A Mental Healthcare Model for Mass Trauma Survivors

Blog post by Metin Basoglu, Professor of Psychiatry, & Ebru Salcioglu, Associate Professor of Psychology and Research Associate, Trauma Studies, Department of Psychological Medicine, Institute of Psychiatry, King’s College London & Istanbul Center for Behavior Research and Therapy (ICBRT / DABATEM), Turkey

Mass trauma events, such as wars, armed conflicts, acts of terror, political violence, torture, and natural disasters affect millions of people around the world. Currently there is no mental healthcare model that is capable of addressing the needs of masses of trauma-exposed people, particularly the dispossessed populations of developing countries that often bear the brunt of mass trauma events. Effective dealing with this problem requires interventions that are (1) theoretically sound, (2) proven to be effective, (3) brief, (4) easy to train therapists in their delivery, (5) practicable in different cultures, and (6) suitable for dissemination through media other than professional therapists, such as lay people, self-help tools, and mass media. Current treatments commonly used with trauma survivors do not meet more than two or three of these requirements. The last requirement is particularly important, as even the most effective treatment is of limited use if it cannot be widely disseminated to millions of people in need of help.

A learning theory approach to understanding mass trauma

The book details 20 years of work in search of a mental healthcare model that satisfies the above requirements. Such a model requires a sound theoretical framework. In a previous book (Başoğlu, 1992) on Torture and Its Consequences: Current Treatment Approaches, we had examined the parallels between animal and human responses to unpredictable and uncontrollable stressors and presented a learning theory formulation of torture trauma (Başoğlu & Mineka, 1992) drawing on the work of prominent learning theorists and anxiety researchers. A series of studies that explored the parallels between animal and human experience under extreme duress demonstrated that helplessness induced by exposure to unpredictable and uncontrollable stressors play an important role in the development of traumatic stress reactions in survivors of war, torture, and earthquakes. Such evidence implied that traumatic stress can be reversed by interventions that enhance sense of control (or resilience against) traumatic stressors and led to the development of Control-Focused Behavioral Treatment (CFBT).

CFBT: A paradigm shift in trauma treatment

CFBT involves encouragement for exposure to distressing trauma cues until sufficient sense of control over anxiety cues develops. It is fundamentally different from other exposure-based treatments in aiming at increased anxiety tolerance and control over (or resilience against) traumatic stressors, rather than mere anxiety reduction. Most psychiatric and psychological treatments developed in western countries aim at anxiety reduction, despite evidence pointing to anxiety tolerance and control as a more important process in recovery from anxiety disorders. Furthermore, anxiety reduction is not a realistic therapy aim, considering the prevalence and prolonged nature of various mass trauma events, particularly in developing countries. Thus, with its focus on resilience, CFBT represents a radical departure from traditional approaches to anxiety that characterize most western treatments.

Evidence shows that increased sense of control over trauma cues and reduced avoidance of trauma reminders result in reduction of traumatic stress symptoms, depression, and functional impairment. CFBT was first tested in earthquake survivors and demonstrated to be highly effective in 90% of the cases when delivered in 1 to 4 sessions. Currently ongoing work with asylum-seekers and refugees suggest that it is as effective in war and torture survivors as in earthquake survivors. 

A self-help model of survivor care

The development of CFBT was inspired in part by our observations of natural recovery processes in war, torture, and earthquake survivors. Examining how survivors coped with debilitating trauma-induced distress or fear of reliving the trauma, we discovered that many survivors, without any guidance from a therapist, used self-exposure to feared situations in their natural environment to overcome their fear. Such examples of self-instigated exposure to trauma reminders can also be observed in other trauma survivors. For example, many road traffic accident survivors who are reluctant to drive for fear of another accident make an effort to start driving again soon after the accident, thinking that surrendering to their fear means they may never be able to drive again. These observations suggest that self-help is not only a viable approach in survivor care but also one that carries great potential.  Using a persuasive treatment rationale (i.e. beat your fear or surrender to it and live your life in misery), CFBT simply provides a motivational impetus for a naturally existing tendency in people to use self-exposure as a means of overcoming trauma-induced helplessness. Evidence also suggests that the treatment can be effectively delivered through a self-help manual. Such evidence helped us conceive a self-help model of survivor care that entails cost-effective treatment dissemination through all possible means, including professional and lay therapists, self-help tools, and mass media. Two structured manuals concerning earthquake trauma (provided in the book) were developed to facilitate cost-effective dissemination of treatment knowledge to care providers as well as to survivors themselves. 

