ment according to needs of each group member but this can be done with one or two survivors to demon- strate how the treatment should be conducted. When this is completed, ask the group if they have under- stood the treatment and if they have any questions.
Closing the session
In closing the session, distribute copies of the self-help manual, explain its purpose, and advise the group to read it and follow the instructions. You can end the session with the following statements:
Now that you know what to do about your problem, the choice is yours: you either do something to beat your fear or it will beat you. You need to understand clearly that success or failure in treatment depends
entirely on you. If you make sufficient efforts to over-
come your problems, your chances of recovery are high. Almost all people who fail in treatment do so because they do not carry out their homework exer- cises. You may experience some setbacks along the way but you need not worry about them as long as you keep making an effort. I suggest you help each other with your exercises. Also, try helping your fam- ily, friends, and neighbors with what you have
learned here.
In groups there are likely to be some particularly smart and articulate persons who understand the treatment very well, show strong motivation, and display remarkable enthusiasm and talent for helping others. They can be recruited as co-therapists to help others with their treatment exercises.
Single-session Earthquake Simulation
Treatment
Earthquake Simulation Treatment was developed to maximize the impact of single-session CFBT. Various
considerations that led to its development are detailed inChapter 6. In brief, it was expected to be a more potent form of CFBT in involving exposure to simu- lated earthquake tremors (i.e. unconditioned stimuli) rather than trauma reminders (i.e. conditioned stim- uli). An earthquake simulator was designed and con- structed for this purpose (shown in Figure 4.3 and
Figure 4.4).
The earthquake simulator sits on a shake table that can simulate earthquake tremors on nine intensity
levels. The movements are controlled by computer software in accordance with various earthquake sce- narios. The treatment session is designed to enhance the survivor’s sense of control over both the tremors and the anxiety or distress evoked by them. For exam- ple, the survivors are allowed to start and stop the tremors at any time and change their intensity by using a mobile control switch (see Figure 4.4). The session lasts one hour, starting with the lowest inten- sity level and going one level up as the survivor gains Figure 4.3 Earthquake simulator: outside view.
sense of control over the tremors. The session often evokes fear in response to the tremors, as well as bringing back distressing memories of traumatic events experienced during the earthquake. Treatment is terminated when the survivor feels no longer intensely distressed by the tremors and memories of the trauma.
As this intervention provides the most striking examples of how a single exposure session facilitates subsequent treatment, it is worth presenting two case vignettes. These cases are among the 31 participants of our controlled study of Earthquake Simulation Treatment (Başoğlu et al., 2007), all treated by the second author. Case vignette #5 was selected as an example of a ‘moderately severe’ case of PTSD (e.g. CAPS score of 57), whereas Case vignette #6 was selected as an example of an ‘extremely severe’ case of PTSD (CAPS score of 92), severity defined accord- ing to CAPS score ranges proposed by Weathers et al. (2001). The latter was the most severe case of PTSD in the study sample.
Case vignette #5
Hasan was a 38-year-old male, married with three children. He worked as a construction worker before the earthquake. Although his house had not sus- tained severe damage he reported intense fear during the earthquake. He participated in rescue work after the earthquake and thus was also exposed to intensely disturbing scenes of people trapped under rubble. He had severe re-experiencing symptoms relating to these events. He had to quit his job because he used to work in neighboring towns and could not leave his family unattended for even short periods for fear of another earthquake. He was also unable to work on scaffold- ings because even a slight shaking evoked intense fear. He had been unemployed and almost house- bound for about 5 years. He supported his family with the help of relatives and friends. At assessment he had moderately severe PTSD (CAPS score 57) and depression (Beck Depression Inventory – BDI score 24).
