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.

Advertisements

2 Responses to A Mental Healthcare Model for Mass Trauma Survivors

  1. Leo Voisey says:

    My name is David Summers of Murfreesboro, TN and I have had MS for 16 years. I am 37 years old and as of January 2012, was effectively an 8.0 on the EDSS scale. Originally RRMS, my disease progression had become SPMS (very progressive) within 4 years of onset. Normally anyone in my position and with my bleak diagnosis is limited to a short future, absolutely no quality of life and a painful end…possibly prior to my 40th birthday if the current progression of the disease continued (without the slightest hesitation or glimmer of hope, my Neurologist just told me: “ Prepare to deteriorate”). But after I heard about Dr. Zamboni’s ‘liberation therapy hypothesis’ in 2010, I began my search for the vein-widening therapy. This put me into a clinic in Duluth, Georgia where they were doing the liberation procedure. I received immediate positive results post-procedure…along with the surgeon’s warning that 50% of the MS patients who undergo the liberation therapy suffer a re-narrowing of the jugular veins within a year or so. Sure enough, within 3 months I knew that I was going to be among the unlucky 50%; all of the original improvements disappeared as I relapsed.

    I felt the only way forward was to get it done again, hopefully this time with more enduring results. But where would I go to get this done again and how would that be possible? If my neck veins restenosed after the first treatment, what was to prevent that from happening again…and again? I began to read the Internet blogs and forum chats placed on the many new CCSVI sites by MS patients about where to go and what their experiences were. In this respect, the Internet became a valuable educational tool for me. On several of the blogs, I discovered a New York clinic where they placed a stent during the procedure to keep the jugular veins open, and that positive results were being seen. Grimly, I also discovered that although rare, the prospect of death as a result of this procedure was also a risk. At least one person in a recent study had died when the stent migrated to his heart. But I was willing to put those thoughts and the risks aside. What did I really have to lose? I was dying a slow death. As long as someone was able to treat me there was a chance to hope, and I was down for it. But that wasn’t the main question I was asking myself.

    As my disease rapidly progressed and my disabilities became more overwhelming, the question I was asking myself was, was it too late for me? Although I was happy with the fact that my original liberation therapy had diminished most of the symptoms above my waist, I had to ask myself if getting stents was merely settling for a compromised improvement. Having had some success, if I had this done again, I wanted more! Don’t get me wrong, I think the liberation therapy is a miracle discovery from God. As soon as I had my first procedure my cog fog lifted, the vision in my right eye improved greatly, the numbness in both hands dissipated by a few degrees, my ability to taste food returned, my energy levels were ’off the charts’, and my sleep was so sweet. Also, because MS had robbed my body of the ability to regulate body temperature by sweating, I had not been able to handle the hot, humid Southern summers where I live, except to blast cold AC non-stop as a survival method during those sickly ‘dog days’. After the procedure this changed too. I knew it when deodorant suddenly became necessity for my personal hygiene once again!

    But it ended by the 90-day point and I was right back where I started. Immediately following the procedure I had dreams of rising from the wheelchair I’d been confined to for ten years and walking like a real man; but even with the incredible improvements overall, it seemed that the only healing occurred above the waist. Perhaps I would just have to accept that even if I could improve to what the full extent of the liberation therapy would allow, I would always be in a wheelchair. While researching the New York clinic and other places, my parents and I came upon CCSVI Clinic through a Google search. We discovered that they are essentially a research clinic operating under an IRB but with a major difference. For the past year, having seen even better results than just doing the liberation therapy alone, they have also been transplanting adult autologous stem cells, cultured and re-injected into the body shortly after the neck venoplasty. If I chose to go there instead of New York, the procedure would be done at CCSVI Clinic at Noble Hospital in Pune India and I would have to get there essentially as a partially paralyzed patient transported in a wheelchair. There would also be a requirement to stay in the hospital for 10-12 days. But after researching the improvements demonstrated in MS patients in stem cell clinical trials, I simply decided that as long as they would take me, nothing was going to stop me from making that trip. On calls with the clinic, it was also explained that stents were not necessary as the stem cells injected intravenously could be enough to keep my veins from restenosing. My confidence in their method increased when I discovered that Dr. Gupte, the neurosurgeon, had been transplanting autologous stem cells for 4 years for a number of different neurodegenerative conditions, including MS and based his therapies on completed stem cell trial methods done in a number of hospitals and universities outside of the US (to be absolutely sure, I confirmed this through searches on Google Scholar). He had already done over 2000 successful transplants! Regarding my communications with CCSVI Clinic, I need to confess here that we did not tell the doctors the truth originally. My mother, who arranged the treatments, told them that I was an EDSS 6.5 in order to qualify. Basically she knew that they wouldn’t accept me into the program if she said I was higher. But if they saw my actual physical condition could they refuse me on the clinic steps? I hoped not.

