D. Stress Inoculation Training (SIT)

BACKGROUND

Stress inoculation training (SIT) is a type of CBT that can be thought of as a tool box or set of skills for managing anxiety and stress (Hembree & Foa, 2000). This treatment was developed for the management of anxiety symptoms and adapted for treating women rape trauma survivors. SIT typically consists of education and training of coping skills, including deep muscle relaxation training, breathing control, assertiveness, role playing, covert modeling, thought stopping, positive thinking and self-talk. The rationale for this treatment is that trauma related anxiety can generalize to many situations (Rothbaum et al., 2000). The Expert Consensus Guideline Series: Treatment of Posttraumatic Stress Disorder notes that anxiety management is among the most useful psychotherapeutic treatments for patients (Foa et al., 1999b).

DISCUSSION

There have been two RCTs that have evaluated SIT and both studies found SIT to be effective with women who have survived sexual assault. A study by Foa and colleagues (1991) with 45 female sexual assault victims compared SIT, Prolonged Exposure (PE), Supportive Counseling (SC) and wait list control. SIT was found to be the most effective treatment for short term symptom improvement and both SIT and PE were effective for long term improvement with PE superior to SIT. Rothbaum (2001) reports, "results suggested that all conditions produced improvement on all measures immediately posttreatment and at follow-up. At follow-up, clients who received PE continued to improve after treatment termination, whereas clients in the SIT and SC conditions evidenced no change between posttreatment and follow-up." Another study with 96 female sexual assault victims compared SIT, PE, combined SIT and PE, and wait list controls (Foa et al., 1999a). The study found all treatments were better than wait list control for ameliorating PTSD severity at posttreatment and at 6-month follow-up. Interestingly, although all three treatments were effective, the combined treatment was not superior to either SIT or PE alone, which may be related to the fact that clients in the combined treatment group actually received less PE and SIT training than participants in the individual treatments as treatment sessions were all equal in length.

A study of 15 women by Kilpatrick et al. (1982) found SIT to be effective in reducing rape related fear and anxiety.

Motor vehicle accident survivors (Hickling & Blanchard, 1997) had a 68 percent reduction of PTSD symptoms after involvement in a modified version of Foa et al.'s SIT/PE combination program.

SIT is designed to "inoculate" people with PTSD from heightened stress responses through teaching anxiety management skills which can include:

• Relaxation training: teaching patients to control fear and anxiety through the systematic relaxation of the major muscle groups.
• Breathing retraining: teaching slow, abdominal breathing to help the patient relax and/or avoid hyperventilation with its unpleasant and often frightening physical sensations.

A controlled study comparing three different forms of relaxation (relaxation, relaxation plus deep breathing, and relaxation plus deep breathing plus biofeedback) for 90 Vietnam veterans found that all treatments were equally, but only mildly, effective in leading to improvement (Watson et al., 1997).

• Positive thinking and self-talk: Teaching the person how to replace negative thoughts (e.g., 'I'm going to lose control') with positive thoughts (e.g., 'I did it before and I can do it again') when anticipating or confronting stressors.
• Assertiveness training: teaching the person how to express wishes, opinions, and emotions appropriately and without alienating others.
• Thought stopping: distraction techniques to overcome distressing thoughts by inwardly 'shouting stop' (Foa et al., 1999b).