A Self-Help Model of Mental Health Care
in War, Torture, and Natural Disaster
Survivors
Section of Trauma Studies, Institute of Psychiatry
King’s College London
&
Istanbul Centre for Behaviour Research and Therapy –
ICBRT / DABATEM
Overview of evidence from data based
on war, torture, and natural disaster
trauma accumulated since 1990
Evidence base –
War / torture survivors (1990 – 2007)
• 3 studies of torture survivors in Turkey
• A study of 2,500 war survivors in former Yugoslavia
countries, including
– combat veterans
– torture survivors
– refugees
– internally displaced people, and
– survivors of aerial bombardment
• Single case experimental studies
Evidence base –
Earthquake survivors (1999 – 2007)
• 4 field surveys and 3 epidemiological studies
involving more than 6,200 survivors
• A study of phenomenology / mechanisms of
earthquake trauma in 387 survivors
• 9 questionnaire development studies
• 2 uncontrolled, 2 randomised controlled treatment
studies involving 331 cases
• 8 single case experimental studies
• Observational data in fieldwork with > 12,000
survivors
Starting the journey in mid 1980s –
Search for a sound theoretical framework in
understanding anxiety disorders
Learning theory based on experimental work
with animals provide ample evidence for the role
of unpredictable and uncontrollable stressors
in development of anxiety / fear responses
(Mineka & Zinbarg, 2006)
Susan Mineka, PhD
Northwestern University
Parallels between animal and human
responses to unpredictable and
uncontrollable stressors
A learning theory model of torture trauma
(Basoglu and Mineka, 1992 –
Torture and Its Consequences, Cambridge University Press)
Before trauma
Before
trauma
Stressor
perceived as
uncontrollable
Genetic &
temperamental factors /
Previous learning of
control over stressors
During trauma
During
trauma
Failed fight-flight /
Loss of control over
stressor event
NATURAL
RECOVERY
PROCESSES
After trauma
trauma
After
Uncertainty
about future
helplessness
(anxiety)
Certainty
about future
helplessness &
hopelessness
Loss of close
ones / resources
Life stressors
Stressor
perceived as
controllable
Successful fightflight / Control over
stressor event
Sense of control
over future
stressors
PTSD / Other
anxiety disorders /
Other psychiatric
disorders &
physical illnesses
Psychosocial
disability
Depression
Positive
psychological
outcome &
Resilience
Evidence I - Torture trauma
Psychological preparedness for torture predicts
• less distress during torture
• lower rates of subsequent PTSD
(Basoglu et al, Psychological Medicine, 1997)
Evidence II – Torture trauma
Loss of control during torture predicts PTSD
and depression
Basoglu et al, Archives of General Psychiatry, 2007
Evidence III – War / torture trauma
Strongest predictor of PTSD and depression
in war / torture survivors
=
Loss of control over fear associated with
perceived ongoing threat to safety
Basoglu et al, JAMA, 2005
Evidence IV – Earthquake trauma
• Strong predictions between fear during the
earthquake and PTSD in field surveys
• Strong correlations among measures of fear,
avoidance, helplessness cognitions, PTSD, and
depression (Salcioglu, 2004).
• Similar evidence from studies of war and torture
survivors
Evidence - V
Naturalistic observations of individual and
collective responses to earthquake trauma
• Striking parallels with animal responses to
inescapable shock
• Humans employ a wide range of cognitive and
behavioural strategies to reduce perceived
unpredictability and uncontrollability of
earthquake stressors
Reliance on safety signals
The absence of threat signals, such as
– birds making a noise
– dogs barking
– a particular colour of the sea
– clear visibility of the stars at night
– an unusually hot and windless day
reduces anxiety.
Belief in frequent rumours about
impending earthquakes
• A tendency to believe in frequent rumours
about an earthquake expected to occur on a
particular date
An attempt to reduce anxiety by making an
unpredictable stressor more predictable and,
therefore, more controllable
Avoidance of threat signals
•
•
•
•
•
•
•
Concrete buildings
Staying alone at home
Staying in the dark
Taking a shower
Getting undressed before going to bed
Sleeping with lights off
Places from which escape during an
earthquake would be difficult
Rapid fear conditioning
Fear of earthquakes – A prepared fear?
