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Helping Survivors: Long-Term Treatment Interventions Following Disaster and Mass Violence

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Helping Survivors: Long-Term Treatment Interventions Following Disaster and Mass Violence

In the immediate aftermath of disaster and mass violence, provision of practical support and psychosocial interventions like Psychological First Aid (PFA) and Skills for Psychological Recovery (SPR) are likely to be sufficient for the majority of those who are exhibiting mild to moderate distress or trouble functioning. In the months following a disaster, a smaller proportion of the population who are exhibiting more severe or protracted reactions may benefit from more intensive interventions.

PTSD Treatment in General Populations

Posttraumatic stress disorder (PTSD) is the most commonly studied mental health problem observed in disaster studies (1,2). Prevalence estimates range from 30% to 40% among direct victims, 10% to 20% among rescue workers, and 5% to 10% among the general population (3). The psychological treatments for PTSD with the strongest empirical support are individual trauma focused-psychotherapies (4). The VA/DoD Clinical Practice Guideline for PTSD defines trauma-focused psychotherapy as therapy that uses cognitive, emotional, or behavioral techniques to facilitate processing a traumatic event and in which the trauma focus is a central component of the therapeutic process (5).

The trauma-focused psychotherapies with the strongest evidence from clinical trials are Prolonged Exposure (PE; 6), Cognitive Processing Therapy (CPT; 7), and Eye Movement Desensitization and Reprocessing (EMDR; 8,9). PE, CPT, and EMDR have been tested in numerous clinical trials, in people with complex presentations and comorbidities, in comparison to active control conditions, and with long-term follow-up designs, Furthermore, these treatments have been validated by research teams other than the developers (e.g., 10-12).

PE helps people process negative trauma-related emotions and overcome avoidance through imaginal exposure (repeatedly re-telling their traumatic event) and in vivo exposure to safe situations that have been avoided because they elicit traumatic reminders. CPT has a primary focus on challenging and modifying maladaptive beliefs related to the trauma. CPT emphasizes cognitive restructuring through the use of Socratic dialogue to help people examine problematic beliefs, emotions, and negative appraisals stemming from the event, such as self-blame or mistrust (13). Those receiving EMDR engage in imaginal exposure to a trauma memory followed by imagining a more healthy cognitive reappraisal while simultaneously performing saccadic eye movements.

PTSD Treatment in Survivors of Mass Violence and Disaster

There are a number of randomized controlled trials (RCTs) of trauma-focused treatments targeting adults with PTSD resulting from mass violence and disaster. Three RCTs have been conducted with those who met criteria for PTSD as a result of exposure to terrorism or mass violence. All three studies evaluated standard 8-12 session trauma-focused psychotherapies that included cognitive restructuring and exposure. In two of the studies, trauma focused cognitive behavioral therapy (CBT) was compared to treatment as usual (14,15) and in one it was compared to waitlist (16). In all three studies trauma-focused CBT resulted in significantly more improvement in PTSD relative to the control condition. In two out of three there were also greater reductions in symptoms of depression.

Studies of PTSD samples after natural disasters have utilized less standard trauma-focused treatments. Two RCTs documented greater decreases in PTSD symptoms, relative to control groups, among participants who received a single session behavioral treatment aimed at increasing control over earthquake related fears through confronting feared situations (17,18). A third RCT examined the effectiveness of four sessions of Narrative Exposure Therapy (NET), a trauma-focused intervention where disaster affected individuals write detailed accounts of their lives with a focus on the impact of the disaster, following an earthquake. Participants in NET showed significant improvement in PTSD relative to a waitlist (19).

There are a several open trials for disaster-related PTSD as well. The majority are trauma-focused CBT interventions (e.g., 20-22) but there are a few studies in support of EMDR as a treatment for disaster-related PTSD (e.g., 23,24), and one utilizing a yoga breath intervention with and without exposure (25). In each case the intervention resulted in significant decreases in PTSD from pre- to post-treatment.

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Other Interventions

Although PTSD is one of the most common post-disaster mental health effects, it is not the only problem. Anxiety and depression are also common, as well as nonspecific psychological distress and health concerns (26). Increases in substance use are also frequently reported. There are no RCTs of treatments in adult disaster survivors with psychiatric diagnoses other than PTSD. Best practice is to use the evidence-based treatments for these other disorders.

