Evolution and evidence base

Why the need for a new approach to mass trauma

Mass trauma events—including wars, armed conflicts, acts of terror, political violence, torture, and natural disasters—affect millions of people worldwide. The so-called “New World Order” following the collapse of the Soviet Union has witnessed a surge in political violence across the globe, as well as a “war on terror” that led to the invasion of Iraq and Afghanistan by the United States and its allies. According to UNHCR figures from 2009, the number of forcibly displaced people worldwide reached 42 million by the end of 2008, including 15.2 million refugees, 827,000 asylum seekers, and 26 million internally displaced persons, with 20% of these individuals residing in industrialized countries. The World Health Organization (2005) estimates that 20% of people exposed to mass trauma events develop posttraumatic stress disorder (PTSD), suggesting that approximately 8.4 million war survivors globally (1.7 million in industrialized countries and 6.7 million in developing countries) are likely to require mental health care. These figures, which would likely be even higher if updated to the present day, do not account for non-displaced civilians exposed to war-related events, political violence, or torture. While reliable estimates of torture prevalence are scarce, it is known to be systematically practiced in at least 81 countries (Amnesty International, 2009) and is associated with severe long-term mental health consequences (Başoğlu et al., 2001; Campbell, 2007; Johnson & Thompson, 2008; Steel et al., 2009).

Among natural disasters, earthquakes are a significant contributor to the public health burden posed by mass trauma. Between 1974 and 2003, a total of 660 earthquakes occurred worldwide, resulting in the deaths of 559,608 people and affecting more than 82 million individuals (Guha-Sapir et al., 2004). The impact of earthquakes is disproportionately felt in developing countries, with over 72% of earthquake-related fatalities in the last decade occurring in Asia (Guha-Sapir et al., 2004). Research (e.g., Armenian et al., 2000; Başoğlu et al., 2004b; Durkin, 1993; Lai et al., 2004; Önder et al., 2006; Wang et al., 2000) indicates that exposure to earthquakes is associated with increased psychiatric morbidity.

Despite the scale of this global problem, there is currently no mental healthcare model capable of addressing the needs of millions of mass trauma survivors, particularly in developing countries, where dispossessed populations often bear the brunt of such events. Effectively tackling this issue requires interventions that are (1) based on sound theory, (2) empirically proven to be effective, (3) brief, (4) easy to train therapists to deliver, (5) cross-culturally applicable, and (6) suitable for dissemination through channels other than professional therapists, such as lay people, self-help tools, and mass media. Current treatments commonly used with trauma survivors meet only a few of these criteria. The final requirement is especially critical, as even the most effective treatment is of limited value if it cannot be widely disseminated to the millions of people in need.

Evolution of Control-Focused Behavioral Treatment (CFBT)

The story of CFBT is a testament to a nearly 35-year journey in pursuit of a mental healthcare approach that meets the rigorous criteria outlined above. Central to such a model is the need for a robust theoretical foundation. In a previous work, Torture and Its Consequences: Current Treatment Approaches (Başoğlu, 1992), we explored the parallels between animal and human responses to unpredictable and uncontrollable stressors, presenting a learning theory formulation of torture trauma (Başoğlu & Mineka, 1992). This formulation drew on the work of Martin E.P. Seligman, Steve Maier, Bruce Overmier, Susan Mineka, and other leading learning theorists and anxiety researchers. However, since much of the supporting evidence for this model stemmed from animal studies, its applicability to human experiences remained somewhat uncertain.

Driven by this gap in understanding, we embarked on an extensive journey to investigate the parallels between animal and human responses under extreme stress and to gather evidence demonstrating the relevance of this formulation to human trauma. Our efforts began with a series of three studies conducted in Turkey between 1993 and 1999, which examined the role of unpredictable and uncontrollable stressors in psychological responses to torture. Following the end of the war in the former Yugoslavia, we expanded our research with a 5-year, multi-site program across Bosnia-Herzegovina, Croatia, and Serbia. This program involved 1,358 survivors of war trauma, including those who had endured combat, internal displacement, refugee status, aerial bombardment, and torture.