Avoidance –
An evolutionary perspective
Vigilant avoidance - most common coping
strategy early in our evolutionary history
(Cantor, 2005)
‘Cost-benefit ratio theory’
• Avoidance is dependent on relative costs and
benefits of avoidance behaviour or the ‘costbenefit ratio’ (Kavaliers & Choleris, 2001).
• Avoidance has survival value in animals as
long as it does not interfere with feeding and
mating opportunities. Animals take greater
risk of predators when hungry (Lima, 1998).
Hypothesis
Cost-benefit theory would predict that
avoidant survivors for whom the costs of
avoidance outweigh its benefits would be
more likely to engage in risk-taking behaviors
and eventually stop avoiding situations that
signal threat to safety (e.g. concrete
buildings).
Risk-taking behaviours - I
• Mean time for resettlement at home = 126
days (SD = 162, range 1 – 905).
• Resettlement in most cases coincided with
onset of severe winter.
• 67% returned home because of hardships of
living in shelters.
Risk-taking behaviours - II
• Entering buildings to fetch various essential
items (e.g. clothes, blankets, electric heaters,
etc.) or to take a shower.
• 95% entered their house within first month of
disaster when aftershocks were most
frequent.
Risk-taking behaviours - III
Accidental discovery of exposure as a useful
coping strategy leading to its systematic use
in overcoming fear.
Risk-taking behaviours - IV
Systematic attempts to gain control over fear
by entering buildings in a graduated fashion.
Effects of exposure to fear cues in
natural environment
Survivors improved in PTSD after they
resettled in concrete houses.
Salcioglu, Basoglu, et al, Disasters, 2007
Role of sense of control in natural
recovery from fear of earthquakes
• 60% of survivors reported decrease in their
fear of aftershocks.
• Reduced fear was associated with
– increased sense of control over fear during
tremors
– learning to cope with aftershocks
– improvement in PTSD
Salcioglu, PhD Thesis, King’s College London, 2004
Conclusions - I
• Trauma is as old as human history
itself. We need to learn from our
evolutionary heritage in dealing with
trauma.
• Identify mechanisms of natural recovery
and develop interventions that
incorporate the same mechanisms.
Conclusions - II
Self-exposure to fear cues –
a major factor in natural recovery process
Before trauma
Before
trauma
Stressor
perceived as
uncontrollable
Genetic &
temperamental factors /
Previous learning of
control over stressors
During trauma
During
trauma
Failed fight-flight /
Loss of control over
stressor event
NATURAL
RECOVERY
PROCESSES
After trauma
trauma
After
Uncertainty
about future
helplessness
(anxiety)
Certainty
about future
helplessness &
hopelessness
Loss of close
ones / resources
Life stressors
Stressor
perceived as
controllable
Successful fightflight / Control over
stressor event
Sense of control
over future
stressors
PTSD / Other
anxiety disorders /
Other psychiatric
disorders &
physical illnesses
Psychosocial
disability
Depression
Positive
psychological
outcome &
Resilience
Implications for post-trauma prevention
and treatment of traumatic stress –
HYPOTHESIS 1:
IF
loss of control over fear induced by traumatic
stressors is the strongest predictor of acute traumatic
stress, chronic PTSD and depression,
THEN
interventions designed to enhance sense of control
over fear should reduce all three conditions.
Before trauma
Before
trauma
Stressor
perceived as
uncontrollable
Genetic &
temperamental factors /
Previous learning of
control over stressors
During trauma
During
trauma
Failed fight-flight /
Loss of control over
stressor event
NATURAL
RECOVERY
PROCESSES
After trauma
trauma
After
Uncertainty
about future
helplessness
(anxiety)
Certainty
about future
helplessness &
hopelessness
Loss of close
ones / resources
Life stressors
Stressor
perceived as
controllable
Successful fightflight / Control over
stressor event
Sense of control
over future
stressors
PTSD / Other
anxiety disorders /
Other psychiatric
disorders &
physical illnesses
Psychosocial
disability
Depression
Positive
psychological
outcome &
Resilience
Implications for pre-trauma prevention
of traumatic stress – Resilience building
HYPOTHESIS 2:
IF
previous learning of control over similar stressors is
associated with less post-traumatic stress,
THEN
pre-trauma interventions designed to enhance sense
of control over similar stressors should increase
resilience against posttraumatic stress.
