Internet interventions for post-traumatic stress

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Internet interventions for post-traumatic stress have grown in popularity due to the limits that many patients face in their ability to seek therapy to treat their symptoms. [1] These limits include lack of resources and residing in small towns or in the countryside. [2] These patients may find it difficult to seek treatment because they do not have geographical access to treatment, and this can also limit the time they have to seek help. [2] Additionally, those who live in rural areas may experience more stigma related to mental health issues. [2] Internet interventions can increase the possibility that those who suffer from PTSD can seek help by eliminating these barriers to treatment. [2]

Contents

Most of the internet interventions for PTSD currently being studied use Cognitive Behavioral Therapy (CBT) tenants to provide treatment. [2] [3] [4] [5] [6] [7] [8] [9] Often these internet interventions also pull from Cognitive Processing Therapy (CPT) and exposure therapy as well. There are two types of internet interventions. Those that are “therapist-assisted,” which means there is an actual therapist guiding the patient through some, but not all of the intervention, and those that are self-guided, which means they do not provide this service. [2] In therapist assisted interventions, patients have access to a live therapist either via video conferencing, instant messenger, or telephone. [10] Therapists can provide feedback to the patient's assignments, and help them process their trauma. [10] In self-guided interventions, patients do not have contact with therapists, unless there is an emergency in which they are a risk to themselves or others. [9] Throughout these interventions, patients are given coping skills and resources. [10] The resources available to patients participating in a self-guided intervention are typically crisis lines, emergency services, and outside sources in which the person can seek help or treatment. [9] The resources provided in a self-guided treatment protocol are not a part of the intervention itself. [9]

While there is a recent shift toward completely removing the need for a therapist in many internet interventions, most of the online interventions currently being researched and used for PTSD still use therapists as part of their protocol. The involvement of the therapist in the intervention varies across interventions. For example, while one study had therapists in direct communication with clients via the Internet every session, [3] another study only had therapists for intake and follow-up purposes. [6] The existing interventions have been shown to be effective in reducing symptoms of PTSD with varying causes such as war in Iraq [6] [7] or miscarriages. [8] This effectiveness is consistent across follow-ups up to a year out from the interventions, [4] [8] [5] but one randomized control trial does report that more structured and highly therapist-assisted interventions are more effective than purely psychoeducational or inspirational interventions. [6]

Therapist-assisted internet interventions

High therapist involvement

One example of an internet intervention with a high level of therapist involvement is Interapy, which was created and named by Alfred Lange and a team of psychologists at the University of Amsterdam in 2003. [11] Interapy uses a CPT approach and assigns two 45-minute writing sessions each week for five weeks. The writing sessions are assigned via the Internet and guide the participant through three phases of treatment. [11]

The first phase, Self-Confrontation, involves describing the traumatic event in great detail within the writing assignment. [11] This phase is a self-guided exposure to the traumatic event aimed at reducing the avoidance and distress of memories or reminders of the event. [11] The second phase, Cognitive Reappraisal, helps the participant to instill new views concerning the traumatic event. [11] This is achieved by a writing assignment that asks the participants to write a letter with encouraging advice to a hypothetical friend who experienced a similar traumatic event. [11] The last phase of Interapy, Sharing and Farewell Ritual, involves participants writing a letter to themselves or others who were involved in the traumatic event about how the event changed or impacted their lives. [11]

Therapists are highly involved in the entire process of Interapy. [11] They not only customize each writing assignment personally for the participants under their care, but also give written feedback about each assignment turned in by the participants. [11] So far, Interapy shows promising results for participants in the Netherlands, Germany, and Iraq, and has been shown to have positive effects on PTSD symptoms as far as three months from the end of treatment. [3] [7] [11]

Medium therapist involvement

PTSD Online is an example of an internet intervention that requires a medium level of therapist involvement. PTSD Online was created by Britt Klein and a team of psychologists in Victoria, Australia in 2010. [4] The intervention was a ten-week interactive program that guides the participant through a different module each week. [4]

The first module focuses on psychoeducation about trauma and trauma responses (including stress and anxiety). [4] Modules 2 and 3 are directed at anxiety and stress reduction tools, such as deep breathing and progressive muscle relaxation. [4] Modules 4 through 6 focus on cognitive restructuring and aid the participant in challenging their negative beliefs. Modules 7 through 9 engage the participant in self-guided exposure to images and memories of the trauma. [4] Lastly, the tenth module gives information and tools to prevent relapse into the trauma response. [4]

The therapists involved in PTSD Online have less week-to-week interaction with the participants, as they are not providing feedback to them regarding their progress or adherence to the intervention. [4] Instead, therapists conduct telephone interviews at the start of treatment and then provide audio files unique to each participant regarding their specific trauma that help guide them through the intervention online. [4] Although PTSD Online is no longer live, it showed promising effects early on, with positive treatment effects found at a 3-month follow-up. [4]