    So in late March it was off to India with my father who is a strong man, and my capable assistant. We arrived on March 26, 2012, and met Surjo Banerjee, CCSVI Clinic’s Managing Director at the airport. He drove us from the airport to Pune, a surprisingly modern city just south of Mumbai. I was amazed to see that the hospital and the CCSVI Clinic itself, (a full wing of suites within the hospital complex) was as clean and modern as any hospital here in the States. After checking in with a number of other patients, I was triaged for the procedures. However, based on my new assessment, it was determined that I would need about twice the amount of stem cells that they had originally programmed, figuring my EDSS scale requirement of 6.5. But paying more was out of the question. We are not rich and had basically ‘sold the farm’ to get here in the first place, and the recommended additional stem cells were going to cost another $12,000 that we had not planned for. Not their fault…I didn’t tell them the extent of my condition in the first place. So the first miracle happened when CCSVI Clinic management offered to personally cover these additional costs. I had never even met some of them, but as a result of their generosity, I received an additional 50,000,000 mesenchymal stem cells and I cannot thank them enough for the difference they have made to my life.

    On Tuesday March 27

    , I once again had the liberation therapy followed by the harvesting of red bone marrow cells from my hip bone. The clinic has strict aftercare protocols around each type of procedure with regard to position control and movement. It didn’t much affect my activity because I was unable to move much anyway. I was supine positioned, tilted slightly head high for two days following my venoplasty and then laid out supine again, in just the opposite tilt…head-lower-than-the-body for several days following the transplants of the stem cells. I was told that this would allow the newly transplanted stem cells to filter through the full length of the nervous system and locate to the points of injury. A Doppler ultrasound of my neck veins was done every day for 10 days following my liberation procedure. This was to check for any clotting or re-narrowing of the veins which had been widened. If they clotted or restenosed at any time I was in the clinic, they would take me back into the cathlab for a re-do. Happily this wasn’t necessary.
    Following the liberation therapy, the changes within my body were just as immediate and dramatic as in my first procedure in 2010, hopefully without the fear of re-stenosis; but my ‘headspace’ almost didn’t accept it. The first time with my liberation therapy in the US, the IR found one narrowing in each jugular, the right side being more severe. This time around, two blockages were found on my right side, and again one on the left. I have heard that second and third procedures for venous angioplasty are more difficult for the surgeons because there is more build up of scar tissue in the interior of the veins, but the medical team took their time and did a perfect job. Words cannot express the emotional joy in getting the blood flowing again and getting those symptomatic improvements back a second time!

    Four days later I underwent a lower lumbar puncture, but this time not simply to gather information on whether I have MS. This time, stem cells cultured from my own body were on their way to do what God designed them to do, and that is to heal. For all of you that might be skeptical about this, I am here to tell you that is exactly what they are doing. The positive changes were noticed as soon as I returned to my suite in the clinic and anyone who is paralysed below the waist will understand this next part. To manoeuvre myself as I usually do, I went to pick my leg up from a sitting position and throw it in front of me. The hope here is that the ‘dead-weight’ of the leg will land just right and in a position where I can best situate myself to haul my body into a position where I can further awkwardly throw my whole body into my wheelchair. If you’ve ever seen a spinal patient do this or are unlucky enough to have to do this yourself, you know what an ugly, uncomfortable process this is. But this time the ‘throw’ of the leg proved to be an over-compensation. To my absolute shock and delight my leg lifted itself just as it’s supposed to work…without aid from my helpful hands and placed itself exactly where my brain told it go! At first I didn’t think much of it…this was a fluke, maybe my imagination, but it was something sure not to last. But it has to this day without any hint of regression as I work out and get stronger. This was the first sign of any recovery whatsoever that has occurred below the waist in over ten years, and it happened only hours after the stem cell transplant!

    Upon returning home on April 14, 2012, I closely followed the Clinic’s physiotherapy program. Since then I have been working out at levels I had been told by my doctors here in the states would not be possible again. When exercising before I had stem cell therapy, I always had to be careful not to overdo it because I would get a sickness that sometimes lasted 2 days, completely wiping me out. This even occurred after the first liberation therapy, but no more. I’ve been working myself silly and have not yet felt sick. Real strength has returned and muscles have been popping out in places on my body where I haven’t seen them in many years. As of this writing today, and for about the last two weeks my right hand has been functioning normally in every respect. I’m not saying it has improved some, I’m saying it is now completely NORMAL! I can hardly believe it myself.