Hasan agreed to self-exposure only with some reluctance, making the therapist feel that he would abandon treatment at the first difficulty with expo- sure. Nevertheless, he readily agreed to a single ses- sion of Earthquake Simulation Treatment. During the session he initially experienced intense fear. He was flooded with thoughts and images related to the events during rescue work. He stopped the
earthquake simulator three times in the first 12 minutes and actually left the simulator on the third occasion. The therapist told him that he could termi- nate the session if he wanted but that would mean accepting defeat. He was encouraged to give himself a chance to beat his fear once and for all and recover from his problems. He decided to resume the session and this time did not stop the earthquake simulator until the end. He was encouraged to go through the events in his mind (most of which related to the first day after the earthquake) as they occurred. At some point he started re-experiencing the events so vividly and with such intense distress that he was not even able to speak. He then burst into tears. Seeing that he was trying to relate his trauma story but could not do it in a coherent fashion, the therapist asked him sim- ply to relive the events in his mind and not make an effort to talk. This phase lasted about 20 minutes, during which his anxiety showed substantial reduc- tion. He stated “I am now finished with the first day of the earthquake.” After another 10 minutes of going through the memories of the second day of the earth- quake in his mind, the disturbing images completely vanished. Without being asked to do so, he got up and walked around the simulator while the tremors continued (an activity that often leads to sudden peaks in fear because of loss of postural control) in an effort to challenge his fear. When he felt in com- plete control and the tremors no longer disturbed him he said “I’ve beaten my fear. I made the images fade away. It was like watching the same movie for the
last time!” He cried in relief, saying that his nightmare
was finally over. The exposure session lasted 51 minutes. At the end of the session he stated that the experience reinforced his resolve to confront his fears (e.g. by travelling to neighboring towns, going out and leaving his family unattended at night, and enter- ing safe buildings) that posed a serious problem in conducting his work. He had been told during recruit- ment in the trial that he would receive only one treat- ment session and that subsequent contacts would be with a different project worker for assessment purpo- ses only. Assessments were conducted at regular intervals for 1.5 years after the session. The assessor refrained from discussing treatment issues and encouraging self-exposure to avoid confounding the impact of the initial treatment session. The improve-
ment in CAPS and FAQ scores is shown inFigure 4.5.
The scores showed a substantial decline at 2-month follow-up, reaching a low point at 3-month follow-up. At week 8 he rated himself as much improved on the self-rated Global Improvement Scale. He resumed work within 2 months after treatment and started a Chapter 4: Control-focused behavioral treatment
new job in a neighboring city, which meant leaving his family unattended for weeks at a time. At 18 months follow-up he was very much improved, with a CAPS score of 0 and 92% reduction in his depression scores.
Case vignette #6
Ayşe was a 38-year-old female patient, married with two children. She was a housewife with a primary school education. Although she had not experienced physical injury or loss due to the earthquake, she reported intense fear and loss of control during the earthquake. During the week following the earth- quake, she was withdrawn, stopped eating, lost weight, smoked excessively, frequently cried, barely talked, and sometimes wandered aimlessly in the streets. She was admitted to a psychiatric hospital where she received drug treatment and was dis- charged after a month with minimal improvement. At assessment she had severe PTSD (CAPS score 92) and was depressed (BDI score 28). Her concentration difficulty and psychomotor retardation were severe enough to interfere with assessment. Before the earthquake she was the strong figure in the family, controlling the family affairs, but she now felt totally out of control of everything in her life. She felt that she was no longer respected by her husband and children and felt very distressed about this situation. She was debilitated by anticipatory fear of a possible
future earthquake. She was constantly hypervigilant and startled by the slightest unexpected noise or movement in the environment. She avoided sexual intercourse with her husband in case she was caught unprepared by an earthquake, a problem that led to serious marital conflict. She had been in this condition for 5 years since the earthquake.
