Psychologist, Former intern at DABATEM
The ever-increasing population of the world is being affected by war, environmental degradation, and poverty. Available resources fail to meet the demand for psychological care, given that there is one psychiatrist per every 100,000 in about 70% of the global population. In African countries this ratio is even lower with an average of 5 million people for every psychiatrist. This ratio is possibly lower still for the 43.3 million displaced individuals around the world (UNHCR, 2010). Although European countries are fortunate enough to have an average of one psychiatrist for every 10,000 people (Klecha, Barke, & Gureje, 2004), there is still an unmet demand for psychological treatment, leading to governmental efforts to improve access to psychological therapy (Morley et al., 2007; Radhakrishnan et al., 2013).
Treatment attendance is often a problem when delivering mental healthcare. Evidence suggests that 45% of people attend only one therapy session, with a further 20% attending only two sessions (Young, Weir, & Rycroft, 2012). Such high attrition rates could be due to work or family commitments, or financial constraints that make treatment attendance difficult. People exposed to mass trauma might have even greater problems attending treatment sessions due to increased demographic mobility. This problem points to the need for treatments that can be effectively delivered in a single session or that can be administered by the survivors on an entirely self-help basis. In this article, I present an overview of current knowledge on single session treatments and self-help approaches in mental healthcare of trauma survivors and review the prospects for effective and cost-effective mental healthcare of mass trauma survivors.
Single-Session Treatment
Although a wealth of evidence points to the efficacy of single-session treatments in other disorders, such as anxiety (de Jongh et al., 1995; Kim, Lundh, & Harvey, 2002; Maxfield & Melnyk, 2000), depressive (Springmann, 1982), and addictive disorders (Hill, 2011; Miller, 2000), there has been limited research on single session treatment (SST) for PTSD. Lack of attention to single session interventions may partially reflect the disappointment caused by Critical Incident Stress Debriefing (CISD), also known as Psychological Debriefing (PD). For over 15 years PD was the most widely practiced and well-recognised brief early intervention used by psychologists in the immediate aftermath of traumatic events. PD involves encouraging survivors to give a full account of their trauma experience and related thoughts and emotions, with the aim to help the survivor normalise them. However, in the early 21st century, four critical reviews concluded that PD did not prevent the development of PTSD and that it may in fact lead to increased rates of PTSD (McNally, Bryant, & Ehlers, 2003; Rose, Bisson, & Wessely, 2002; Rose, Bisson, & Wessely, 2003; Van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). Several reasons have been forwarded for this finding. First, PD was originally developed by Mitchell (1983), not as a psychological treatment, but as a form of crisis intervention. Another reason is that the intervention is too short, therefore not allowing habituation to occur, and consequently “re-traumatising” clients (Rose et al., 2003). As habituation is deemed essential for recovery (Foa, Huppert, & Cahill, 2006), several sessions are said to be necessary for within- and between- session habituation to occur. This view will be contended later in this article.
Some uncontrolled or case studies have reported varying degrees of improvement with a single session of EMDR (McCann, 1992; Rogers et al., 1999), imaginal exposure (Rogers et al., 1999; Rothbaum et al., 2008), and Control-Focused Behavioural Treatment (CFBT; Basoglu, Livanou, & Salcioglu, 2003). As explained in more detail elsewhere in DABATEM’s website, CFBT is a brief intervention designed to enhance sense of control over distress, anxiety, or fear through live exposure to trauma cues; it involves no cognitive interventions. Only two randomised controlled trials (RCT) examined the efficacy of single-session therapy for PTSD and both involved CFBT. The first study (Salcioglu, Basoglu, & Livanou, 2007) was conducted with earthquake survivors and involved a single session of exposure to earthquake tremors using an earthquake simulator. This was combined with self-exposure instructions to help gain control over fear. The findings showed a strong treatment effect on PTSD at 8 weeks follow-up. Indeed, 92% of the study participants reached the criterion for clinically significant change (i.e. 2 standard deviations or more of improvement from baseline; Jacobson & Truax, 1991) on the Clinician-Assessed PTSD Scale (CAPS) at 1-2 years follow-up. This outcome is particularly impressive when compared with the results of multiple-session treatments. For example, 62% of active duty soldiers showed clinically significant change after approximately 7.4 sessions of prolonged exposure therapy using virtual reality (Reger et al., 2011). Another study, which compared the percentage of study participants that achieved clinically significant change from different treatments reported rates of 72% for eight sessions of mixed imaginal and live exposure, 39% for a minimum of three sessions of relaxation, and 50% for full-course EMDR (Taylor et al., 2003). Similar percentages of clinically significant change have also been reported elsewhere for full-course EMDR (Wilson, Becker, & Tinker, 1997).