The findings from these studies provided substantial evidence supporting a learning theory model of traumatic stress. Crucially, they suggested that traumatic stress could be mitigated through interventions designed to enhance an individual’s sense of control over—or resilience against—traumatic stressors. This pivotal insight ultimately paved the way for the development of CFBT, a therapeutic approach grounded in the principles of learning theory and tailored to empower individuals in the face of adversity.

The critical role of a sense of control in the treatment of anxiety disorders is well-established among anxiety researchers. Barlow (2002), in his seminal work Anxiety and Its Disorders, provided a comprehensive review of the research on this topic. However, despite this recognition, there have been few efforts to develop behavioral interventions specifically aimed at enhancing an individual’s sense of control over anxiety-evoking cues or traumatic stressors. Such an intervention would need to prioritize resilience rather than focusing solely on anxiety reduction.

In the mid-2000s, there was growing awareness of the need to shift the focus in treatment away from anxiety reduction. In a review of the mechanisms underlying exposure therapy, Craske et al. (2008) found no definitive evidence linking treatment outcomes to the degree of fear reduction during or between sessions. Instead, Craske and Mystkowski (2006) argued that it is time to move away from using fear reduction as the primary measure of therapeutic success. They proposed a new framework for exposure therapy, stating, “…it is time to shift away from an emphasis on fear reduction during exposure therapy as an index of learning at the process level toward a model of exposure therapy that emphasizes…weakening of avoidance and strengthening tolerance of aversive internal states and fear” (pp. 233).

This is precisely what we achieved in the late 1980s and early 1990s—nearly two decades before these insights began to gain traction in the Western world—based on findings from our research, which underscored the pivotal role of a sense of control in both the development and treatment of anxiety disorders. We reoriented the focus of treatment from habituation to the enhancement of a sense of control over anxiety cues, rather than merely promoting anxiety tolerance, which is only one of the pathways to resilience.

This paradigm shift in psychotherapy, driven by the rationale detailed later on this website, was designed to achieve greater therapeutic outcomes. It not only resulted in significant procedural changes in the application of behavioral treatment but also expanded the treatment focus to encompass a wider range of psychological problems, including but not limited to avoidance behaviors. This approach ultimately gave rise to the development of CFBT, a therapeutic model that prioritizes empowerment and resilience by enhancing an individual’s ability to exert control over their anxiety and stressor events.

In 1999, a devastating 7.4 magnitude earthquake struck the Marmara region of Turkey, claiming more than 17,000 lives and exposing millions to severe trauma. Up until that point, much of our experience with behavioral treatment had been confined to patients with anxiety disorders in clinical settings. Our understanding of how traumatic stress reactions develop and evolve in naturalistic settings was relatively limited. This catastrophe, however, marked a significant turning point in our work. It not only provided an opportunity to test CFBT on a broader scale but also offered invaluable insights into the natural processes of recovery from trauma.

By observing how individuals recovered from traumatic stress without therapeutic intervention, we gained a deeper understanding of resilience and coping mechanisms in the face of extreme adversity. Additionally, having personally experienced the earthquake and its aftershocks, we were able to draw lessons from our own reactions and recovery processes. This unique combination of professional observation and personal experience enriched our understanding of trauma and recovery, further shaping and refining the principles of CFBT.

In 1999, we established a research-driven treatment delivery project and conducted extensive fieldwork with more than 10,000 survivors over six years. As we began testing CFBT in the immediate aftermath of the disaster, we were quickly overwhelmed by the sheer volume of survivors seeking help. It became evident that the standard 8 to 10-session treatment format was impractical under such chaotic post-disaster conditions. Compounding the challenge, the high demographic mobility in the affected region and the day-to-day struggles for survival meant that many survivors could only attend a single treatment session. Faced with these constraints, we had no choice but to adapt our approach, delivering treatment in a single session and hoping for the best.

Given the limited time available, we focused the 60-minute session on providing clear instructions for self-exposure to fear-evoking trauma cues, accompanied by a treatment rationale designed to enhance the survivor’s sense of control over their fear. While we knew from prior research that significant improvement in anxiety disorders often occurs within the first few weeks after just a few exposure sessions (Marks et al., 1988; Marks et al., 1993), we were uncertain whether survivors in a post-disaster setting would adhere to self-exposure instructions without regular follow-up or monitoring.