There are no RCTs of treatments that target non-specific distress in adults post-disaster, but there are a few disaster-specific interventions that have been evaluated with open trials. Cognitive Behavioral Therapy for Postdisaster Distress (CBT-PD) is an 8-12 session treatment with a primary focus on identifying and challenging maladaptive disaster-related beliefs. It is conceptualized as a transdiagnostic treatment because it targets the core psychological processes of negative affect and avoidance that underlie a range of disorders common after disaster, rather than a specific disorder, such as PTSD. CBT-PD has been used in response to both natural disasters and terrorism (e.g., the 9/11 terrorist attacks, Hurricane Katrina, and the L’Aquila earthquake in Italy). Open trials in a variety of settings suggest CBT-PD is not only acceptable and tolerable to disaster survivors, but also effective in reducing distress (27,28).

Following the 9/11 terrorist attacks, the New York State Office of Mental Health initiated an enhanced services program that did not require survivors to meet criteria for PTSD diagnosis. The program offered a cognitive behavioral intervention to address current symptoms of PTSD, depression, and anxiety along with a traumatic grief intervention. Survivors who received enhanced services had fewer symptoms of depression and grief and improved functioning as compared to those who received standard crisis counseling (29).

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There is strong evidence in support of trauma-focused treatments for adult disaster survivors with PTSD. For survivors who present with other disorders, evidence-based treatments for those disorders should be utilized. There is some support for using interventions that do not target specific disorders.

For more information about early and intermediate interventions for those affected by disaster and mass violence events, see:

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  1. Norris, F. H., & Elrod, C. L. (2006). Psychosocial consequences of disaster: A review of past research. In F. H. Norris, S. Galea, M. J. Friedman, & P. J. Watson (Eds.), Methods for Disaster Mental Health Research (pp. 20-42). New York, NY: Guilford Press.
  2. Norris, F. H., Friedman, M. J., & Watson, P. J. (2002). 60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry, 65, 240-260. doi:10.1521/psyc.
  3. Galea, S., Nandi, A., & Vlahov, D. (2005). The epidemiology of post-traumatic stress disorder after disasters. Epidemiologic Reviews, 27, 78-91. doi:10.1093/epirev/mxi003
  4. Department of Veterans Affairs and Department of Defense. (2017). VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Washington DC: Author. Retrieved from:
  5. Schnurr, P. P. (2017). Focusing on trauma-focused psychotherapy for posttraumatic stress disorder. Current Opinion in Psychology, 14, 56-60. doi:10.1016/j.copsych.2016.11.005
  6. Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A. M., Riggs, D. S., Feeny, N. C., & Yadin, E. (2005). Randomized trial of Prolonged Exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73, 953-964. doi:10.1037/0022-006X.73.5.953
  7. Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of Cognitive Processing Therapy with Prolonged Exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70, 867-879. doi:10.1037/0022-006X.70.4.867
  8. Rothbaum, B. O., Astin, M. C., & Marstellar, F. (2005). Prolonged Exposure versus Eye Movement Desensitization and Reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, 607-616. doi:10.1002/jts.20069
  9. Shapiro, F. (1989). Eye movement desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20, 211-217. doi:10.1016/0005-7916(89)90025-6
  10. Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database Systematic Reviews, 12, CD003388. doi:10.1002/14651858.CD003388.pub4
  11. Lee, D. J., Schnitzlein, C. W., Wolf, J. P., Vythilingam, M., Rasmusson, A. M., & Hoge, C. W. (2016). Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: Systematic review and meta-analyses to determine first-line treatments. Depression and Anxiety, 33, 792-806. doi:10.1002/da.22511
  12. Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74, e541-550. doi:10.4088/JCP.12r08225
  13. Resick, P.A., & Schnicke, M. K. (1996). Cognitive Processing Therapy for rape victims: A treatment manual. Newbury Park, CA: Sage Publications.
  14. Bryant, R. A., Ekasawin, S., Chakrabhand, S., Suwanmitri, S., Duangchun, O., & Chantaluckwong, T. (2011). A randomized controlled effectiveness trial of cognitive behavior therapy for post‐traumatic stress disorder in terrorist‐affected people in Thailand. World Psychiatry, 10, 205-209. doi:10.1002/j.2051-5545.2011.tb00058.x
  15. Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., Giosan. C., & Hoffman, H. G. (2007). Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. Journal of Clinical Psychiatry, 68, 1639-1647. doi:10.4088/jcp.v68n1102
  16. Duffy, M., Gillespie, K., & Clark, D. M. (2007). Post-traumatic stress disorder in the context of terrorism and other civil conflict in Northern Ireland: Randomised controlled trial. British Medical Journal, 334, 1147-1150. doi:10.1136/bmj.39021.846852.BE
  17. Basoglu, M., Salcioglu, E., & Livanou, M. (2007). A randomized controlled study of single-session behavioural treatment of earthquake-related post-traumatic stress disorder using an earthquake simulator. Psychological Medicine, 37, 203-213. doi:10.1017/s0033291706009123
  18. Basoglu, M., Salcioglu, E., Livanou, M., Kalender, D., & Acar, G. (2005). Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: A randomized waiting list controlled trial. Journal of Traumatic Stress, 18, 1-11. doi:10.1002/jts.20011
  19. Zang, Y., Hunt, N., & Cox, T. (2013). A randomised controlled pilot study: The effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake. BMC Psychiatry, 13, 41. doi:10.1186/1471-244x-13-41
  20. Brewin, C. R., Fuchkan, N., Huntley, Z., Robertson, M., Thompson, M., Scragg, P., D’Ardenne, P., & Ehlers, A., (2010). Outreach and screening following the 2005 London bombings: Usage and outcomes. Psychological Medicine, 40, 2049-2057. doi:10.1017/A0033291710000206
  21. Gillespie, K., Duffy, M., Hackmann, A., & Clark, D. M. (2002). Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb. Wem 345-357. doi:10.1016/S0005-7967(02)00004-9
  22. Levitt, J. T., Malta, L. S., Martin, A., Davis, L., & Cloitre, M. (2007). The flexible application of a manualized treatment for PTSD symptoms and functional impairment related to the 9/11 World Trade Center attack. Behaviour Research and Therapy, 45, 1419-1433. doi:10.1016/j.brat.2007.01.004
  23. Konuk, E., Knipe, J., Eke, I., Yuksek, H., Yurtsever, A., & Ostep, S. (2006). The effects of eye movement desensitization and reprocessing (EMDR) therapy on posttraumatic stress disorder in survivors of the 1999 Marmara, Turkey, earthquake. International Journal of Stress Management, 13, 291-308. doi:10.1037/1072-5245.13.3.291
  24. Silver, S. M., Rogers, S., Knipe, J., & Colelli, G. (2005). EMDR therapy following the 9/11 terrorist attacks: A community-based intervention project in New York City. International Journal of Stress Management, 12, 29-42. doi:10.1037/1072-5245.12.1.29
  25. Descilo, T., Vedamurtachar, A., Gerbarg, P. L., Nagaraja, D., Gangadhar, B. N., Damodaran, B., Adelson, B., Braslow, L. H., Marcus, S., & Brown, R. P. (2010). Effects of a yoga breath intervention alone and in combination with an exposure therapy for post-traumatic stress disorder and depression in survivors of the 2004 South-East Asia tsunami. Acta Psychiatrica Scandinavica, 121, 289-300. doi:10.1111/j.1600-0447.2009.01466.x
  26. Norris, F. H., Friedman, M. J., Watson, P. J., Bryne, C., Diaz, E., & Kaniasty, K. (2002). 60,000 disaster victims speak: Part 1. An empirical review of the empirical litertaure, 1981-2001. Psychiatry: Interpersonal and Biological Processes, 65, 207-239. doi:10.1521/psyc.
  27. Hamblen, J. L., Norris, F. H., Pietruszkiewicz, S., Gibson, L. E., Naturale, A., & Louis, C. (2009). Cognitive behavioral therapy for postdisaster distress: A community based treatment program for survivors of Hurricane Katrina. Administration and Policy in Mental Health and Mental Health Services Research, 36, 206-214. doi:10.1007/s10488-009-0213-3
  28. Hamblen, J. L., Norris, F. H., Symon, K. A., & Bow, T. E. (2017). Cognitive behavioral therapy for postdisaster distress: A promising transdiagnostic approach to treating disaster survivors. Psychological Trauma: Theory, Research, Practice, and Policy, 9, 130-136. doi:
  29. Donahue, S. A., Jackson, C. T., Shear, K. M., Felton, C. J., & Essock, S. M. (2006). Outcomes of enhanced counseling services provided to adults through Project Liberty. Psychiatric Services, 57, 1298-1303. doi:10.1176/

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