Although this treatment appears to be highly effective in a single-session, it still requires a trained therapist to deliver the ‘active ingredients’ of the treatment within the session to achieve significant recovery. Empowering the client to administer the treatment on their own through brief instructions given by a therapist would begin to address our need for mass-scale dissemination of effective psychological treatment. This brings us to the second of the two RCTs mentioned earlier, which focuses on processes outside the session rather than within it. Basoglu et al. (2005) conducted another study with earthquake survivors, which involved only self-exposure instructions and no therapist-delivered exposure. The results showed large improvement effects on clinician-assessed PTSD scores in the treatment group at 6 weeks follow-up, whereas the waiting-list controls showed little change in their PTSD symptoms. Moreover, 71% of treated survivors achieved clinically significant change (Jacobson & Truax, 1991) on CAPS. This suggests that this treatment is highly effective, even without therapist-delivered exposure.
Mechanisms of improvement
What is it about Basoglu and colleagues’ treatment which makes it so effective, leading to such significant improvement after a single session? To answer this question we need to compare CFBT with other treatments for PTSD. In her extensive review of treatment of PTSD, Salcioglu and Basoglu (unpublished manuscript) conducted a meta-analysis to look at which ingredients within cognitive behaviour treatments contribute to the largest reduction in PTSD symptoms. She found that imaginal exposure and cognitive therapy had limited efficacy when used alone and that adding live exposure to either of these treatments enhanced their efficacy. Moreover, the addition of other interventions to exposure packages, such as cognitive restructuring, did not lead to better treatment outcomes. Therefore, Salcioglu concluded that live exposure is the main active ingredient in CBT packages. CFBT was not included in her meta-analysis, because it is different from other exposure treatments in its theoretical basis.
Exposure treatment is said to reduce anxiety or fear through habituation and corrective learning (Foa et al., 2006; Foa, Steketee, & Rothbaum, 1989). This theory posits that every fear network within memory is made up of associations among (1) information about the feared stimulus, (2) information about the physiological, emotional, verbal and behavioural responses to the feared stimulus, and (3) interpretive information about the meaning of the situation, mainly related to the degree of threat. Foa argues that this adaptive fear network becomes maladaptive when a traumatic event violates formerly held basic assumptions of safety and self-competency. She therefore suggests that a treatment that facilitates the incorporation of new information incompatible with the current interpretive (and fear-inducing) information in the maladaptive fear network will achieve long-term recovery (Foa & Kozak, 1986). In order to achieve emotional processing, three processes must occur within the imaginal or in-vivo exposure session. First, initial fear activation (a physiological response to the fear cues) must take place to activate the fear network for subsequent processing. Second, within-session habituation (a reduction in fear during exposure to fear cues) leads to extinction of fear. This is a prerequisite for the third process, i.e. between-session habituation (reduction of fear between sessions), which leads to new interpretive information becoming incorporated into the network.
Although Foa et al.’s theory is the most popular explanation of the mechanisms of exposure therapy, it has been criticised by some authors. In an extensive review, Craske et al. (2008) suggests that there is little empirical support for the role of habituation in the extinction of fear. She argues that ‘inhibitory processes’ are central to breaking the association between cue and fear response. Furthermore, she suggests that rather than aiming for fear reduction with prolonged exposure, one should conduct exposure therapy with the primary goal of tolerating fear.