Examples of resilience building
Exposure to stressors in a controlled environment
until stress / anxiety tolerance develops
• Training of Buddhist monks, dervishes of Mevlevi
order of Islamic sophism
• Training of soldiers, commandos, special forces,
political activists
• Survival, Evasion, Resistance, Escape (SERE)
Before trauma
Before
trauma
Stressor
perceived as
uncontrollable
Genetic &
temperamental factors /
Previous learning of
control over stressors
During trauma
During
trauma
Failed fight-flight /
Loss of control over
stressor event
NATURAL
RECOVERY
PROCESSES
After trauma
trauma
After
Uncertainty
about future
helplessness
(anxiety)
Certainty
about future
helplessness &
hopelessness
Loss of close
ones / resources
Life stressors
Stressor
perceived as
controllable
Successful fightflight / Control over
stressor event
Sense of control
over future
stressors
PTSD / Other
anxiety disorders /
Other psychiatric
disorders &
physical illnesses
Psychosocial
disability
Depression
Positive
psychological
outcome &
Resilience
Control-Focused Behavioural Treatment –
CFBT
1. Identify fear and avoidance behaviours
2. Provide treatment rationale
3. Give self-exposure instructions
4. Monitor progress (if more than 1 session)
CFBT is not CBT
• Treatment aim = enhancement of sense of
control over fear - NOT fear reduction
• Treatment focus solely on avoidance
behaviours
• No systematic cognitive restructuring or other
anxiety-reduction techniques
Study I
The Effectiveness of Control-Focused
Behavioural Treatment for Chronic PTSD
in Earthquake Survivors:
Results from an Open Clinical Trial
Başoğlu, Livanou, Şalcıoğlu et al.
Psychological Medicine, 2003
Study design
(n = 231)
Screen
Treatment sessions
S0 S1 S2 S3 S4 S5 S6 S7 S8 S9
Follow-up sessions
1m 3m 6m
Cumulative probability of improvement
in PTSD and non-PTSD cases
PTSD
non-PTSD
100
97
100
89
100
76
80
60
85
94
90
91
66
40
Median improvement time
PTSD cases = 1.7 sessions
Non-PTSD cases = 1.8 sessions
20
0
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Study II
Single-session
control-focused behavioural treatment
of earthquake-related PTSD:
a randomised waitlist controlled trial
Başoğlu, Şalcıoğlu, Livanou et al
Journal of Traumatic Stress, 2005
Patient’s Global ImpressionImprovement Ratings at Follow-up
No change / Slightly improved
Much / very much improved
80%
86%
83%
85%
59%
41%
20%
6 weeks
12 weeks
15%
24 weeks
17%
1-2 year
14%
Last available
assessment
What improves first? Behavioural
avoidance or other PTSD symptoms?
Analyses of sequence of improvement show that
behavioural avoidance improves first early in treatment
(week 6), followed by other PTSD and depression
symptoms.
Şalcıoğlu, Başoğlu, Livanou. Behaviour Research and Therapy, 2007
Next question: What happens when
you introduce UCS in treatment?
Unconditioned stimulus
=
earthquake tremors
Study III
A single-session of
Earthquake Simulation Treatment
Başoğlu, Livanou, Şalcıoğlu
American Journal of Psychiatry, 2003
Earthquake Simulation Treatment
• Exposure to simulated earthquake tremors
using an earthquake simulator
• Aim = to reduce earthquake-related traumatic
stress by enhancing sense of control over
earthquake tremors
An artist’s imagination of
Earthquake Simulation Treatment
Courtesy of Jose Carlos Fernandez
Earthquake Simulator – Outside view
Earthquake Simulator – Inside view
Study Design
(n = 10)
EST
W0
W2
W4
W8
W12
No explicit self-exposure instructions at post-session
EST = Earthquake Simulation Treatment
Fear and Avoidance Questionnaire
60
40
p<.05
p<.05
20
p<.05
p<.01
0
Baseline
Week 2
Week 4
Week 8
Week 12
Clinician Administered PTSD Scale (CAPS)
80
60
p<.001
40
20
0
Baseline
Week 12
Beck Depression Inventory
30
p<.01
20
p<.01
10
0
Baseline
Week 2
Week 4
Week 8
Week 12
Study conclusion
• Earthquake Simulation Treatment enhances
sense of control over fear of earthquakes
• Facilitates subsequent self-exposure even
when no explicit self-exposure instructions
are given.
