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 BOOK REVIEWS

A Mental Healthcare Model for Mass Trauma Survivors: Control-Focused Behavioral Treatment of Earthquake, War and Torture Trauma

Richard Balon, MD

Wayne State University, Detroit, Michigan, USA

By Metin Baoğlu and Ebru Salcioğlu. New York, NY: Cambridge University Press; 2011; ISBN 978-0-521-88000-8; pp 284; $105 (hardcover)

As the authors of this book point out, “mass trauma events, such as wars, armed conflicts, acts of terror, political violence, torture, and natural disasters affect millions of people around the world” (p 1). Mass trauma events pose a major challenge for the mental health field, because there is no suitable model of effective, timely, and “affordable” care for addressing the psychological needs of mass trauma survivors. However, mass traumas also may provide unique opportunities to explore the psychological consequences of various traumas and their possible management or treatment. The ability to study these consequences and their potential treatments requires expertise, long-term, if not lifelong, focus, and the opportunity to be “there”—if not frequently then at least repeatedly.

Drs. Baoğlu and alcioğlu, 2 Turkish experts in the field, have spent at least 2 decades studying the consequences of mass trauma and their possible treatments. Living and working in Turkey—a country frequently inflicted by major earthquakes, and where torture of political activists occurred in the aftermath of a military coup—provided them with ample and unique opportunities for this kind of study. This book is a summary of their extensive work in this area, their learning theory of traumatic stress, their recommendations for assessment and treatment of mass trauma survivors using what they call control-focused behavioral treatment (p 79), and implications of their theory and treatment approach to the care of mass trauma survivors.

The book is divided into 3 parts (Theory; Assessment and treatment; and Implications for care of mass trauma survivors), and includes 3 appendices. In the introduction (which is largely a brief summary of this volume), the authors point out that any effective dealing with mass trauma, especially in developing countries, 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” (p 1). The introduction also emphasizes that behavioral intervention designed to enhance the sense of control over—or resilience against—anxiety cues or traumatic stressors “needs to aim for anxiety tolerance and control rather than anxiety reduction” (p 2). They also bring our attention to their serendipitous discovery of the fact that “many survivors, without any instruction or guidance from a mental health professional, used self-exposure in their natural environment to overcome their fear of earthquakes” (p 3). This discovery “suggested that self-help is not only a viable approach in survivor care but also one that carries great potential” (p 3).

The 2 chapters in Part 1 discuss the learning theory formulation of earthquake trauma, and torture and war trauma. Both chapters stress the unpredictable and uncontrollable nature of both earthquake and war and torture traumas. It also is important to note that earthquake trauma is not a single stressor, but “rather a prolonged trauma period of stressors starting with the initial major shock and followed by hundreds of aftershocks that may last for months or even more than a year” (p 16). The major psychiatric consequences of mass traumas are posttraumatic stress disorder (PTSD) and depression. There also are physical consequences, such as increased blood pressure, myocardial infarction, stroke, and increased incidence of gastric and bleeding ulcers.

The authors also describe cognitive and behavioral responses to earthquake and other mass traumas, such as the quest for safety (eg, people who feel safer knowing that the contractor who built their apartment lives in the same building as them), reliance on safety signals, fatalistic thinking (eg, more specified to Turkey and Arabic-speaking countries, the notion of Tawakkul or “to resign oneself unto God” [p 22]), and avoidance. Weaving all these facts together the authors then present their learning theory formulation of earthquake trauma, emphasizing the role of unpredictability and uncontrollability of stressors in the development of fear, helplessness, avoidance, and traumatic stress response such as PTSD and depression. The chapter discussing torture and war trauma is filled with many interesting observations that are quite relevant to the field of mental health, especially in a world filled with numerous conflicts and other stressful, violent events.

The authors describe several stressor categories associated with experiences of imprisonment: 1) falling captive to an enemy, 2) interrogation and manipulation designed to induce distress, fear, and helplessness, 3) acts designed to inflict physical discomfort or pain, and 4) deprivation of basic needs (p 39). The discussion of interrogation and helplessness-inducing psychological manipulation brings forth numerous fascinating examples, including the “good cop/bad cop” strategy, stripping the detainee naked, sham executions, or confronting the detainee with an impossible choice (eg, if a detainee does not comply, they are told that a close relative will be arrested, raped, or tortured in front of them [p 41]). According to the authors, survivors often describe forced viewings of others being tortured “as one of the most distressing aspects of their past experience” (p 41). Another important observation is that those who experienced a perceived risk of death during the process of torture (ie, sham execution) appeared more traumatized by that experience than by torture methods involving physical pain but posed no real threat to their life (p 41). The chapter also discusses coping with captivity and torture. Coping with physical torture occurs on 3 overlapping levels: psychophysiological, behavioral, and cognitive. The authors state that the behavioral and cognitive strategies seem to be geared towards maintaining a sense of perceived control. Interestingly, some cognitive factors, such as awareness of broader political dynamics, seem to have a protective effect against the cognitive impact of torture. When summarizing the discussion of natural recovery from captivity and torture trauma, the authors emphasize that resilience factors—such as immunization against traumatic stress—appear to be the most important in determining successful coping and recovery. This part is quite fascinating and interesting to read.

The 4 chapters in Part 2 review the assessment and treatment of mass trauma victims. The chapter on assessment reviews several assessment tools (eg, Screening Instrument for Traumatic Stress in Earthquake Survivors [SITSES]; the child variation of SITSES; and Screening Instrument for Traumatic Stress in Survivors of Wars [SITSOW]). The authors write that despite what some suggest, use of these instruments does not traumatize the victims, and may be useful in the therapeutic process. Chapter 4 describes the central aspect of this book—the control-focused behavioral treatment (CFBT)—in great detail, from the initial assessment through to treatment sessions (steps of the first session include identifying trauma cues and avoidance behavior, explaining the treatment and its rationale, defining treatment tasks, and giving self-exposure instructions—including some very concrete, focused self-exposure exercises) and treatment termination (when clinically significant improvement occurs [eg, ≥60% reduction in traumatic stress and depression scores and much or very much improved ratings on self- and assessor-rated global improvement scale]). Chapter 4 also discusses comorbid conditions, the use of medication, specific aspects of treatment of children, and single-session applications of treatment of earthquake survivors (single session CFBT, single session group CFBT, and single session earthquake simulation treatment [using an earthquake table or room simulator]).

The next chapter of this section reviews the assessment and treatment of prolonged grief. The final chapter of this part presents an overview of treatment efficacy and mechanisms of recovery. The third part of this book discusses a mental health care model for earthquake survivors, issues in care of mass trauma survivors, and issues in rehabilitation of war and torture survivors. The outreach treatment program for earthquake survivors includes treatment delivered via a self-help manual, single-session treatment involving self-exposure instructions, single-sessions involving therapist-administered exposure, and full-course treatment delivered on average over 4 sessions. The outreach program is crucial in the aid of victims scattered across various refugee shelters. The authors also describe the dissemination of treatment through self-help tools, lay therapists, and mass media.

The authors also note that “uncritical acceptance and use of treatments developed in western countries is a common problem in developing countries, reflecting a cultural tendency to view everything coming from the west as ‘good’” (p 159). Another cultural issue pointed out is the fact that many psychiatrists in developing countries tend to prescribe antidepressants first in mass trauma victims without acknowledging alternative, evidence-based, or psychological interventions (p 167). In the final chapter of this section, as is the case with many others, the authors present a lot of their own data. For instance, the authors did not find any evidence to support the theory that war, torture, and earthquakes differ substantially in their subjective impact and cognitive effects, or the nature, prevalence, and severity of their mental health outcomes (p 187). In the conclusion of the book’s final chapter, the authors write that empowerment of trauma survivors is essential to their recovery, and point out that only a small fraction of survivors are likely to need more intensive mental health care.

Appendix A includes a number of questionnaires; Appendix B features a control-focused behavioral therapy manual; and Appendix C contains a self-help manual for recovery from earthquake trauma. Both the control-focused behavioral therapy manual and self-help manual are instructive and concrete texts.

This is a solid, informative book for anyone interested in the psychological consequences of mass trauma, and their respective treatments. The book includes a good number of clinical examples, but also, probably unfortunately, the results of the authors’ own research. I am calling this unfortunate because it dilutes the instructive and clinical usefulness of this valuable book a bit, because readers may get lost in the conclusions of some chapters. Nevertheless, all those involved with mass trauma survivors will find this book interesting. Those of us treating victims of other traumas may try incorporating CFBT or its parts into our treatment plans.