In line with Craske’s review and because of its origins in contemporary learning theory, CFBT focuses on enhancing sense of control over fear and, as such, is distinct from other exposure treatments. Using Seligman’s concept of ‘learned helplessness’ (Overmier & Seligman, 1967; Seligman & Maier, 1967) as the basis of PTSD, learning theory quotes animal and human studies to evidence that gaining control over environment and fear can reverse helplessness and, thereby, traumatic stress (Mineka & Zinbarg, 2006). Accordingly, habituation or reduction in fear is not deemed necessary; perceived control over the feared situation is sufficient. Thus, a sharper focus on sense of control rather than anxiety reduction might explain the differences in effect sizes in CAPS when we compare Basoglu, et al.’s (2005) single-session treatment (1.7 at week 24) with 10 sessions of imaginal exposure (0.9; Tarrier et al., 1999) and in-vivo exposure treatment (1.3; Marks et al., 1998).
A further explanation concerning the remarkable potency of CFBT concerns the evolutionary basis of the need to maintain control over a threatening environment. Indeed, survival could not have been possible without sufficient control over environmental threats and their mental effects (Basoglu, personal communication). Basoglu & Salcioglu (2011) note that humans have an evolutionarily determined potential for ‘natural’ recovery from trauma by engaging in risk-taking behaviours, such as confronting fear by not avoiding feared situations, and thereby learning effective ways of overcoming fear and coping with threats. (The word ‘natural’ here is used to refer to recovery by own means without the help of a mental health professional). Avoidance of life-threatening situations is a natural self-protective response required for survival but avoidance itself can become incompatible with survival when it interferes with essential life functioning. Indeed, after the 1999 earthquakes in Turkey, Basoglu and Salcioglu (2011) observed that survivors living in shelters because of fear of concrete buildings began to make an effort to overcome their fear by instigating gradual self-exposure to buildings (in much the same way as would be prescribed by a behaviour therapist) when the harsh living conditions in shelters became unbearable or even dangerous. A study found that 94% of the interviewed survivors who fled their houses resettled in their house within a month of the initial earthquake, despite intense anticipatory fear caused by ongoing aftershocks (Salcioglu, 2004). A further study showed that resettlement, which inevitably involved exposure to feared situations, was associated with improvement in traumatic stress symptoms (Salcioglu, Basoglu, & Livanou, 2007, 2008). These findings suggest that self-exposure to fear cues is the critical process in natural recovery from trauma. CFBT is an intervention designed to facilitate natural recovery essentially by mobilising one’s naturally existing potential for such recovery. Its efficacy could thus be explained by the fact that its mechanism of action closely matches the natural recovery process.
Interventions administered on solely self-help basis
The effectiveness of a single therapy session with minimal therapist contact suggests that an entirely self-help approach with no therapist involvement might be a viable option in delivery of psychological care. Indeed, recent meta-analyses have indicated that self-help treatments are just as effective as face-to-face psychotherapy for many disorders (Cuijpers, et al., 2010; Reger & Gahm, 2009). To the best of the author’s knowledge, only three RCTs have been conducted to evaluate the efficacy of self-help in treatment of traumatic stress. The first study by Litz, Engel, Bryant, & Papa in 2007 compared Internet-based self-managed CBT (which included self-administered live exposure) to Internet supportive counselling for service members in the Iraq war or 9/11. They found that Internet-based CBT significantly reduced self-reported PTSD symptoms in an intent-to-treat analysis, with a moderate difference between the two treatments.
The second study conducted by Knaevelsrud & Maercker (2007), compared an Internet-based therapist-guided CBT (which included exposure in the form of written narration of the trauma story) with a wait-list control in a sample of civilians with PTSD. At 3-month follow-up, greater improvement was found in self-rated PTSD symptoms in the treatment group relative to the wait-list controls. Furthermore, in a follow-up paper, Knaevelsrud & Maercker,(2010) found that treatment gains were maintained and even increased after 18-months.