Study IV
A randomised controlled study of
Earthquake Simulation Treatment
Başoğlu, Şalcıoğlu, Livanou
Psychological Medicine, 2007
Fear and Avoidance Questionnaire
CFBT
60
WL
p < .001
40
p < .01
20
0
Week 0
Week 4
Week 8
Week 12
Week 24 1-2 Years
Clinician Administered PTSD Scale
CFBT
WL
60
p < .01
40
p < .01
20
0
Week 0
Week 4
Week 8
Week 12
Week 24 1-2 Years
General Improvement Scale Patient Version: 1-2 Year Assessment
Much / Very much
Moderate
Slight
80%
12%
8%
Combined treatment versus
CFBT alone
CFBT
CFBT+Earthquake Simulation Treatment
60
40
ES = .90
20
0
Week 0
Week 12
Week 24
1-2 Years
Comparison of effect sizes with CFBT and other
treatments for PTSD
(reviewed by Bradley et al, 2005)
2.45
1.57
1.65
1.66
1.43
0.59
0.35
E
13 studies
CBT
EC
EMDR
WL
SC
CFBT
5 studies 9 studies 10 studies 15 studies 8 studies 4 studies
E: Exposure, CBT: Cognitive-Behavioural Tx, EC: Exposure & Cognitive Restructuring, EMDR: Eye
Movement Desensitization Reprocessing, WL: Waiting List, SC: Supportive Control, CFBT = Control
Focused Behavioural Treatment
Implications for self-help treatment
If CFBT merely facilitates natural recovery,
is therapist essential for this process?
Study V
A self-help manual for earthquake survivors:
Single-case experimental studies
Başoğlu, Şalcıoğlu, Livanou. Journal of Behaviour Therapy and
Experimental Psychiatry, 2009
Study Design
(n = 8)
2 baseline
assessment in 4
weeks
B1
B2
Posttreatment
Treatment
assessment
Manual
W10
Follow-up
W4
W12
W24
Fear and Avoidance Questionnaire
70
60
ns
50
40
p < .001
30
20
10
0
Baseline 1 Baseline 2
Post-Tx
W4
W12
W24
Clinician Administered PTSD Scale
70
60
ns
50
40
p < .001
30
20
10
0
Baseline 1 Baseline 2
Post-Tx
W4
W12
W24
Conclusions - I
• CFBT is a potent intervention that reduces
PTSD, depression, and functional disability
• Facilitates natural recovery processes
• Increases resilience
• Likely to have preventive value
Conclusions - II
• CFBT is a predominantly self-help intervention.
The critical component of treatment (exposure)
is often self-administered
• 90% of survivors comply with self-exposure
instructions
• Therapist not essential for recovery
Possible treatment dissemination
methods - I
• Self-help manual
• Lay therapists / survivors
Treatment delivery through
lay therapists
Possible treatment dissemination
methods - II
•
•
•
•
•
Videocassettes
CDs
Internet
Public educational campaigns
Mass media, e.g. TV, radio
Conclusions - III
CFBT is likely to be effective in other types of
trauma where fear and loss of control are the
primary mediating factors in traumatic stress.
These include traumatic events that involve
threat to safety or life.
Conclusions - IV
• Studies provide largest body of evidence to date in
support of learning theory of traumatic stress in
humans.
• Findings have important implications for treatment of
other psychiatric conditions, including anxiety
disorders and depression.
A cost-effective treatment delivery model
Treatment non-responders – Number of
cases = 2
STAGE 3: 4-session CFBT for 20 cases
Total N of sessions: 80; Likely response rate
= 90%
STAGE 2: Therapist-delivered live exposure for
100 cases Total N of Sessions: 100; Likely
response rate = 80%
STAGE 1: SS-CFBT + self-help manual for
500 cases Total N of sessions = 20; Likely
response rate = 80%
SCREENING: Number of cases
identified as not in need of treatment
(per 1,000)
18
80
400
500
Therapist time costs of current trauma
treatments
Mean N of
sessions
per case
Cost per case* Cost ratio
relative to
CFBT
CFBT
1.16 (0.4)§
£96 (£33)
-
CBT
10
£825
8.6 (25)
EMDR
4.6
£380
3.9 (11.5)
* Based on cost of 1 CBT session in U.K. = £82.5
§ Individual treatment (treatment in groups of 25)
Directions for future work
• Develop self-help tools for war & torture survivors
(e.g. self-help, manual, video treatment)
• Test self-help tools
• Test outreach model
• Test alternative treatment dissemination methods
(e.g. computerised treatment programmes,
Internet, mass media, public campaigns, etc)