At trial entry Ayşe was assigned to waitlist control condition. During the 8-week waiting period she showed no improvement. At the end of this period she received a single session of CFBT, followed by
Earthquake Simulation Treatment. The first part of
the treatment session lasted longer than usual (about 90 minutes) because of her concentration dif- ficulties. She understood the treatment rationale and agreed to try self-exposure to various feared situa- tions (e.g. taking a bath while alone at home, sleeping with lights off, staying at home alone at night, and having sexual intercourse once a week). During the exposure session, which started at the lowest tremor magnitude level, she experienced intense fear in the beginning (rating her anxiety as 8 on a 0–8 scale) and tried to avoid distressing trauma-related thoughts and images flooding into her mind, while also dis- tracting her attention away from the tremors. The therapist encouraged her to think about trauma expe- riences and to focus on the sounds and movements of the earthquake simulator. She kept the tremor intensity at the same level throughout the session to keep her distress within manageable limits. The ses- sion was terminated when a behavioral test (i.e. get- ting the survivor to recall the most distressing
Clinician Administered PTSD Scale Fear and Avoidance Questionnaire
50 60 35 40 40 25 30 20 30 15 20 10 5 10 0 0 Month18
Baseline Month2 Month3 Month6 Month18 Baseline Month2 Month3 Month6
memories) demonstrated that she was able to recall the most distressing aspects of the trauma with no significant distress. After the session she reported marked increase in her sense of control and reduction
in her anticipatory fear of earthquakes. Figure 4.6
shows the improvement in treatment outcome meas- ures at follow-up.
Improvement was gradual in the first three months after the session (slight at month 1 and moderate at month 3). She was able to conduct self-exposure at a rather slow pace, because of inca- pacitating depressive symptoms. Nevertheless, improvement accelerated after month 3, reaching a maximum at month 6 (with 91% reduction in PTSD symptoms and 93% reduction in depressive symp- toms). She was able to function normally, resumed sexual activity, and regained control over her life and family. At this point she reported having been exposed to another earthquake in the region (4.8 on the Richter scale), during which she experienced no fear or subsequent return of symptoms. At 1-year follow-up she reported almost complete recovery, with 96% reduction in PTSD and 100% reduction in depression symptoms. On a scale designed to
evaluate attributions of improvement, she attributed 60% of her recovery to the simulator experience, 40% to self-exposure exercises, and 0% to assessment or any change in life circumstances.
Case #5 demonstrates how debilitating earthquake- related fears and avoidance can be, even in the absence of severe PTSD and comorbid illness. This is also true for war and torture survivors. Case #6, on the other hand, is characteristic of very severe cases of PTSD that fail to respond to single-session CFBT, mainly because of the debilitating effects of pervasive fear and depres- sion. When depression is secondary to persistent fear and related traumatic stress, even inpatient treatment with medication is unlikely to be useful, as her case demonstrates. The helplessness and hopelessness effects of depression can be overcome in such cases by a therapist-administered exposure session. Progress might be slow, improvement taking a few months, but they eventually recover, provided they continue with self-exposure exercises. Note that in both cases PTSD and depression started to improve with increase in their
100
Clinician-Administered PTSD Scale
80 100
Fear and Avoidance Questionnaire
40 60 80
40 60
EST session EST session
0 20
0 20
60
Beck Depression Inventory
32
Sense of Control Scale
30 40 50 16 24 0 10 20 B1 B2 B3 M1 M3 M6 M12 B3 M1 M3 M6 M12 B1 B2 B3 M1 M3 M6 M12 B1 B2 B3 M1 M3 M6 M12 0 8
EST session EST session
Figure 4.6 Improvement in avoidance, PTSD, depression, and sense of control after a single session of Earthquake Simulation Treatment in Case #6. B1 = First baseline assessment at trial entry at week 0; B2 = Second baseline assessment at week 4; B3 = Third baseline assessment at week 8; EST = Earthquake Simulation Treatment; M1 = 1-month follow-up; M3 = 3-month follow-up; M6 = 6-month follow-up; M12 = 12-month follow-up.
sense of control over fear (as measured by the Sense of Control Scale). Such improvement patterns were char- acteristic of the 31 cases that participated in our treat- ment study. These cases illustrate how useful a single exposure session can be in helping the survivors over- come their helplessness and initiate a self-help process.
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