    Since I returned, and after only one month, the positive changes have been happening regularly and most every day. Most significantly, I think, my incontinence has completely improved and I am now able to almost totally control my urinary and elimination functions. All other disabilities aside, I think that this is one of the most important deficits that anyone with MS wishes they could get back! Incontinence is so embarrassing and not having control of that particular function somehow makes you feel lesser as a person. So I’m very happy to see the improvements there. My speech is back to normal. Although I never slurred my words, the thought process was oh-so-slow. Now my words come so quickly that I sometimes find myself stumbling over them…trying to say too much at once. I can’t complain about that!

    I am convinced that CCSVI Clinic is on to important discoveries about MS. They have figured this out and are doing the sequence of therapies correctly and the addition of the stem cells completes the need to repair the nerve damage that’s been done by the disease. In retrospect what they are doing suddenly makes complete sense to me. It’s still early yet and I guess time will tell to what extent my motor functions will come back, but if the last month is any indication, it could be everything, which excites me so much. I don’t know if that’s too much to hope for, but it’s the first time in 10 years that I’ve even really allowed the thought to cross my mind. The first fleeting thoughts of this after the original liberation therapy 2 years ago weren’t realistic. The good changes didn’t last. And consider this; a few months ago, I was in a wheelchair, in a permanent brain fog losing more of my independence and quality of life on a daily basis. All I had to look forward to was a deteriorating condition where others would have to take care of my every bodily function. Now I can’t wait to wake up every morning to check myself out. If anything I’m too impatient and working out too hard. But at least I can! Given my current state of health and ability to live and function on my own, the thing that is very certain is that I have a much better quality of life back and that wouldn’t have even been possible if it hadn’t been for the lucky discovery of CCSVI Clinic through an Internet search. My family and I will be eternally grateful for what has happened no matter how this turns out. Thanks to Dr. Gupte, the other doctors, the medical team and staff at the Clinic who made this all happen for me, I’m looking forward to each day with new health and optimism! May God Bless them all!

    I have a long way to go, but as long as my jugular veins are wide open and the stem cells continue to clean up the mess those narrowed veins left behind, and damaged nerves continue to regenerate, I believe the sky is truly the limit! My main focus at this point is not only to rebuild muscle but to get my legs to work together, which will restore my balance.

    Every day is a new gift that allows me more recovery. I can hardly wait for each morning to see the next improvement! There’s so much more happening in my body than I’ve even mentioned in this writing but I hope I’ve related the main message here…MS was my previous diagnosis.

    I will be starting a blog on my progress in a week or two if anyone wants to contact me or follow my improvement. I’m sure there are many of you out there who are skeptical or would want to know how this is going for me. I’ll post the site information back here once I have it up.The first fleeting thoughts of this after the original liberation therapy 2 years ago weren’t realistic. The good changes didn’t last. And consider this; a few months ago, I was in a wheelchair, in a permanent brain fog losing more of my independence and quality of life on a daily basis. All I had to look forward to was a deteriorating condition where others would have to take care of my every bodily function. Now I can’t wait to wake up every morning to check myself out. If anything I’m too impatient and working out too hard. But at least I can! Given my current state of health and ability to live and function on my own, the thing that is very certain is that I have a much better quality of life back and that wouldn’t have even been possible if it hadn’t been for the lucky discovery of CCSVI Clinic through an Internet search. My family and I will be eternally grateful for what has happened no matter how this turns out. Thanks to Dr. Gupte, the other doctors, the medical team and staff at the Clinic who made this all happen for me, I’m looking forward to each day with new health and optimism! May God Bless them all!

    I have a long way to go, but as long as my jugular veins are wide open and the stem cells continue to clean up the mess those narrowed veins left behind, and damaged nerves continue to regenerate, I believe the sky is truly the limit! My main focus at this point is not only to rebuild muscle but to get my legs to work together, which will restore my balance.

    Every day is a new gift that allows me more recovery. I can hardly wait for each morning to see the next improvement! There’s so much more happening in my body than I’ve even mentioned in this writing but I hope I’ve related the main message here…MS was my previous diagnosis.

    I will be starting a blog on my progress in a week or two if anyone wants to contact me or follow my improvement. I’m sure there are many of you out there who are skeptical or would want to know how this is going for me. I’ll post the site information back here once I have it up.For more information visit our site http://davidsmsstemcelljourney.blogspot.in/

  2. Fascinating and important work which deserves a wide audience.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: