Psychosocial problems associated with impunity

1
A Self-Help Model of Mental Health Care in War,
Torture, and Natural Disaster Survivors Section
of Trauma Studies, Institute of Psychiatry Kings
College London Istanbul Centre for Behaviour
Research and Therapy ICBRT / DABATEM
2
Overview of evidence from data based on war,
torture, and natural disaster trauma accumulated
since 1990
3
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

4
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 gt 12,000
  survivors

5
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)

6
Susan Mineka, PhDNorthwestern University
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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)

8
Before trauma
During trauma
After trauma
Before trauma
During trauma
After trauma
Certainty about future helplessness
hopelessness
Genetic temperamental factors / Previous
learning of control over stressors
9
Evidence I - Torture trauma

• Psychological preparedness for torture predicts
• less distress during torture
• lower rates of subsequent PTSD
• (Basoglu et al, Psychological Medicine, 1997)

10
Evidence II Torture trauma

• Loss of control during torture predicts PTSD and
  depression
• Basoglu et al, Archives of General Psychiatry,
  2007

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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

12
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

13
Evidence - VNaturalistic 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

14
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.

15
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

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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

17
Rapid fear conditioning

• Fear of earthquakes A prepared fear?

18
Avoidance An evolutionary perspective

• Vigilant avoidance - most common coping strategy
  early in our evolutionary history
• (Cantor, 2005)

19
Cost-benefit ratio theory

• Avoidance is dependent on relative costs and
  benefits of avoidance behaviour or the
  cost-benefit 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).

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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).

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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.

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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.

23
Risk-taking behaviours - III

• Accidental discovery of exposure as a useful
  coping strategy leading to its systematic use in
  overcoming fear.

24
Risk-taking behaviours - IV

• Systematic attempts to gain control over fear by
  entering buildings in a graduated fashion.

25
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

26
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, Kings College London,
  2004

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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.

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Conclusions - II

• Self-exposure to fear cues
• a major factor in natural recovery process

29
Before trauma
During trauma
After trauma
Before trauma
During trauma
After trauma
PTSD / Other anxiety disorders / Other
psychiatric disorders physical illnesses
Uncertainty about future helplessness (anxiety)
Stressor perceived as uncontrollable
Failed fight-flight / Loss of control
overstressor event
Certainty about future helplessness
hopelessness
Psychosocial disability
Genetic temperamental factors / Previous
learning of control over stressors
Depression
Loss of close ones / resources Life stressors
Positive psychological outcome Resilience
Stressor perceived as controllable
Sense of control over future stressors
Successful fight-flight / Control over stressor
event
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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.

31
Before trauma
During trauma
After trauma
Before trauma
During trauma
After trauma
PTSD / Other anxiety disorders / Other
psychiatric disorders physical illnesses
Uncertainty about future helplessness (anxiety)
Stressor perceived as uncontrollable
Failed fight-flight / Loss of control
overstressor event
Certainty about future helplessness
hopelessness
Psychosocial disability
Genetic temperamental factors / Previous
learning of control over stressors
Depression
Loss of close ones / resources Life stressors
Positive psychological outcome Resilience
Stressor perceived as controllable
Sense of control over future stressors
Successful fight-flight / Control over stressor
event
32
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.

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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)

34
Before trauma
During trauma
After trauma
Before trauma
During trauma
After trauma
PTSD / Other anxiety disorders / Other
psychiatric disorders physical illnesses
Uncertainty about future helplessness (anxiety)
Stressor perceived as uncontrollable
Failed fight-flight / Loss of control
overstressor event
Certainty about future helplessness
hopelessness
Psychosocial disability
Genetic temperamental factors / Previous
learning of control over stressors
Depression
Loss of close ones / resources Life stressors
Positive psychological outcome Resilience
Stressor perceived as controllable
Sense of control over future stressors
Successful fight-flight / Control over stressor
event
35
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)