To assess the effectiveness of this approach, we conducted research to evaluate treatment outcomes. To our surprise, an open trial (Başoğlu et al., 2003b) revealed that nearly 80% of participants showed improvement after just one session. This finding was later corroborated by randomized controlled studies (Başoğlu et al., 2007b; Başoğlu et al., 2005b). These results marked the birth of single-session CFBT, demonstrating once again that necessity drives innovation. This adaptation not only proved effective but also highlighted the resilience and capacity for self-directed recovery in survivors, even under the most challenging circumstances.

This serendipitous discovery prompted us to search for an explanation. As we examined how survivors coped with their debilitating fear of earthquakes, we found that many individuals, without any guidance or instructions from mental health professionals, instinctively used self-exposure in their natural environment to overcome their fear. This revelation was transformative in several ways. Most significantly, it suggested that self-help is not only a viable approach in survivor care but also one with immense potential. From an evolutionary perspective, this is hardly surprising, given that trauma has been a part of human history since its inception. Our survival as a species would not have been possible without an innate, genetically encoded mechanism for trauma recovery.

Second, this discovery underscored the central role of live exposure as the most potent therapeutic element in behavioral treatment. This insight reinforced CFBT’s sharp focus on anxiety cues and avoidance behaviors, while excluding cognitive restructuring and other anxiety management strategies commonly used in traditional cognitive-behavioral therapies. It also made us realize that CFBT essentially provides a motivational boost to a natural, pre-existing tendency in individuals to use self-exposure as a means of overcoming trauma-induced helplessness. In a sense, the intervention mirrors a key natural recovery process inherent in humans.

With this understanding, we began to search for additional evidence supporting the idea that exposure is an evolutionarily determined process in trauma recovery. Over time, such evidence helped us conceptualize a self-help model of mental health care for survivors. This model incorporates several variants of CFBT, which were developed and routinely applied with positive outcomes in more than 6,000 earthquake survivors. Drawing on this extensive experience, we also created tools designed to facilitate the cost-effective dissemination of treatment knowledge—both to care providers and to survivors themselves. These tools aim to empower individuals and communities, enabling them to harness their innate capacity for recovery and resilience in the face of trauma.

This website consolidates the knowledge and experience accumulated over three decades of work with survivors of torture, war, and natural disasters. While its scope is broader, it can be seen as a sequel to the 1992 book on torture (Torture and Its Consequences: Current Treatment Approaches, Başoğlu, 1992), as the hypotheses generated by the learning theory formulation of torture presented in that work guided much of the research detailed here. Although our work addresses diverse traumatic events, its focus remains on the mechanisms of traumatic stress and recovery that are common to all forms of trauma, whether caused by human actions or natural forces. As such, this platform is designed to foster a deeper understanding of seemingly different traumas through a unifying theoretical framework and to demonstrate how they may respond to brief behavioral interventions that align closely with the underlying mechanisms of traumatic stress.

Because research guided by learning theory emphasizes universal principles of behavior under duress—applicable across both species and cultures—its findings transcend cultural and biological boundaries. This is a crucial point to consider when evaluating the cross-cultural relevance of the evidence reviewed here.

Although CFBT can incorporate a variety of techniques or strategies designed to enhance an individual’s sense of control, this website focuses specifically on its application through live exposure to anxiety- or fear-evoking situations. This stems from the fact that CFBT was originally developed to treat traumatic stress in survivors of trauma, and live exposure alone has proven sufficient to achieve satisfactory outcomes. The efficacy of exposure-based treatments is well-supported by extensive research, as evidenced by reviews conducted by the American Psychiatric Association (2004) and the National Institute for Clinical Excellence (2005). However, it is important to clarify that CFBT is not merely another form of exposure therapy. While exposure is an important component, CFBT can also utilize additional techniques aimed at enhancing control. Moreover, it differs fundamentally from other exposure-based treatments in its theoretical foundations, objectives, and delivery procedures. These distinctions are explored in greater detail elsewhere on this website.