Controversies in treatment of torture survivors

Fairly prevalent among care providers is the view that traumas of human design, such as war and torture, are different from natural disasters in being more severe and therefore more difficult to treat. Available literature evidence does not support this belief. In a heated debate that followed a British Medical Journal editorial (Basoglu, 2006) pointing to lack of evidence regarding the effectiveness of current torture rehabilitation programs, some mental health professionals dismissed the idea of brief treatments for torture survivors as a ‘quick fix’ approach. The difficulty experienced in treating torture survivors (in costly rehabilitation programs lasting 1 to 3 years) arises largely from use of essentially ineffective interventions that do not closely match the underlying mechanisms of traumatic stress in torture trauma. The book reviews the evidence suggesting that brief treatment of torture trauma is possible by instigating a behavioral self-help process that takes about 2-3 months to reach its maximum therapeutic effects and provides a detailed discussion of mechanisms of improvement that account for recovery from traumatic stress. 

Controversies in definition of torture: A learning theory perspective

A learning theory formulation of torture not only sheds light on potentially effective treatments but also facilitates understanding of what constitutes torture. Following allegations of human rights abuses by the U.S. military in Guantanamo Bay, Iraq, and Afghanistan, the previous U.S. government argued that various interrogation or detention procedures, such as blindfolding, hooding, waterboarding, forced nudity, isolation, forced stress positions, deprivation of sleep and other basic needs, humiliation, and psychological manipulations to induce fear in detainees do not constitute torture. Such a restriction in the definition of torture triggered a debate in political and academic circles, as well as in the media and public on what constitutes torture and whether certain ‘aggressive interrogation techniques’ are permissible under certain circumstances. Such debate was not informed by scientific evidence, as no study had investigated this issue. We examined the distinction between torture and other ‘cruel, inhuman, and degrading treatment’ (CIDT) in 279 tortured war survivors from former Yugoslavia (Basoglu et al., 2007). Comparing physical and non-physical stressor events in terms of associated distress and uncontrollability, no clear-cut distinction was found between physical torture and CIDT in terms of their immediate and long-term psychological impact. A second study (Basoglu, 2009) of 432 torture survivors from Turkey and former Yugoslavia countries demonstrated that CIDT is more psychologically damaging than physical torture and that contextual factors (e.g. context of captivity, appraisal of threat, stressor interactions) pose a greater risk for posttraumatic stress than torture. These studies received wide media attention in showing that the previous U.S. administration’s narrow definition of torture is not supported by scientific evidence. The learning theory formulation of torture trauma presented in the book, together with previously unpublished evidence in support of this formulation, sheds more light on what constitutes torture. 

References

Basoglu M (1992) Torture and Its Consequences: Current Treatment Approaches. Cambridge: Cambridge University Press.

Basoglu M & Mineka S (1992) The role of uncontrollable and unpredictable stress in post-traumatic stress responses in torture survivors. In Torture and its Consequences: Current Treatment Approaches, ed. M. Basoglu. Cambridge: Cambridge University Press, 182-225.

Basoglu M (2006) Rehabilitation of traumatised refugees and survivors of torture – After almost two decades we are still not using evidence based treatments. British Medical Journal, 333, 1230-1231.

Basoglu M, Livanou M, Crnobaric C (2007) Torture vs other cruel, inhuman, and degrading treatment – Is the distinction real or apparent? Archives of General Psychiatry, 64, 277-285.

Basoglu M (2009) A multivariate contextual analysis of torture and cruel, inhuman, and degrading treatments: Implications for an evidence-based definition of torture. American Journal of Orthopsychiatry, 79, 135-145.