Theoretical framework

Control-Focused Behavioral Treatment (CFBT) is based on learning theory of anxiety, which posits that exposure to unpredictable and uncontrollable stressors is the primary mediating process in traumatic stress (Mineka and Zinbarg, 2006). Its development can be traced back to our work in the early 1990’s when we examined the parallels between animal responses to inescapable shocks and human responses to torture and presented a learning theory formulation of torture trauma (Başoğlu & Mineka, 1992) drawing on the work of Martin Seligman, Steve Maier, Bruce Overmier, Susan Mineka, and other prominent learning theorists and anxiety researchers. Over the years we conducted a series of studies to examine the role of unpredictable and uncontrollable stressors in human responses to war and torture trauma. These studies revealed ample evidence showing that helplessness anxiety or loss of control over threats to safety is indeed strongly associated with traumatic stress. Such evidence implied that traumatic stress can be reversed by interventions that enhance sense of control (or resilience against) traumatic stressors. Hence, CFBT came into existence. It was first tested with earthquake survivors and subsequently with war and torture survivors. A more detailed account of the developmental history and evidence base of CFBT can be found in the introduction to our book (Başoğlu et al, 2011).

Application

A live exposure session at the disaster site

CFBT is a fairly simple intervention with a sole focus on anxiety-evoking trauma cues and behavioral avoidance. It is designed to enhance sense of control over distress or fear associated with traumatic stressors. This is achieved by  encouraging the person not to avoid distressing or feared trauma-related situations. Anxiety and avoidance are common features of traumatic stress and they are particularly intense 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, 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.  Evidence shows that 99% of mass trauma survivors experience either cognitive / behavioral avoidance or distress in response to trauma reminders or their combination. Generalized fear and avoidance may lead to feelings of total helplessness, loss of control over life, and eventually hopelessness and depression.

The administration of CFBT is described in detail in our 2011 book A Mental Healthcare Model for Mass Trauma Survivors. Briefly, it involves the following procedures:

Step 1: Identify trauma cues or reminders that trigger anxiety, fear, or distress

Step 2: Explain the treatment rationale (i.e. confront your anxiety, fear, or distress until you gain control over it)

Step 3: Give self-exposure instructions (i.e. do not avoid situations that evoke anxiety, fear, or distress) and monitor progress.

Distinguishing features

CFBT is fundamentally different from Cognitive-Behavioral Treatment (CBT) and other exposure-based treatments in its underlying theory, aims, presumed mechanisms of action, and treatment techniques and procedures. Below is a summary of its most important distinguishing features:

• CFBT is not based on habituation paradigm. The primary aim is to increase anxiety tolerance or sense of control over anxiety, rather than anxiety reduction. Although anxiety diminishes with increased sense of control in most cases, improvement occurs even without substantial reduction in anxiety. This implies that patients are not required to conduct extensive exposure until complete habituation occurs. Exposure until anxiety tolerance or control develops is sufficient.
• A focus on resilience-building rather than anxiety reduction makes it more suitable for environments involving ongoing threats to safety, where anxiety reduction is neither feasible nor desirable.
• It is a streamlined intervention that does not involve any of the other techniques or procedures commonly used with CBT, such as systematic cognitive restructuring and imaginal exposure. This makes it relatively easier to administer and train therapists in its delivery.
• A behavioral focus makes it more applicable across different cultural settings.
• The therapeutic benefits of CFBT arise mainly from self-exposure to anxiety cues in the person’s natural environment. In most cases the therapist’s role is limited to explanation of the treatment rationale, giving self-exposure instructions, and monitoring of progress. As such, it is more suitable as a self-help intervention than other treatments.