36
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

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The Effectiveness of Control-Focused Behavioural
Treatment for Chronic PTSD in Earthquake
Survivors Results from an Open Clinical
TrialBasoglu, Livanou, Salcioglu et al.
Psychological Medicine, 2003
Study I
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Study design(n 231)
Screen
Treatment sessions
S0
S1
S2
S3
S4
S5
S6
S7
S8
S9
Follow-up sessions
1m
3m
6m
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Cumulative probability of improvement in PTSD
and non-PTSD cases
Median improvement time PTSD cases 1.7
sessions Non-PTSD cases 1.8 sessions
40
Study II
Single-session control-focused behavioural
treatment of earthquake-related PTSD a
randomised waitlist controlled trial Basoglu,
Salcioglu, Livanou et al Journal of Traumatic
Stress, 2005
41
Patients Global Impression-Improvement Ratings
at Follow-up
Last available assessment
6 weeks
12 weeks
24 weeks
1-2 year
42
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.
• Salcioglu, Basoglu, Livanou. Behaviour Research
  and Therapy, 2007

43
Next question What happens when you introduce
UCS in treatment?

• Unconditioned stimulus
• earthquake tremors

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Study III

• A single-session of
• Earthquake Simulation Treatment
• Basoglu, Livanou, Salcioglu
• American Journal of Psychiatry, 2003

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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

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An artists imagination of Earthquake Simulation
Treatment
Courtesy of Jose Carlos Fernandez
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Earthquake Simulator Outside view
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Earthquake Simulator Inside view
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Study Design(n 10)
No explicit self-exposure instructions at
post-session
EST Earthquake Simulation Treatment
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Fear and Avoidance Questionnaire
plt.05
plt.05
plt.05
plt.01
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Clinician Administered PTSD Scale (CAPS)
plt.001
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Beck Depression Inventory
plt.01
plt.01
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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.

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A randomised controlled study of Earthquake
Simulation Treatment
Study IV
Basoglu, Salcioglu, Livanou Psychological
Medicine, 2007
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Fear and Avoidance Questionnaire
p lt .001
p lt .01
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Clinician Administered PTSD Scale
p lt .01
p lt .01
57
General Improvement Scale -Patient Version 1-2
Year Assessment
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Combined treatment versus CFBT alone
ES .90
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Comparison of effect sizes with CFBT and other
treatments for PTSD (reviewed by Bradley et al,
2005)
E
CBT
EC
EMDR
SC
WL
CFBT
13 studies
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
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Implications for self-help treatment

• If CFBT merely facilitates natural recovery,
• is therapist essential for this process?

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A self-help manual for earthquake survivors
Single-case experimental studies
Study V
Basoglu, Salcioglu, Livanou. Journal of Behaviour
Therapy and Experimental Psychiatry, 2009
62
Study Design(n 8)
2 baseline assessment in 4 weeks
Post-treatment assessment
Treatment
Follow-up
63
Fear and Avoidance Questionnaire
ns
p lt .001
64
Clinician Administered PTSD Scale
ns
p lt .001
65
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

66
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

67
Possible treatment dissemination methods - I

• Self-help manual
• Lay therapists / survivors

68
Treatment delivery through lay therapists
69
Possible treatment dissemination methods - II

• Videocassettes
• CDs
• Internet
• Public educational campaigns
• Mass media, e.g. TV, radio

70
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.

71
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.

72
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
18
80
STAGE 2 Therapist-delivered live exposure for
100 cases Total N of Sessions 100 Likely
response rate 80
400
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)
500
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Therapist time costs of current trauma treatments

Cost ratio relative to CFBT
Cost per case
Mean N of sessions per case

-
96 (33)
1.16 (0.4)
CFBT
8.6 (25)
825
10
CBT
3.9 (11.5)
380
4.6
EMDR
Based on cost of 1 CBT session in U.K.
82.5 Individual treatment (treatment in groups
of 25)
74
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)