Low therapist involvement

David Ivarsson and a team of psychologists in Sweden created an unnamed internet intervention for PTSD in 2014 that required very little therapist involvement. [5] The intervention is an eight-week text-based intervention that delivers a different module to participants each week. [5]

Within the first module, participants are given psychoeducation about PTSD and are invited to commit to change through a treatment contract. [5] The second module is focused on anxiety coping skills such as controlled breathing or relaxation. [5] Modules 3 through 6 guides the participants through exposures to memories and images of the trauma, using both imaginal and in-vivo techniques. Module 7 focuses on cognitive restructuring and module 8 is relapse prevention. [5]

The structure of the intervention was very similar to PTSD Online, but in this intervention, therapists did not tailor the assignments each week and provided only minimal feedback to participants on their progress. [5] Therapists were, however, available to provide encouragement or help. Again, the intervention showed promising results with significant positive treatment effects at a one-year follow-up. [5]

Self-guided internet interventions

One intervention under development is Coming Home and Moving Forward. [9] This treatment protocol has not been implemented for public use. [9] It was utilized as a randomized control trial (RCT) to investigate if it would be a feasible tool for reducing PTSD symptoms in veterans. [9] This intervention is meant to treat veterans who have recently moved back home from deployment, and have been using excessive amounts of substances. [9] One of the characteristics that sets this intervention apart from other emerging internet interventions, is that it is tailored toward Vets who would rather seek help for their physical complaints, rather than focus on their psychological symptoms. [9] Therefore, primary care providers can recommend it to their patients. [9] This intervention applies CBT tools to treat veterans, which means it focuses on challenging distorted cognitions related to trauma, increasing coping and self-management skills, and preventing social isolation. [9]

The study in which this intervention was implemented utilized veteran feedback 6 months after they completed the protocol. [9] Veterans felt this intervention was ideal for individuals who had been home from deployment for a period of 3–4 months. [9] They did not believe someone who had only been home for month or two would find this intervention useful, because most veterans do not realize something is wrong until they have had time to adjust. [9] Most veterans who participated in Coming Home and Moving Forward thought this treatment would be “a foot in the door,” for veterans who were on the fence about seeking treatment. [9] Due to issues related to stigma, veterans are wary of seeking help. [9] Those who engaged in this online intervention felt it could decrease this stigma and enable veterans to feel comfortable enough in seeking psychological services. [9]

Veterans’ feedback regarding Coming Home and Moving Forward was not all good: there were some downsides to this intervention as well. [9] While most veterans felt this tool allowed other Vets to participate in treatment in the privacy of their own homes, they also felt that sharing their personal information online felt unsafe. [9] Veterans were afraid their identifying information such as their demographics, and their responses to homework assignments would be leaked somehow. [9] Due to this fear, some veterans who participated in the online intervention admitted that they were dishonest throughout some aspects of it. [9] These veterans believed that other Vets participating in this intervention would do the same based on their fears. [9]

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation, as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies, and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis followed by synthesis.

Psychological trauma, mental trauma or psychotrauma is an emotional response to a distressing event or series of events, such as accidents, rape, or natural disasters. Reactions such as psychological shock and psychological denial are typical. Longer-term reactions include unpredictable emotions, flashbacks, difficulties with interpersonal relationships and sometimes physical symptoms including headaches or nausea.

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed by Francine Shapiro in the 1980s that was originally designed to alleviate the distress associated with traumatic memories such as post-traumatic stress disorder (PTSD). In EMDR, the person being treated recalls distressing experiences whilst doing bilateral stimulation, such as side-to-side eye movement or physical stimulation, such as tapping either side of the body.

Barbara Rothbaum is a psychologist at Emory University School of Medicine in Atlanta, Georgia. She is a professor in the Psychiatry department and a pioneer in the treatment of anxiety-related disorders. Rothbaum is head of the Trauma and Anxiety Recovery Program (TARP) at Emory as well as the Emory Healthcare Veterans Program. In the mid-1990s she founded a virtual exposure therapy company called Virtually Better, Inc. This company treats patients with anxiety disorders, addictions, pain, and the like using virtual reality instead of the actual place or scenario. It also allows the therapist to control the environment. She also played a key role in the development of the treatment of posttraumatic stress disorder (PTSD).