The third RCT conducted by Ehlers et al. (2003) compared multiple-session cognitive therapy, minimal guided self-help cognitive therapy and repeated assessments in survivors of motor traffic accidents. In contrast to the previous research, there was no difference between their self-help booklet and repeated assessments, although a positive outcome was achieved by therapist-delivered cognitive therapy.
Ehlers et al.’s (2003) study highlights an important issue discussed earlier, as it used a treatment protocol different from that used in the previous two RCTs. Litz et al. (2007) and Knaevelsrud & Maercker (2007) used in-vivo and written narration of the trauma story, respectively. In comparison, Ehlers et al. focused on changing maladaptive cognitions with no exposure. If exposure is the most critical ingredient of all CBT packages in the treatment of PTSD, as the meta-analysis by Salcioglu & Basoglu (unpublished manuscript) suggests, then the lack of exposure in Ehlers et al.’s (2003) treatment manual may explain its inefficacy. This is consistent with another finding of Salcioglu & Basoglu (unpublished manuscript), which shows that cognitive therapy programs that do not include imaginal or live exposure elements perform significantly worse than cognitive programs that do. Thus, Ehlers et al.’s study demonstrates the importance of choosing a treatment with effective ingredients, especially when using treatments with minimal or no therapist contact.
A further distinction between the first two RCTs and the Ehlers et al. (2003) study is the method of delivery. The first two studies utilized the Internet in order to deliver therapy, whereas the study conducted by Ehlers et al. used a written format. A meta-analysis of self-help treatments for various psychological disorders found a large treatment effect for computerised self-help treatments over written treatments (Haug, Nordgreen, Öst, & Havik, 2012). Although this effect may be due to other factors, such as increased access to guidance from the therapist made more possible in Internet-based treatment, a growing wealth of evidence suggests that there is no difference between guided self-help, and ‘pure’ self-help without any therapist contact (Berger et al., 2011; Farrand & Woodford, 2013; Gould & Clum, 1993). Therefore, these results may be regarded as offering preliminary evidence for a possible advantage of delivering therapy over the Internet.
Computerised self-help would have obvious advantages in war or natural disaster zones where access to survivors is difficult. With a prediction of 5 billion people connected to the Internet by 2020 (Smith, 2011), the Internet is becoming more accessible for people all over the world. In line with such development, people are increasingly turning to the Internet to seek answers to their health-related questions and to initiate self-help. In fact, research suggests that over two-thirds of Norwegians and Germans have been using the Internet for health purposes (Otto & Eichenberg, 2010; Wangberg et al., 2009). This trend is evidenced in high-income countries by the online publication of self-help books (e.g. Moodjuice of the NHS), the introduction of stepped healthcare models using self-help for a variety of psychological problems (NICE, 2007, 2009), and the recent establishment of the first online outpatient mental health clinic in Sweden.
The demand for self-help knowledge is also being addressed by non-health professionals. An analysis of 80 websites targeting trauma survivors found that 42% of websites provided inaccurate or even harmful information (Bremner et al., 2006), a finding that has also been replicated in relation to self-help books (Redding et al., 2008). This points to the need for evidence-based protocols when issuing self-help manuals for public consumption.
Prospects of self-help approach in developing world
Although Western countries have begun to increase its capacity for patients through a self-help approach, the developing world is yet to harness the potential of this approach. If utilised effectively, the self-help approach raises the prospect of mass-scale dissemination of treatment in regions where resources are scarce. One pilot study looking at an Internet-based guided self-help CBT (which included written narration of the trauma story) in war-torn Iraq, found a large treatment effect in self-rated PTSD symptoms (Wagner, Schulz, & Knaevelsrud, 2012), despite exposure to a mean of 4.5 types of trauma events, such as kidnapping, killing of a close relative, torture, and sexual violence. Although this study had a small sample size of 13, it nevertheless provides encouraging evidence for the usefulness of Internet-based self-help manuals in conflict settings.