Evidence base

The review presented here synthesizes findings from more than 40 studies that have contributed to the development of CFBT and a mental healthcare model based on it. To facilitate the evaluation of these findings, the methodologies of the studies are briefly summarized in Table 1, Table 2, and Table 3, which also provide an overview of the evidence base supporting CFBT. Much of this work has been extensively detailed in our 2011 book (Başoğlu et al., 2011), and readers are encouraged to refer to this source for a more comprehensive understanding of CFBT. The first two chapters of the book, which present a learning theory formulation of earthquake and torture trauma, offer valuable insights into how seemingly different trauma events can be understood through a unifying theoretical framework.

Table 1 highlights studies that investigated the mechanisms of traumatic stress in torture, war, and earthquake survivors using similar methodologies. The first of these is a series of three consecutive studies designed to explore the mechanisms of traumatic stress in torture survivors. A significant portion of the empirical evidence regarding traumatic stress mechanisms in earthquake survivors emerged from a multi-site study examining the cognitive effects of war and natural disaster trauma and their association with traumatic stress responses. This study was conducted in former Yugoslavia countries and Turkey, with the results from Turkey documented in Şalcıoğlu’s (2004) PhD dissertation. These studies collectively provide a robust foundation for understanding the commonalities in traumatic stress responses across different types of trauma and underscore the theoretical and practical basis for CFBT.

Table 2 shows the field surveys that examined PTSD prevalence and symptom profile and the risk factors for traumatic stress in earthquake survivors, while Table 3 lists the treatment studies with torture and earthquake survivors. Other studies that examined psychometric properties of various questionnaires for assessment of earthquake, war and torture trauma are reviewed in Başoğlu et al, 2011.

Research Program (1993-2025)

The objective of our research program launched in early 1990s was to develop a mental healthcare model for mass trauma survivors based on brief treatments that can be cost-effectively disseminated to large survivor populations on a self-help basis. Work involved:

• Theoretical conceptualization of the model
• Studies of mechanisms and phenomenology of traumatic stress
• Prevalence studies
• Development of assessment tools and brief diagnostic screening instruments
• Case studies and clinical trials to test brief interventions
• Development of treatment tools, and
• Development of an outreach treatment dissemination model.

Below is a listing of the completed projects since 1993.

I. Research with asylum-seekers and refugees (2009 – 2017)

Treatment studies

• Development of Control-Focused Behavioral Treatment for care of asylum-seekers and refugees – Phase I (2009 – 2017)
• A collaborative study of behavioral treatment of torture survivors in Sweden and Turkey (In collaboration with Assoc. Prof. Solvig Ekblad (Unit for Immigrant Environment and Health, IPM / Karolinska Institute, Sweden) (2001-2002)

2. Research with survivors of torture (1993-1997)

Phenomenological studies

• A study of long-term psychological effects of torture in survivors tortured during the period of dictatorship in Greece. Conducted in collaboration with the Medical Rehabilitation Centre for Torture Victims in Athens
• Study of the role of cognitive processes (beliefs about safety, justice, and trust, attributions of responsibility for trauma, appraisal of redress and compensation) in torture-related posttraumatic stress disorder
• Psychological effects of torture in individuals with no history of political involvement and prior preparedness for trauma: A comparison of tortured political activists with tortured non-activists in Turkey
• A study of the psychological effects of torture in political activists in Turkey

3. Research with survivors of war (1997-2005)

Community studies

• A multi-site controlled study of psychiatric effects of war and torture trauma (combat, torture, internally displacement, refugee status, aerial bombardment) in 2013 survivors from countries of former Yugoslavia (Sarajevo – Bosnia-Herzegovina, Banja Luka – Republica Sirpska, Rijeka – Croatia, and Belgrade

Phenomenological studies

• Effects of war trauma on beliefs about safety, justice, and trust, attributions of responsibility for trauma, appraisal of redress and compensation, and their relationship with posttraumatic stress disorder in war survivors

