therapy would be to help Virginia manage the emotional reactions she was having to the HIV diagnosis, resolve her PTSD and depression, and identify barriers that were keeping her from managing her medications better.

Virginia’s first task was to focus on her emotions so that she could become more aware of the sources of distress and introduce coping strategies to manage them better. A simple tracking form was introduced to identify emotions, triggers, thoughts, and actions. Specifically, the therapist asked Virginia to track the feelings and thoughts she had when she was taking her medications. The tracking form was also used to identify situations that gave her peace and pleasure, in order to recognize and engage in them in a purposeful and planned way when they might be used to change a mood or protect her from the dark moods she could feel coming on some days. Before this work began, however, the therapist asked Virginia to review how emotions were handled in her family when she was growing up.

Virginia’s home life had been one in which emotions had no place, children were to be seen and not heard. As far as her mother was concerned, feelings were to be happy ones or otherwise swept under the rug. Virginia had the sense her mother did not really like her or have any genuine interest in her well-being. During this session, Virginia spontaneously disclosed about some aspects of her abuse, an unusual action for her. Virginia described that her stepfather would come into her bedroom at night and put his hand over her mouth. He told her to be quiet and tell no one and everything would be alright. At other times, he told her she was “bad” and that problems in the house were her fault. The therapist did not dwell on the details of the trauma but rather focused on explicitly acknowledging the disclosure (“I am so sorry to hear that happened to you”) with compassion and neither going into details nor moving too quickly away from the disclosure. The therapist did explore the impact of those experiences on her expectations and reactions in intimate relationships in the present, stating “No wonder you feel like you are suffocating when you get physically close to someone.”

Virginia wrote down her feelings and thoughts to the experience of taking her first set of pills of the day. She logged fear (I have HIV, and am sick and going to die), nausea (I am stuffing poison into my body), disgust (I am a bad person), and shame (I deserve this). The therapist broke down these reactions into the three channels of experiencing (feeling, thoughts, and behaviors) and for each one explored coping strategies that would be a good fit for Virginia to act as an “antidote” to the negative experience.

In reviewing the tracking sheets, it became clear that the medications had become a traumatic stimulus, a reminder to Virginia of her HIV status, which elicited fear as well as a reminder of what she believed about herself, that she was a bad and shameful person. The therapist proposed reframing the medications as an ally in her goal toward health rather than as an enemy. Virginia was willing and the therapist proceeded to provide an intervention for each of the channels of emotional experience identified.

Virginia used this exercise effectively. The above exchange focuses on changing beliefs but along with certain visual and gustatory associations that were involved in taking the medications. The therapist also explored positive associations of the pills to other sensory modalities (e.g., the blue and white colors of the pills like blue sky and clouds on a beautiful day).

The exercise in revising cognitions, emotions/sensations, and actions (taking the pills) engaged Virginia’s curiosity in linking sensations with names of feelings and with the idea that feelings could be helpful rather than to be ignored and avoided. The therapist introduced the STAIR “feelings wheel” to help Virginia learn to identify and label more feelings.

Virginia was initially amazed at the number of feelings on the wheel and used them to complete the feelings monitoring form typically using at least three feeling words for every situation. New coping strategies were introduced that were targeted for each channel that was feasible and acceptable to Virginia. These included daily focused breathing to reduce anxiety (feelings) and difficulty concentrating (cognition). Behavioral strategies included knitting for her step-grandchildren, which she found a soothing activity and which also had the function of getting her more socially engaged with her stepchildren with whom she had maintained a good relationship. The therapist proposed that she attend an HIV support group (at a different hospital) but Virginia turned this down because she did not want to take the risk of being recognized by someone in her community.

She reported that she could see the happiness in the grandchildren’s eyes as they looked at her, crawled on her lap, and hugged her. She wrote down these experiences in her feelings monitoring form, allowing herself the pleasure of acknowledging their affection (emotional awareness). As part of her therapy, she made a commitment to call, e-mail, or visit the grandchildren at least once a week (behavior change). In addition, she countered thoughts that she was a bad, shameful person and focused on a mantra for herself “I am a good person and worthy of love” (cognitive change). Her daughter was pleased that her mother and children were spending more time together and this improved the relationship with her daughter. As she was making progress with her family, Virginia realized that she could possibly do better in her relationships at work as well.

Sessions 5–8 have several goals one of which is the identification of interpersonal schemas from childhood and recognition of how the client is being currently influenced by expectations and feelings from the past. Interpersonal schemas are the emotionally charged “templates” created by early life experiences that continue to unconsciously influence the client’s life in the present. Another goal is the generation of new schemas based on adult understandings of the self and others gained from treatment. The following vignette describes how Virginia’s therapist accomplishes these goals.