<span class="mw-page-title-main">Complex post-traumatic stress disorder</span> Psychological disorder

Complex post-traumatic stress disorder is a psychological disorder that is theorized to develop in response to exposure to a series of traumatic events in a context in which the individual perceives little or no chance of escape, and particularly where the exposure is prolonged or repetitive. It is not yet recognized by the American Psychiatric Association or the DSM-5 as a valid disorder, although was added to the eleventh revision of the International Classification of Diseases (ICD-11). In addition to the symptoms of post-traumatic stress disorder (PTSD), an individual with C-PTSD experiences emotional dysregulation, negative self-beliefs and feelings of shame, guilt or failure regarding the trauma, and interpersonal difficulties. C-PTSD relates to the trauma model of mental disorders and is associated with chronic sexual, psychological, and physical abuse or neglect, or chronic intimate partner violence, bullying, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, and prisoners kept in solitary confinement for a long period of time, or defectors from authoritarian religions. Situations involving captivity/entrapment can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self. C-PTSD is linked to adverse childhood experiences, especially among survivors of foster care.

Virtual reality therapy (VRT), also known as virtual reality immersion therapy (VRIT), simulation for therapy (SFT), virtual reality exposure therapy (VRET), and computerized CBT (CCBT), is the use of virtual reality technology for psychological or occupational therapy and in affecting virtual rehabilitation. Patients receiving virtual reality therapy navigate through digitally created environments and complete specially designed tasks often tailored to treat a specific ailment; and is designed to isolate the user from their surrounding sensory inputs and give the illusion of immersion inside a computer-generated, interactive virtual environment. This technology has a demonstrated clinical benefit as an adjunctive analgesic during burn wound dressing and other painful medical procedures. Technology can range from a simple PC and keyboard setup, to a modern virtual reality headset. It is widely used as an alternative form of exposure therapy, in which patients interact with harmless virtual representations of traumatic stimuli in order to reduce fear responses. It has proven to be especially effective at treating PTSD, and shows considerable promise in treating a variety of neurological and physical conditions. Virtual reality therapy has also been used to help stroke patients regain muscle control, to treat other disorders such as body dysmorphia, and to improve social skills in those diagnosed with autism.

Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.

Cognitive processing therapy (CPT) is a manualized therapy used by clinicians to help people recover from posttraumatic stress disorder (PTSD) and related conditions. It includes elements of cognitive behavioral therapy (CBT) treatments, one of the most widely used evidence-based therapies. A typical 12-session run of CPT has proven effective in treating PTSD across a variety of populations, including combat veterans, sexual assault victims, and refugees. CPT can be provided in individual and group treatment formats.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy or counselling that aims at addressing the needs of children and adolescents with post traumatic stress disorder (PTSD) and other difficulties related to traumatic life events. This treatment was developed and proposed by Drs. Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006. The goal of TF-CBT is to provide psychoeducation to both the child and non-offending caregivers, then help them identify, cope, and re-regulate maladaptive emotions, thoughts, and behaviors. Research has shown TF-CBT to be effective in treating childhood PTSD and with children who have experienced or witnessed traumatic events, including but not limited to physical or sexual victimization, child maltreatment, domestic violence, community violence, accidents, natural disasters, and war.

<span class="mw-page-title-main">Richard Bryant (psychologist)</span> Australian psychologist

Richard Allan Bryant is an Australian medical scientist. He is Scientia Professor of Psychology at the University of New South Wales (UNSW) and director of the UNSW Traumatic Stress Clinic, based at UNSW and Westmead Institute for Medical Research. His main areas of research are posttraumatic stress disorder (PTSD) and prolonged grief disorder. On 13 June 2016 he was appointed a Companion of the Order of Australia (AC), for eminent service to medical research in the field of psychotraumatology, as a psychologist and author, to the study of Indigenous mental health, as an advisor to a range of government and international organisations, and to professional societies.

Andreas Maercker is a German clinical psychologist and international expert in traumatic stress-related mental disorders who works in Switzerland. He also contributed to lifespan and sociocultural aspects of trauma sequelae, e.g. the Janus-Face model of posttraumatic growth.

Post-traumatic stress disorder (PTSD) can affect about 3.6% of the U.S. population each year, and 6.8% of the U.S. population over a lifetime. 8.4% of people in the U.S. are diagnosed with substance use disorders (SUD). Of those with a diagnosis of PTSD, a co-occurring, or comorbid diagnosis of a SUD is present in 20–35% of that clinical population.

<span class="mw-page-title-main">MDMA-assisted psychotherapy</span> Controlled administration of psychoactive drug MDMA to facilitate psychotherapy efficacy

MDMA-assisted psychotherapy is the use of prescribed doses of MDMA as an adjunct to psychotherapy sessions. Research suggests that MDMA-assisted psychotherapy for post-traumatic stress disorder (PTSD), including Complex PTSD, might improve treatment effectiveness. In 2017, a Phase II clinical trial led to "breakthrough therapy" designation by the US Food and Drug Administration (FDA).

