A mental healthcare model for earthquake survivors
The mental healthcare model summarized here has been developed for earthquake survivors 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. Broadly, it has 4 components:
1. Assessment instruments: Screening Instrument for Traumatic Stress in Earthquake Survivors, 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
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. 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.
Survivors in need of treatment are identified by screening the population using the Screening Instrument for Traumatic Stress in Earthquake Survivors (SITSES), Depression Rating Scale (DRS), and Fear and Avoidance Questionnaire (FAQ). These instruments take about 20-25 minutes to administer. The SITSES and DRS predict PTSD and depression, respectively, with 80% certainty. Our research shows that about 35% of people exposed to a major earthquake in the epicenter region are likely to need (and request) help because of traumatic stress problems (Başoğlu et al, 2011).
3-stage outreach 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 anxiety- or fear-evoking situations (often reflecting conditioned and unrealistic anxiety or fears), instigate the process by themselves, and recover from traumatic stress without any guidance or help from a therapist. Some survivors, however, may be unable to instigate such process because of higher levels of anxiety, fear , or depression arising from feelings of helplessness and hopelessness. CFBT simply enhances motivation for self-exposure in such cases by showing them a way out of their disabling traumatic stress problems and instilling hope for recovery and return to normal life. Our research shows that such exposure is strongly associated with substantial reduction in traumatic stress reactions.
The first stage of treatment involves delivery of only the Self-Help Manual, because this is the only instrument that can make it possible to disseminate the treatment to large masses of survivors in the shortest time possible in the aftermath of major devastating earthquakes. While we have only preliminary evidence attesting to the usefulness of this manual, our study findings are encouraging enough to include it in this mental healthcare model at this stage, subject to further research. First, in study (Başoğlu et al, 2009) using a multiple baseline single case experimental design, 7 of the 8 cases who received the manual after an initial assessment showed as much improvement as in treatment delivered by a therapist. In a further study (Başoğlu, unpublished data) that examined the usefulness of the manual when distributed to the homes of about 90 survivors without any therapist contact (and without any further contact until posttreatment assessment 3 months later), 50% never read the manual, a further 25% read it but did not utilize it, and a further 25% read and utilized the manual and recovered. Thus, 1 in 4 survivors utilized the manual and benefited from it. These findings suggest that the manual has the potential to achieve high rates of improvement, if the survivors can be encouraged and motivated to utilize it.
Once the survivors receive the manual, a further screening is conducted 2 to 6 weeks later to identify responders and non-responders. A good understanding of the treatment rationale and early engagement in self-exposure tasks are the most important predictors of good treatment outcome. Potential treatment responders who often display such understanding and commitment to treatment can be identified fairly early in the process, usually after about 2 weeks. If they have initiated self-exposure exercises and show at least 30% reduction in FAQ scores after 2 to 6 weeks, they can be considered as treatment responders and left on their own to continue treatment on a self-help basis.
Non-responders, on the other hand, move on to Stage 2 to receive a single session of therapist-delivered CFBT in groups of 25 (or Earthquake Simulation Treatment, if available). After a further screening, treatment responders continue treatment on a self-help basis and non-responders move on to Stage 3 to receive 3 more weekly sessions of therapist-delivered CFBT in groups of 10, thereby completing the full course treatment.
Figure 2 shows the total number of therapist delivered treatment sessions and expected rates of improvement at each stage. Expected improvement rate at Stage 1 is set to 25%, a rather conservative estimate based on our research finding mentioned above. This means 375 non-responders need to receive a single session of therapist-delivered treatment at Stage 2. Our studies show that 80% of survivors recover at this stage and, of the 75 non-responders who complete Stage 3 treatment, all recover. Thus, out of 500 cases in need of help, only 15% need up to 4 sessions. The total number of sessions needed to treat 500 cases is 37.5 or 0.075 sessions per case.
Cost of treatment
Cost-effectiveness of a treatment is of paramount importance in the aftermath of major disasters, considering that there may not be enough resources or mental health professionals to deliver psychological care to millions of people who may be in need. Widely used evidence-based treatments have limited usefulness in such circumstances, as their delivery often requires between 5 to 15 sessions. To illustrate the nature of this problem, let us take two widely used trauma treatments, such as Cognitive Behavioral Treatment (CBT) and Eye Movement Desensitization and Reprocessing (EMDR), which are delivered in an average of 14.8 and 4.6 sessions, respectively, according to literature findings.