An interesting issue raised by the above study was the high incidence of drop-outs (62%). The authors were able to follow-up some of their drop-outs (24%) and found that 12% left the study due to bad Internet connection, whereas the other 12% said they doubted the neutrality of the website and were concerned that it may be run by foreign secret services, such as the CIA or Mossad. Such potential problems needs to be taken into account in war-torn countries where Internet connections are not reliable and where fear is rife. In such situations, a written manual that can be printed and distributed within a community might circumvent these problems.
The usefulness of a written manual has been examined in Turkey in a pilot study conducted by Basoglu, Salcioglu, & Livanou (2009) in a post-earthquake setting. They found that a manual based on CFBT achieved 88% reduction in PTSD symptoms, comparable to that achieved by therapist-delivered treatment. Although this study included only 8 cases, it nevertheless provides encouraging evidence suggesting that therapist involvement in treatment is not essential for recovery, provided that the right treatment is chosen. While some degree of therapist involvement might be required in cases that are unable to instigate self-exposure on their own, self-help tools might help a substantial proportion of survivors recover from trauma without any therapist assistance. Accordingly, Basoglu and Salcioglu (2011) have developed a mental healthcare model for mass trauma survivors that entails a solely self-help approach for the majority of cases, while reserving therapist input for cases that do not respond to self-help interventions.
Implications for other mental disorders
If humans have an innate potential to recover from traumatic stress, this might also be true for other mental disorders. Preliminary evidence suggests that single-session treatment of general disorders that focuses on problem-solving and empowerment of the client can be effective (de Shazer, 1990; Hoyt, Rosenbaum, & Talmon, 1992; O’Hanlon & Weiner-Davis, 2003; Talmon, 1990; Weakland, Fisch, Watzlawick, & Bodin, 1974). An interesting RCT (Perkins, 2006), which examined the effectiveness of a general SST model in an outpatient CAMHS unit in Melbourne, randomly assigned children into either solution-focused SST (n=86) or waiting-list control (n=87). At 6 weeks follow-up 70-74% of young clients in the treatment group showed improvement in problem frequency and severity as rated by the child’s family. Improvement was maintained at 18 months follow-up in 60% of children, while the other children needed one or more additional sessions for further improvement (Perkins & Scarlett, 2008). Improvement occurred across a range of problems, suggesting that SST can be used even in more ‘complex’ disorders.
Although many SST models are eclectic (Hoyt et al., 1992), they all involve problem-solving and empowerment strategies designed to induce behavioural and cognitive change. This reflects the behavioural model of mental health, which aims to achieve recovery through behavioural interventions (e.g. behavioural activation, response prevention, exposure). Empowering clients leads to a sense of control over life, an outcome that has been shown to affect all aspects of mental health, including psychiatric symptoms, self-esteem, and quality of life (Corrigan, Faber, Rashid, & Leary, 1999). The behavioural model may also help immunise people against stressors that lead to mental health problems, consistent with experimental work with animals showing that such psychological immunisation is possible (Williams & Maier, 1977). Also consistent with this view is the evidence from Basoglu et al.’s (2011) studies showing that gaining sense of control over simulated earthquake tremors have a protective effect against the traumatic impact of real earthquakes.
Conclusion
The evidence briefly reviewed in this article suggests that a self-help approach capitalising on the innate human capacity for recovery carries great potential in treatment of not only traumatic stress but also other psychological disorders. The importance of such an approach is better appreciated when one considers a predicted global population of 9.6 billion by 2050 (UN DESA, 2013) and unsustainable consumption and shrinking resources that will lead to land- and water-wars, natural disasters, and environmental degradation. The need for effective and cost-effective mental healthcare is becoming more and more urgent. With increased access to the Internet, the prospect of mass treatment, even in the face of political and environmental obstacles, appears to be within our reach.
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Acknowledgement
This article is based on my experience and knowledge gained during my 9 months of internship at DABATEM. I would like to thank Professors Basoglu and Salcioglu for their guidance and assistance in the preparation of this article.