Tema Prioritario 57 “Otras ayudas para mejorar los servicios turísticos”

A good understanding of how the treatment works on the part of both the therapist and the survivor is essential for success in therapy. To illustrate how CFBT works, it is worth briefly reviewing the processes of change during exposure to fear cues. Figure 4.1

compares the change processes in anxiety and sense of control during exposure that ends with escape from the situation (avoidance) with those that occur during continued exposure where control over fear is exer- cised (non-avoidance).

It is helpful to recall our discussion in Part 1 as to how repeated exposures to uncontrollable stressors induce a state of helplessness, reducing pre-trauma sense of control over stressors to a level where the person no longer has expectations of control over the outcomes of future stressor events. The dotted line labeled as pre-session baseline sense of control repre- sents this reduced level of sense of control before an encounter with a stressor event. Such low sense of con- trol facilitates actual loss of cognitive, behavioral, and emotional control when a trauma cue is encountered. As sense of control drops to a maximum low, anxiety rapidly rises, reaching a peak. Heightened loss of control and anxiety triggers avoidance or escape behavior, which in turn leads to a reduction in loss of control and anxiety. If the person manages to stay in the situation and continues to experience heightened anxiety, they eventually learn to tolerate and control it. It is important to note here that anxiety may not reduce substantially in some cases (dotted arrow inFigure 4.1), even when sense of control increases. This does not pose a problem for therapy, as the purpose of exposure is to enhance tolerance and control of anxiety, rather than reduce it. Accordingly, the treatment aim needs to be presented in such a way that the person makes an effort to invite, challenge, tolerate, and control fear / distress rather than try to reduce it. In a post-earthquake sit- uation, challenging fear means, for example, entering an undamaged building and doing things to maintain anxi- ety for as long as possible, such as seeking and focusing on additional fear cues (e.g. examining supporting col- umns for signs of damage, looking at cracks on the wall plaster, standing in a place where ground vibrations caused by passing trucks can be felt, etc.), tackling more frightening aspects of the situation (e.g. going to the upper floors), and inviting anxiety-evoking thoughts (e.g. ‘an earthquake might happen now’). In the example of the survivor in case vignette #1,

challenging fear means not only going out alone but also doing things to invite fear, such as going to crowded places, going near police officers or men with a mous- tache on the street, approaching white Ford cars, walk- ing close to the street, etc. It is such newly acquired ability to challenge fear and not mere reduction in anxiety that accounts for perceived improvement in treatment. Such experience often signifies a major vic- tory or liberation from fear, particularly in survivors with a long history of pervasive fear, avoidance, and feelings of helplessness. Fear reduction is not a requirement for a sense of well-being, as the latter is more closely related to increased sense of control (see Chapter 6 for more discussion of this issue). Accordingly, the treatment rationale makes no explicit reference to anxiety reduction in treatment. Although anxiety often diminishes as the treatment progresses, setting anxiety reduction as the treatment goal is not consistent with the expressed aim of the therapy. It may be counterproductive in survivors who may not experience reduction in their anxiety or who expe- rience a return in anxiety at some stage during treatment, leading them into thinking that the treatment is not working or that they are a treatment failure.

The context-dependent nature of fear reduction is a well-known problem in traditional exposure

treatment that accounts for return of fear in situations different in their contextual character- istics from the one in which fear reduction took place (Bouton, 1988; Hermans et al., 2005; Mineka et al.,

1999; Mystkowski et al.,2002; Rodriguez et al.,1999; Rowe & Craske, 1998). Accordingly, some authors (Craske et al., 2008; Vansteenwegen et al., 2005; Vansteenwegen et al.,2007) recommend that exposure treatment is conducted in multiple contexts so that treatment effects are generalized and the likelihood of relapse is reduced. This is not a requirement in CFBT, simply because it does not aim at reducing anxiety in any context. In CFBT each fear-evoking situation is regarded as an opportunity to build up anxiety tolerance or resilience. Generalized improve- ment can occur in both fear and related traumatic stress reactions with one session of CFBT (e.g. as in Earthquake Simulation Treatment described later in this chapter; see also Chapter 6), suggesting that increased sense of control, unlike anxiety reduction, can generalize to other contexts. The remarkably low rate of relapse in our treatment studies with earth- quake survivors (evidence reviewed in Chapter 6), despite ongoing aftershocks (i.e. unconditioned stim- uli), is further evidence of generalized treatment effects.

Avoidance/Escape _{Non-avoidance/Exposure}

FEAR

SENSE OF CONTROL FEAR

Trauma cue

Post-session baseline sense of control Trauma cue

Pre-session baseline sense of control

CFBT session

after treatment session

SENSE OF CONTROL

Avoidance/Escape

before treatment session

Figure 4.1 Processes of change in fear and sense of control during exposure to trauma cues before and after first treatment session.