<span class="mw-page-title-main">Internet-based treatments for trauma survivors</span>

Internet-based treatments for trauma survivors is a growing class of online treatments that allow for an individual who has experienced trauma to seek and receive treatment without needing to attend psychotherapy in person. The progressive movement to online resources and the need for more accessible mental health services has given rise to the creation of online-based interventions aimed to help those who have experienced traumatic events. Cognitive behavioral therapy (CBT) has shown to be particularly effective in the treatment of trauma-related disorders and adapting CBT to an online format has been shown to be as effective as in-person CBT in the treatment of trauma. Due to its positive outcomes, CBT-based internet treatment options for trauma survivors has been an expanding field in both research and clinical settings.

<span class="mw-page-title-main">Narrative exposure therapy</span>

Narrative Exposure Therapy (NET) is a short-term psychotherapy used for the treatment of post-traumatic stress disorder and other trauma-related mental disorders. It creates a written account of the traumatic experiences of a patient or group of patients, with the aim of recapturing self-respect and acknowledging the patient's value. NET is an individual treatment, NETfacts is a format for communities.

Psychedelic treatments for trauma-related disorders are the use of psychedelic substances, either alone or used in conjunction with psychotherapy, to treat trauma-related disorders. Trauma-related disorders, such as post-traumatic stress disorder (PTSD), have a lifetime prevalence of around 8% in the US population. However, even though trauma-related disorders can hinder the everyday life of individuals with them, less than 50% of patients who meet criteria for PTSD diagnosis receive proper treatment. Psychotherapy is an effective treatment for trauma-related disorders. A meta-analysis of treatment outcomes has shown that 67% of patients who completed treatment for PTSD no longer met diagnostic criteria for PTSD. For those seeking evidence-based psychotherapy treatment, it is estimated that 22-24% will drop out of their treatment. In addition to psychotherapy, pharmacotherapy (medication) is an option for treating PTSD; however, research has found that pharmacotherapy is only effective for about 59% of patients. Although both forms of treatment are effective for many patients, high dropout rates of psychotherapy and treatment-resistant forms of PTSD have led to increased research in other possible forms of treatment. One such form is the use of psychedelics.

Imagery Rescripting is an experiential therapeutic technique that uses imagery and imagination to intervene in traumatic memories. The process is guided by a therapist who works with the client to define ways to work with particular traumatic memories, images, or nightmares.

References

  1. ↑ Jian-Ping Wang, & Maercker, A. (2014). Web-based interventions for traumatized people in mainland china. European Journal of Psychotraumatology, 5, 1-1. Doi:10.3402.
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  3. 1 2 3 Knaevelsrud, C., & Maercker, A. (2007). Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC psychiatry, 7(1), 13.
  4. 1 2 3 4 5 6 7 8 9 10 11 Klein, B., Mitchell, J., Abbott, J., Shandley, K., Austin, D., Gilson, K., ... & Redman, T. (2010). A therapist-assisted cognitive behavior therapy internet intervention for posttraumatic stress disorder: pre-, post-and 3-month follow-up results from an open trial. Journal of anxiety disorders, 24(6), 635-644.
  5. 1 2 3 4 5 6 7 8 9 Ivarsson, D., Blom, M., Hesser, H., Carlbring, P., Enderby, P., Nordberg, R., & Andersson, G. (2014). Guided internet-delivered cognitive behavior therapy for post-traumatic stress disorder: a randomized controlled trial. Internet interventions, 1(1), 33-40.
  6. 1 2 3 4 Litz, B. T., Engel, C. C., Bryant, R. A., & Papa, A. (2007). A randomized, controlled proof-of-concept trial of an internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder. American Journal of Psychiatry, 164(11), 1676-1684.
  7. 1 2 3 Wagner, B., Schulz, W., & Knaevelsrud, C. (2012). Efficacy of an Internet-based intervention for posttraumatic stress disorder in Iraq: a pilot study. Psychiatry research, 195(1), 85-88.
  8. 1 2 3 Kersting, A., Dölemeyer, R., Steinig, J., Walter, F., Kroker, K., Baust, K., & Wagner, B. (2013). Brief internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial. Psychotherapy and psychosomatics, 82(6), 372-381.
  9. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Possemato, K., Acosta, M. C., Fuentes, J., Lantinga, L. J., Marsch, L. A., Maisto, S. A., Rosenblum, A. (2015). A web-based self-management program for recent combat veterans with PTSD and substance misuse: Program development and veteran feedback. Cognitive and Behavioral Practice, 22(3), 345-358. Doi:10.1016
  10. 1 2 3 Morland, L., Ruzek, J., & Rosen, C. (2015). Technology and PTSD care: An update. PTSD Research Quarterly, 26(2), 1-10.
  11. 1 2 3 4 5 6 7 8 9 10 Lange, A., Rietdijk, D., Hudcovicova, M., Van De Ven, J. P., Schrieken, B., & Emmelkamp, P. M. (2003). Interapy: a controlled randomized trial of the standardized treatment of posttraumatic stress through the internet. