A mental healthcare model for mass trauma survivors
The mental healthcare model summarized here has been developed for earthquake survivors years after the 1999 earthquakes in Turkey. Although its basic principles apply to all mass trauma events, it is described here in relation to earthquake trauma because it was first developed for care of earthquake survivors. Research is currently underway to develop a similar model for survivors of war and torture.
Broadly, the model has 4 components:
1. Assessment instruments: Screening Instrument for Traumatic Stress in Earthquake Survivors (SITSES), Fear and Avoidance Questionnaire, and Depression Rating Scale,
2. Brief interventions: Single-session CFBT, 4-session CFBT, and Earthquake Simulation Treatment
3. Treatment dissemination tools: Self-Help Manual, Treatment Delivery Manual for lay and professional therapists
4. Treatment dissemination methods: A 3-stage outreach treatment delivery model, treatment delivery through mass media channels
Once the target population is determined, the basic principle is to utilize the above components in ways to minimize therapist time and costs and maximize the number of survivors accessed, assessed, and delivered treatment. The model can be implemented in survivor shelters, community centers, outpatient clinics in psychiatric hospitals, primary health care facilities, work places, or in the community.
Survivors in need of treatment are identified by screening the population using the SITSES. The instrument takes about 10-15 minutes to administer. It predicts PTSD and comorbid depression with 80% certainty. Our research shows that about 50% of survivors with high earthquake exposure are likely to need (and request) help because of traumatic stress problems.
3-stage treatment delivery model
Once the survivors in need of treatment are identified, a 3-stage approach in treatment delivery is implemented (Figure 1). The basic idea here is to initiate natural recovery processes by encouraging self-exposure with minimal therapist input (e.g. by delivering a self-help manual or single-session CFBT) and reserving therapist time and other resources for non-responders to self-help approach.
This approach is inspired by our observations of natural recovery processes in earthquake survivors. Many survivors discover the beneficial effects of exposure to feared situations, instigate the process by themselves, and recover from traumatic stress without any guidance or help from a therapist. CFBT simply enhances motivation for such self-exposure. Our research shows that such exposure is strongly associated with reduction in traumatic stress reactions.
A good understanding of the treatment rationale and early engagement in self-exposure tasks are the most important predictors of good treatment outcome and, therefore, once such cases are identified early in treatment (e.g. 1 or 2 weeks later), they can be left on their own to continue treatment on a self-help basis.
Non-responders to Stage 1 intervention are provided a single session of therapist-assisted exposure to a feared / avoided situation or a single session of Earthquake Simulation Treatment (individually or in groups), if an earthquake simulator is available.
Figure 2 shows the expected rates of improvement at each stage. Our studies show that 80% of survivors recover at Stage 1 and, of the non-responders, 80%, recover at Stage 2. Thus, out of 500 cases in need of help, only 20 (or 4%) need up to 4 sessions.
The total number of therapist sessions required for 500 cases at all three stages is 696 or mean 1.4 sessions per case. Based on the cost of 1 hour of therapist time in Turkey (12.50 USD), the cost of treatment per case is 17.5 USD. We estimated that the cost of CFBT per case is 3.3 to 10.6 times less than other trauma treatments, such as EMDR, Cognitive-Behavioral Treatment, and other exposure-based treatments.
The treatment cost can be further reduced by delivering single-session CFBT at Stage 1 in groups. In survivor shelters we usually delivered Stage 1 intervention in groups of 20 to 30 survivors. When the treatment is delivered in groups of 25 at Stage 1, the number of therapy sessions required at this stage can be reduced from 500 to 20. This means that 500 cases can be treated in a total of 216 sessions at the three stages; this yields a ratio of 0.43 sessions per case, thereby reducing the costs by 3.3 fold. Furthermore, Stage 1 intervention could also be delivered through self-help tools without any therapist involvement, if their usefulness as stand-alone tools is established by future work.
A further cost-effectiveness issue concerns the costs of training care providers. Current trauma treatments involve fairly elaborate procedures that rely heavily on therapist skills (e.g. cognitive restructuring, imaginal exposure, relaxation training, coping skills training, breathing training, thought stopping, guided self-dialogue, etc.) and thus require not only a certain amount of training by specialists but also additional supervision in the process of treatment delivery. Aside from the problem of finding sufficient numbers of therapists for care of large numbers of survivors in the aftermath of a major disaster, such training and supervision process is likely to incur substantial costs. Considering that CFBT is a relatively simple intervention, dissemination of treatment knowledge to care providers is likely to be much easier and less costly. A Treatment Delivery Manual is prepared to facilitate this process.
Treatment dissemination through mass media
The outreach programs could be complemented by media campaigning (e.g. through radio and TV) aimed at educating the survivor populations in the rationale and principles of treatment. Although the usefulness of this form of treatment dissemination remains to be tested, our field observations suggest that it is likely to be helpful. For example, we have seen many survivors who heard about the treatment by word of mouth (e.g. from friends, neighbors) and successfully implemented it without any therapist help or guidance. As noted above, CFBT simply provides an impetus for a naturally existing tendency in humans to overcome fear by not avoiding it. If the usefulness of this treatment delivery method is confirmed by future research, it can be delivered at the first stage, followed by other interventions for non-responders.
It is worth noting that this is the only outreach model for disaster survivors that has been empirically tested and demonstrated to be effective. While some of its components (e.g. various dissemination methods) need further testing, the model provides a much more cost-effective means of dealing with the mental health effects of major disasters than any other currently available treatment methods. It should also be noted that the brief treatments on which the model is based are substantially more effective than other treatments (as measured by their effect sizes). Furthermore, it is the only model that can be implemented on a largely self-help basis with minimal therapist involvement. Finally, the underlying principles of the model make it highly suitable for dissemination through mass media channels. Planning is underway for development of software to make dissemination of CFBT over the Internet possible.
More detailed guidelines for implementing this model in post-earthquake settings are provided in our 2001 book on A Mental Healthcare Model for Mass Trauma Survivors.