Dabatem | Earthquake - Control Focused Behavioral Treatment

CONTROL - FOCUSED BEHAVIORAL TREATMENT

Psychological effects of trauma Psychological trauma due to natural disasters, wars, torture, road traffic accidents, physical assaults, or various forms of violence leads to a psychiatric condition known as Posttraumatic Stress Disorder (PTSD). This condition typically involves re-experiencing (e.g. intrusive thoughts about the trauma, flashbacks, nightmares, distress when reminded of the trauma, and physiological hyperarousal), avoidance (cognitive and behavioral avoidance, psychogenic amnesia, loss of interest, alienation, sense of foreshortened future, emotional numbing), and arousal symptoms (sleeping difficulty, hypervigilance, startle, memory / concentration difficulty).

Fear and related stress symptoms are often prominent features of PTSD induced by traumatic events that involve a threat to safety. Fear is particularly intense after traumatic events when where there is a continuing (real or perceived) threat to safety. In the case of earthquakes, for example, the initial devastating shock is often followed by hundreds of aftershocks that pose further danger. Torture survivors may face (or perceive) risk of further arrest and torture. In such situations sleeping difficulty, extreme alertness (scanning the environment for signs of an impending danger), and startle reactions in response to sudden movements and sounds are quite common. Many survivors fear and avoid various situations that signal further threat. For example, earthquake survivors often avoid going into their houses or other concrete buildings even when it is safe to do so, stay alone at home, sleep alone or in the dark, take a shower, get undressed when going to bed, or any other situation where they think they may be caught helpless during an earthquake. Torture survivors avoid military or police officers on the street, people in positions of authority, interviews that resemble interrogation, medical examinations involving instruments, or any other situation or activity that reminds them of their torture. Trauma survivors also avoid situations that bring back distressing memories of the original trauma. Such avoidance can generalize to a wide range of situations and activities, leading to significant disruption in social, work, and family functioning. The prevalence of behavioral avoidance can be quite high in trauma survivors (e.g. 70% in earthquake survivors during the first year after the disaster). Generalized fear and avoidance may lead to feelings of total helplessness, loss of control over life, and eventually depression. Most trauma survivors experience these symptoms in the early aftermath of the trauma. While these symptoms disappear in some people in a few months, they may persist in others and evolve into PTSD. Our studies of Turkish earthquake survivors have shown that the prevalence of PTSD can be as high as 40% among people who have been most severely exposed to the devastating effects of earthquakes. In our studies of war survivors, the prevalence rates of PTSD ranged from 20% to 60%, depending on the severity of the traumatic events experienced. PTSD is a chronic and disabling condition, which, if left untreated, may persist for years, decades, or even a lifetime. Traumatic events may also lead to other problems, such as anxiety disorders other than PTSD, psychoses, alcohol and drug abuse, marital discord, and suicide. Research has shown, however, that the most common psychiatric conditions after mass trauma events are PTSD, other anxiety disorders, and depression. Our 20 years of research work with mass trauma survivors revealed that fear and loss of control over stressors are the primary mediating factors in traumatic stress. This is consistent with evidence from experimental work with animals showing that traumatic stress is associated with exposure to unpredictable and uncontrollable stressors.^1,2 This implies that traumatic stress can be reduced by interventions that enhance sense of control over traumatic stressors. Accordingly, we developed a control-focused behavioral treatment designed to increase a person’s sense of control over distress or fear associated with trauma reminders. Basoglu M. and Mineka S (1992) The role of uncontrollability and unpredictability of stress in the development of post-torture stress symptoms. In M. Basoglu (Ed.) Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press. Mineka S & Zinbarg R (2006). A contemporary learning theory perspective on the etiology of anxiety disorders – It is not what you thought it was.American Psychologist, 61, 10-26.

What is control-focused behavioral treatment (CFBT)?

Control-focused behavioral treatment (CFBT) is an intervention designed to enhance sense of control over distress or fear associated with traumatic stressors by encouraging the person to stop avoiding distressing or feared trauma-related situations. A brief description of the treatment is as follows:

The first step in treatment (10 minutes) involves identification of the presenting problems, which often include fear of reliving the same trauma events, fear and avoidance of trauma reminders, and re-experiencing and hyperarousal symptoms.

The second step (30 minutes) consists of an explanation of the treatment rationale. The treatment focus is on increasing sense of control over trauma-related fears, distressing trauma reminders, and associated emotional and/or behavioral responses (e.g., confront your fear / distress until you feel you can control and overcome it), rather than habituation to trauma reminders (e.g.. stay in the situation until your anxiety subsides). For example, fear is personified by presenting it as an adversary that has to be fought back. A choice has to be made between surrendering to fear and or defeating it. Avoidance means surrender and the consequence would be living the rest of one’s life in fear and helplessness. The most effective way of defeating fear is confronting it until one feels in control.

The final step (20 minutes) involves treatment target setting and self-exposure instructions. The treatment targets involve four of the most functionally disabling avoidance behaviors. Once agreement is achieved on the targets, self-exposure instructions are given. The survivors are explained how they should conduct exposure and deal with commonly encountered problems during treatment. No systematic cognitive restructuring is undertaken during treatment.

A typical example of Control-Focused Behavioral Treatment - Survivors learning to gain control over fear induced by earthquake tremors in an earthquake simulator

How is CFBT different from cognitive-behavioral treatment (CBT)?

CFBT is a fairly simple intervention involving only instructions not to avoid distressing or feared situations in the daily course of life (self-exposure to anxiety cues). It does not involve any other intervention commonly used with CBT, such as cognitive restructuring and imaginal exposure (e.g. mentally focusing on distressing trauma-related memories and imagery). Cognitive interventions are limited to the explanation of the treatment rationale only.

Unlike traditional CBT or exposure treatment, CFBT aims to increase sense of control over distress / fear and traumatic stressors, rather than reduce fear (although reduced fear is a common but not an invariable outcome of the intervention). This implies that patients are not required to conduct extensive exposure until complete habituation occurs. Exposure until sense of control is regained is sufficient.

Development of the treatment

This treatment was first tested in an open clinical trial¹that involved 231 earthquake survivors. This study was conducted to examine the minimum number of sessions required to achieve significant clinical improvement. The treatment improved PTSD and depression in 76% of the cases after one session and in 88% after two sessions. A survival analysis indicated that the mean number of sessions required for improvement is 1.7 and the probability of improvement after 4 sessions is 100%. These results showed that the majority of the cases improve after 1-2 sessions, while a small proportion may require up to 4 sessions.

This study established the framework for full-course control-focused behavioral treatment program. It also suggested that the intervention could be effectively delivered in a single session in 76% of the cases. This led to the development of a single-session version of the treatment behavioral treatment, which was tested by a randomized controlled study (see single-session behavioral treatment).

Two more variants of the intervention were developed. Earthquake Simulation Treatment is a more potent version of the intervention involving exposure to simulated earthquake tremors. Self-administered treatment using a self-help manual was designed for cost-effective dissemination of the intervention.

Although the 4-session treatment program is suitable for situations where regular treatment attendance is not a problem for survivors, it is best used as an alternative treatment for those who do not respond to a single-session intervention. Given that the response rate with a single session is 90%, the use of 4-session treatment could be limited to a small group of non-responders to save valuable therapist time.

Basoglu et al (2003) A brief behavioural treatment of chronic post-traumatic stress disorder in earthquake survivors: Results from an open clinical trial. Psychological Medicine, 33(4), 647-654.