Once thefirst encounter with a feared situation is managed successfully, the increase in sense of control makes subsequent encounters with the same or similar situations easier to tackle. At each subsequent expo- sure peak anxiety (highest anxiety level reached during the encounter) tends to be lower in intensity and increase in sense of control and decrease in anxiety occurs faster. Such improvement process can also be observed within the same exposure session when fear cues of increasing intensity are presented in succession.1Figure 4.2shows the pattern of change

in anxiety with repeated encounters with anxiety cues as treatment progresses.

Note that the baseline anxiety level before an encounter with a trauma cue is higher than the pre- trauma baseline anxiety level (dotted line), because of anticipatory anxiety or hypervigilance associated with expectations of further threat to safety. An increase in sense of control after each exposure reduces anticipa- tory anxiety, resulting in lower baseline anxiety before the next encounter with another trauma cue. Enhanced sense of control also leads to lower peak anxiety during the next exposure and faster return to pre-exposure baseline anxiety level. Thus, as peak anxiety declines with repeated exposures to different anxiety cues, so does baseline anxiety, which may eventually return to pre-trauma level. This is often

Trauma cues

Intensity of anxiety

Time

Pre-trauma baseline anxiety Cue 1

Cue 2

Cue 3

Cue 4

Figure 4.2 Pattern of anxiety reduction with repeated exposures to trauma cues.

1 _{For example, in our study (Başoğlu et al.,}

2007) of Earthquake Simulation Treatment in earthquake survivors, the magnitude of simulated tremors ranged from 1 (corresponding to a 3- to 4-strong earthquake on the Richter scale) to 5 (magnitude of about 7 on the Richter scale). We obtained within-session anxiety ratings through- out the session based on a 0–8 scale to examine the process of change. At each tremor magnitude level sufficient time was allowed for substantial increase in sense of control to occur before moving to the next level up. At each higher level anxiety surged to a peak and then started to decline. Peak anxiety was highest (mean 6.5, SD = 1.7) at level 1, steadily declining as higher levels were achieved,

reaching its lowest point (mean 1.0, SD = 0.9) at level 5 (unpublished data). In addition, the time required for a substantial increase in sense of control and reduction in anxiety was much longer at the lower tremor magnitude levels, decreasing as the session progressed to higher levels. In fact, 80% of the session time was spent at the lowest levels.

accompanied by a substantial reduction in traumatic stress and depression symptoms (evidence reviewed in

Chapter 6).

While such a detailed account using visual illustra- tions of change processes in treatment may be helpful in some survivors with higher socio-educational status, a brief explanation as follows is sufficient in most cases.

When you come across situations that make you distressed or anxious, you feel an urge to get away from them and you often surrender to this urge. When you get away, your anxiety diminishes and you feel relieved. This is obviously not an effective strategy, given that it has not helped you with your fear and stress problems. Instead, try confronting your anxiety by not avoiding distressing situations every time you come across one. This will give you an opportunity to learn how to tolerate and control anxiety. Once you

manage to do this, your confidence in yourself will

grow and you willfind it easier to tackle other anxiety-

evoking situations. As your resilience against anxiety increases, you will feel less helpless and this will lead to an improvement in your stress problems. To use an analogy, building up your resilience by allowing your- self to experience anxiety is like getting vaccinated against a virus. You need a small dose of the virus in your system so that your body can build up its defense against the virus. This is also like practicing weight- lifting. The more you do it, the stronger you get and

the more weight you can lift.

Note that the emphasis in this account is ontolerance andcontrol of fear or distress, rather than a reduction of these emotions. Although it is acceptable practice to inform the survivor that anxiety is likely to reduce during as well as between encounters with feared sit- uations, this should not be set asthe treatment goal or emphasized. Anxiety needs to be presented, not as an undesirable phenomenon that needs to be reduced or eradicated at all costs, but rather as an opportunity to test, reinforce, and enhance one’s capacity to tolerate and control it. As discussed in detail inPart 1, this is the process that leads to resilience. Such resilience- building processes, often referred to as a‘toughening’ (Dienstbier, 1989) or ‘steeling’ effect in psychiatric literature (Bleuler, 1974; Rutter, 1985), are also widely utilized in training of soldiers, special forces, commandos, and militant political activists. It is also worth noting that a good understanding of this process on the part of the survivor is one of the most important predictors of good outcome with CFBT. Survivors who quickly grasp the treatment rationale and actively

seek opportunities to challenge their fear recover much faster and to a greater extent than others.

Step 3: defining treatment tasks and giving

self-exposure instructions

Once the survivor is prepared to go along with treat- ment, the next step is to describe the course of action required to achieve the treatment aim. Such action involves (a) normalizing life routines by not avoiding anxiety-evoking situations as they are encountered in daily life and (b) focused exposure exercises in relation to specific anxiety-evoking situations.