Clinical and field applications

As CFBT was first tested with earthquake survivors after the 1999 earthquakes in Turkey, most of its applications reviewed here relate to earthquake trauma. These applications or variants include full course CFBT (4 sessions in earthquake survivors and average of 6 sessions in war and torture survivors), single-session CFBT, and single-session Earthquake Simulation Treatment. Furthermore, two tools have been developed with a view to disseminating treatment to masses in a cost-effective fashion. These include a Self-Help Manual to assist survivors in self-administration of treatment and a Therapist Training Manual to assist professional and lay therapists in delivering treatment.  These applications and tools are often used in combination in post-disaster settings as part of a mental healthcare model.

Full course CFBT

CFBT was first tested in an open trial (Başoğlu et al, 2003) involving 231 earthquake survivors. Using a flexible treatment duration design, the study aimed at examining the minimum number of sessions required for significant clinical improvement. Seventy-two percent of the cases had Posttraumatic Stress Disorder (PTSD)(28% had sub-threshold PTSD) and 47% had major depression. Treatment sessions were discontinued at any stage when significant clinical improvement occurred. Follow-up assessments ranging from 1 month to 9 months (mean 66 days) post-treatment were possible with 75 cases.

The survivors were given a mean of 4.3 treatment sessions. Analyses showed that 76% of the cases improved after 1 session, while 88% improved after 2 sessions. Substantial improvement was observed in all outcome measures, including PTSD symptoms (74%-77% in re-experiencing symptoms, 79%-86% in avoidance symptoms, 64%-83% in hyperarousal symptoms ), depression symptoms (71%-77%), and social disability, suggesting a patholytic effect of treatment.  Improvement was maintained at 3 to 9 months posttreatment in the 75 cases that were followed up in all but one cases, despite ongoing exposure to aftershocks in the region, suggesting that the treatment enhanced the survivors’ resilience against earthquake trauma. These findings also suggested that the treatment can be delivered in a single session, when necessary.

Single-session CFBT

In post-disaster circumstances, many survivors may not be able attend treatment more than once, because of disrupted life routines, demographic mobility, and daily struggle for survival. Such circumstances necessitate a single-session treatment that does not require further contact with the client.

A randomized clinical trial (Başoğlu et al, 2005) has shown that CFBT can be delivered in a single session to initiate a self-help process (i.e. self-exposure to trauma reminders) resulting in significant clinical improvement in traumatic stress reactions in over 80% of survivors. Such improvement achieved in 3 months was found to have been maintained at 1-2-year follow-up. These findings show that therapist involvement in treatment can be reduced to a minimum and the intervention can be delivered on a largely self-help basis.

Earthquake Simulation Treatment

Earthquake simulator – Exterior view

Earthquake Simulation Treatment (EST) is designed to help an earthquake survivor gain sense of control over earthquake tremors using an earthquake simulator. It is an innovative treatment designed by Professor Başoğlu to enhance the potency of CFBT even further by helping survivors develop a sense of control over earthquake tremors and used for the first time in Turkey. The earthquake simulator is specifically designed for treatment purposes. It is a small furnished house based on a shake table that simulates earthquake tremors up to 8 magnitude on a Richter scale. A computer executes the movements of the simulator in accordance with various preprogrammed earthquake scenarios.

Earthquake simulator – Interior view

The users can control the tremors from the inside using a mobile control switch, stopping or starting it anytime they want and increasing the intensity whenever they feel ready for it. Being in complete control of the tremors enables users to keep their distress or anxiety within manageable levels. The experience often evokes two types of emotions: fear associated with the tremors and distress related to memories of the traumatic events during the earthquake. This allows opportunities for the users to exercise and gain control over both types of emotions. The session is terminated when the users feel in complete control of their distress or fear. In almost all cases the experience leads to a substantial reduction in these emotions. The treatment session usually lasts 45 minutes. About 80% of the session time is spent on the lowest tremor intensity level (3-4 on the Richter scale).

An imaginative depiction of Earthquake Simulation Treatment – Courtesy of José Carlos Fernandes – a Portuguese artist

A randomized controlled study (Başoğlu et al, 2007) showed that EST achieves marked improvement in PTSD and depression in 90% of survivors. Improvement generalizes to social, work, and family functioning. In our studies relapse was rare (only 1 case), despite some survivors having been exposed to real earthquakes after treatment, suggesting increased resilience against the traumatic effects of earthquakes.