Table 2 presents a comparison of costs of CFBT, CBT, and EMDR in terms of therapist time alone. Assuming that the average monthly salary of a psychologist in Turkey is 1,000 USD and one month involves 160 work hours, the cost of 1 hour of therapist time is estimated to be 6.25 USD. Thus, the cost of CFBT per hour is 0.47 USD (6.25 USD x N of sessions per case), compared with 92.5 USD for CBT and 34.50 USD for EMDR. This means that the costs of CBT and EMDR are, respectively, 196 and 73 times more than the cost of CFBT. The magnitude of these differences can be better appreciated when they are translated into actual costs of treatments when delivered to all individuals in need of psychological care (estimated to be 1 in 3 people) in the aftermath of devastating earthquakes, such as those that occurred in the southeast region of Turkey on February 6, 2023 (last column in Table 2).
As noted earlier, the improvement rate of 25% achieved by the Self-Help Manual is based on a conservative estimate. This rate can be substantially increased by media campaigns promoting the manual and encouraging its utilization. Even a 25% increase in this rate reduces the cost of treatment per case from 0.47 USD to 0.31 USD.
Furthermore, the treatment dissemination model reviewed so far does not include two important instruments. The first one is dissemination of treatment knowledge through mass media, such as TV, Internet, and social media. Though we never had a chance to test this method, we believe it is likely to be a powerful method of treatment dissemination. After all, we know from our research and observations of natural recovery processes that what accounts for recovery in treatment is the knowledge of treatment per se and not the therapist. This method of dissemination could be easily tested during the implementation of the model and incorporated into the first stage.
The second instrument is the Therapist Training Manual. This manual was inspired by our many observations of successfully treated survivors transferring treatment knowledge to others and assisting them successfully during their self-exposure exercises. These observations suggest that this highly structured manual (including assessment measures) can be useful to lay therapists in guiding them through delivery of treatment. The use of lay therapists can further reduce the costs of treatment dissemination.
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. The Therapist Training Manual can further facilitate this process.
Implementation of the model on a regional or national scale
So far we have examined how the model can be utilized to deliver psychological care to various targeted survivor populations. The model can also be used in a regional or national scale in earthquake-prone countries during both pre- and post-disaster phases. Table 3 shows the measures that can be taken before and after earthquakes (first column) and the tools and procedures that can be used to implement these measures (second column).
As noted earlier, the main objective here is to disseminate treatment knowledge to masses as widely as possible using various tools, including mass media channels. Such knowledge is likely to be useful in both phases. It is worth bearing in mind that the pre-disaster phase in a country where earthquakes occur from time to time is also the post-disaster phase following a previous earthquake. Thus, psychological preparedness for future earthquakes in such countries is also likely to be a treatment process for some individuals who have not fully recovered from the traumatic effects of previous earthquakes.
Earthquake Simulator Treatment is likely to be one of the most useful tools in enhancing resilience against the traumatic effects of future earthquakes in the pre-disaster phase. We know from our research that, among the many traumatic events experienced by people during and after an earthquake (including collapse of one’s house and being trapped under the rubble), the intensity of fear during exposure to earthquake tremors is the single most important predictor of traumatic stress reactions in the long-term. This means that one does not need to experience the full-scale devastating effects of earthquakes to get traumatized; repeated exposures to earthquake tremors alone is sufficient (a phenomenon that possibly reflects an evolutionary tendency to respond to unpredictable and uncontrollable life-threatening events with intense fear.) This indeed explains the prevalent and pervasive nature of earthquake-related fears in earthquake-prone countries. Our studies show that a 45-minute experience of simulated earthquake tremors in an earthquake simulator help people overcome their fear and gain resilience against traumatic effects of earthquakes. The use of this tool is therefore likely to be useful in increasing people’s psychological preparedness in the pre-disaster phase. Based on what we know about risk factors for traumatic stress in earthquake-exposed people, this tool can be used selectively, giving priority to at-risk individuals.
To conclude this section, the mental health model summarized here is rather unique in allowing cost-effective dissemination of effective psychological care to large masses of disaster survivors. It is based on a sound theory and has been empirically tested and validated to a significant extent. While some treatment dissemination methods need further testing, the model has prospects that cannot be easily matched by approaches based on other currently available treatments. There is also evidence to suggest that the brief treatments on which the model is based are distinctly more effective than other treatments (see a recent article for review of evidence). More detailed guidelines for implementing the model in post-earthquake settings are provided in our 2011 book on A Mental Healthcare Model for Mass Trauma Survivors. The basic principles of the model also apply to other mass traumas and research is currently underway to develop a similar model for survivors of war and torture but further work is needed to develop self-help instruments for wide treatment dissemination.
- Başoğlu et al (2011) A mental healthcare model for mass trauma survivors: Control-Focused Behavioral Treatment of earthquake, war, and torture trauma. Cambridge University Press.
- Başoğlu et al (2009) Single-case experimental studies of a self-help manual for traumatic stress in earthquake survivors. Journal of Behaviour Therapy and Experimental Psychiatry, 40, 50-58.