Questionnaire development studies

• Screening Instrument for Traumatic Stress in War Survivors
• Semi-Structured Interview Form for Survivors of War
• Emotions and Beliefs after Trauma Questionnaire – War version
• Redress for Trauma Survivors Questionnaire – War version
• Depression Rating Scale

4. Research with survivors of earthquakes (2000-2006)

Development of an outreach treatment delivery model

Work involved the development of a low-cost treatment delivery training program using brief assessment and treatment strategies. A team of 11 mental health professionals, based in 13 project sites in survivor camps, prefabricated and permanent housing sites, and two community centers in the disaster region (Avcılar and Degirmendere), served a catchment area about 60,000 survivors. Over 10,000 survivors were provided assessment and / or treatment over 3 years.

Phenomenological studies (2000-2002)

The effects of earthquakes on beliefs about safety, justice, and trust, attributions of responsibility for trauma, appraisal of redress and compensation, and their relationship with posttraumatic stress disorder

Questionnaire development studies (2000-2004)

• Screening Instrument for Traumatic Stress in Earthquake Survivors
• Last 1-month version of the Screening Instrument for Traumatic Stress in Earthquake Survivors
• 5-item and 1-item versions of Screening Instrument for Traumatic Stress in Earthquake Survivors
• Fear and Avoidance Questionnaire’ for earthquake survivors
• Semi-Structured Interview Form for Earthquake Survivors
• Emotions and Beliefs after Trauma Questionnaire – Earthquake version
• Redress for Trauma Survivors Questionnaire – Earthquake version
• Depression Rating Scale
• Semi-Structured Interview for Grief in bereaved earthquake survivors
• Grief Assessment Scale and Grief Behaviour Checklist

Field surveys and epidemiological studies (1999-2003)

• Prevalence of posttraumatic stress disorder and depression among survivors living in shelters (1-year post-disaster, n=1,000)
• Prevalence of posttraumatic stress disorder and depression among treatment seeking survivors of the 1999 Kocaeli earthquake in Turkey
• An epidemiological study of the prevalence of posttraumatic stress disorder and depression among survivors living in the epicenter region of the 1999 Kocaeli earthquake in Turkey (n=530)
• An epidemiological study of PTSD and comorbid depression among survivors living in a suburb of Istanbul (Avcılar) 100 kilometres from the epicenter of the 1999 Kocaeli earthquake in Turkey (n = 420)
• Two-year mental health outcome of the 1999 Kocaeli earthquake in Turkey among survivors living in prefabricated housing compounds
• Long-term mental health outcome of the 1999 Kocaeli earthquake in Turkey among survivors settled in permanent housing compounds (n=769)
• A community-based epidemiological study of the prevalence of posttraumatic stress disorder and depression among survivors living in a town (Yalova) hit by the 1999 Kocaeli earthquake in Turkey (n=849)
• A community-based study of earthquake survivors four years after the Parnitha earthquake in Greece

Clinical and field trials

Development of Control-Focused Behavioral Treatment (2000-2003)

• An open clinical trial for brief behavioral treatment of posttraumatic stress disorder in earthquake survivors (n=231)
• A randomized controlled trial of single-session control-focused behavioral treatment in earthquake survivors (n=59)
• Single case studies of brief behavioral treatment of prolonged grief in earthquake survivors (n=8)

Development of resilience-enhancing interventions (2000-2005)

• The development of protocol for control-focused behavioral treatment involving exposure to simulated earthquake tremors and design and construction of an earthquake simulator in accordance with the treatment protocol
• An open trial of the effectiveness of control-focused behavioral treatment of earthquake survivors using an earthquake simulator (n=10)
• A randomized controlled study of exposure treatment of earthquake-related PTSD using an earthquake simulator (n=31)

Development of treatment dissemination tools (2000-2005)

• Development of a self-help manual based on Control-Focused Behavioral Treatment
• Single-case multiple baseline experimental studies of the effectiveness of behavioral treatment in PTSD delivered through a self-help manual
• A community based experimental case studies of the usefulness of behavioral treatment in PTSD delivered through a self-help manual (n=84)

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