EST combined with single-session CFBT achieves 20% more reduction in PTSD than does single-session CFBT alone. Therefore, combined treatment should be the preferred option, whenever an earthquake simulator is available. EST makes subsequent self-exposure easier for survivors who are unable to initiate it by themselves because of high levels of anxiety. Groups of 5 to 10 people could be treated in a single session. Its resilience-building effects suggest that the intervention could also be used in psychologically preparing people against the traumatic effects of future earthquakes in earthquake-prone countries.

Self-help manual

A self-help manual has been developed to facilitate cost-effective treatment dissemination to large numbers of earthquake survivors in the aftermath of major disasters. This is a highly structured manual that can be used as a stand-alone treatment dissemination tool or as an adjunct to therapist-delivered treatment. Its structure closely parallels therapist-delivered treatment. It consists of sections that provide information about traumatic stress symptoms, treatment rationale, self-exposure instructions, target setting, and trouble-shooting at various stages of treatment. The manual also includes questionnaires for self-assessment. These questionnaires help the survivor obtain feedback on and monitor progress during treatment.

A pilot study (Başoğlu et al, 2009) suggested that, when delivered after initial therapist contact, about 50% of survivors are likely to improve as much as they do with therapist-delivered treatment. In a further (unpublished) study 1 in 4 survivors utilized the manual and improved when it was disseminated to them without any therapist contact. In our routine fieldwork it was delivered to more than 1,000 survivors with no untoward problems or complications pertaining to self-administered treatment. Audio or video versions of the manual can be used to deliver treatment to illiterate survivors.

Therapist Training Manual 

Circumstances after major disasters often require treatment delivery by all means possible. These include mental and other health professionals, general practitioners, nurses, social workers, counselors, schoolteachers, local priests, or other lay people with adequate educational background. The Therapist Training Manual is designed to guide such people in the delivery of CFBT.

This manual was inspired by our frequent observation that successfully treated survivors often tended to help other family members, friends or neighbors, using the experience they acquired during their own treatment. Sometimes they acted like therapists, encouraging others to conduct self-exposure and even accompanying them into feared situations to help them overcome their fears. In our fieldwork in survivor shelters we actually recruited such survivors as lay therapists and often observed good results. This encouraged us to prepare this manual to facilitate treatment delivery by lay people. The manual is highly structured, guiding the user through all stages of assessment and treatment.

CFBT and other trauma treatments

A comparison of CFBT with other trauma treatments in terms of percentage of treatment responders is shown in the figure on this page. These data were obtained from meta-analyses published in the literature (see Başoğlu, 2022 for more details of the comparative analysis).

The first two red bars show the percentages of cases that meet the “treatment responder” criterion in CFBT studies involving earthquake and war / torture survivors. A distinct difference between CFBT and other treatments can be observed in the rates of improvement achieved. While improvement rates range from 47% to 60% in other treatments, they are around 90% with CFBT. It is also worth noting that such improvement rates are obtained with only 1-2 sessions in studies of earthquake survivors and an average of 6 sessions in studies of war and torture survivors. While definitive conclusions in this regard require studies directly comparing CFBT with other treatments, these differences are nonetheless remarkable enough to deserve attention for future study.

References

Başoğlu 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.

Başoğlu M & 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.

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 (2005) Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: a randomized waiting list controlled trial. Journal of Traumatic Stress, 18: 1-11.

Başoğlu et al (2007) A randomized controlled study of single-session behavioral treatment of earthquake-related posttraumatic stress disorder using an earthquake simulator.  Psychological Medicine, 37 (2): 203-214.

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.

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.

Başoğlu M (2022) Control-Focused Behavioral Treatment: A brief intervention for survivors of war and torture. Torture, 32, 1-2, 251-263. [DOWNLOAD]