Guided by the interpersonal schemas worksheet, the therapist and Virginia considered a specific recent interpersonal interaction that had been distressing. Virginia and a male coworker had an argument about how to conduct an inventory check. Together they considered what happened (“I blew up, yelled at him, and then left the room”), how Virginia felt (“I am out of control; I should not have screamed; no one really wants to listen to me; I am ashamed of myself”), and how she expected her colleague to act (“He should respect my 25 years of experience but he doesn’t”). The therapist asked how the interaction ended: Virginia admitted she was more stressed about the increase in tension and felt ashamed about her behavior. Virginia and her therapist considered the situation in light of her childhood abuse. Virginia had learned to believe “no one listens to her,” so in order to achieve her goals, she would hold back on her thoughts and feelings, until they exploded. The resulting consequence was actually the thing she feared and was trying to prevent. She had been minimizing her effectiveness on the job and the respect of her coworkers by screaming. Virginia’s therapist asked her to consider what she might do differently, a step toward beginning to change core beliefs about the self and others.

An important therapist skill in STAIR Narrative Therapy is the ability to engage patients in role-playing with the primary objective of developing and testing alternatives to old childhood schemas. Role-playing commonly encountered relationship dynamics (assertiveness, control, flexibility) creates opportunities to practice new behaviors in a safe environment, explore how they feel, and revise as needed. The therapist acts as regulator of the patient’s emotions, pulling for the contextually salient emotions, helping the patient sustain or reduce emotional intensity as needed, and helping the patient identify alternative emotions (e.g., joy, or sadness, instead of guilt, or shame) through the use of collaborative exploration.

At the next session, Virginia’s therapist asked about how her problem with her coworker and completion of the inventory process was going. Virginia said that her colleague had avoided her during the week and she was handling the inventory on her own. She was angry but felt unable to ask for help. The therapist suggested role-playing the situation as a way to practice some alternatives in a safe environment. Before the role-play, the therapist normalized Virginia’s anger in light of the stress of her diagnosis and all that it had churned up. The therapist also suggested that Virginia have a bit more compassion for herself under these circumstances. While the behavior was rude and not particularly effective, it was also not necessary for Virginia to feel so shamed by it. Virginia had difficulty accepting that her behavior was not a product of her being a bad person but rather a situation in which a good person engaged in some bad behavior. While Virginia agreed she should apologize, she could not find a way to do it without feeling like she was groveling and humiliating herself as she believed she would be exposing her essential “badness.” The therapist then modeled a statement of apology in tones of mutual respect for both the apologizer and the one being apologized to and asked Virginia to “try it out.” Once Virginia had practiced the statement, the therapist and Virginia practiced an exchange in which the therapist infused some humor.

The therapist used a bit of humor (“I just walk on by”) to reinforce that the role-play was not “real.” The therapist’s affective approach and responses, particularly expressions of curiosity and playfulness can shape the meaning of these experiences to the patient. Playfulness and humor are incompatible with feelings of fear, and their presence in skills practice such as role-plays conveys the idea that the patient can explore or “try on for size” feelings and attitude that approximate and finally represent a skilled presentation of the message that the patient wishes to give. Playfulness also recognizes that there is both a pretend and real aspect to role-playing. In the pretend aspect, the emotional experience is not as intense because the context does not elicit it (e.g., “I am just pretending to be angry at you, but you are not really Jim”), while the real aspect pulls for a more genuinely felt emotion (e.g., “If I really imagine you are my coworker, it is scary to feel this much anger sitting here in your office”). While this brand of humor will not work with every patient, the goal is to give the individual an authentic emotional experience in which they feel positive self-efficacy in the context of safety and acceptance provided by the therapist.

The interventions in the first module of treatment focus on improving quality of life and functional capacity, stressing emotion regulation. In addition, the experience with the therapist in the titration of emotions during role-play and discussion of emotionally daily-life matters reinforces confidence in the working relationship. Building on these gains, the second module of treatment (sessions 9–16) focuses on the working through of the traumatic past.

Emotional awareness and engagement in feelings associated with the trauma are elicited through explicit verbalization and description of the memories and associated feelings. The telling of these feelings and memories are organized within the structure of a narrative with a beginning, middle, and end. The use of autobiographical narration and its inherent structure help support, reinforce, and consolidate important self-regulatory activities. In the telling of a narrative, the patient (1) learns to regulate the flow of emotion as the narrator of the story; (2) experiences directed, contained, and goal-oriented emotional expression through the presence of an explicitly defined narrative structure; and (3) strengthens metacognitive functioning and self-awareness as the patient is both in the story as its subject and also removed from the story as its narrator.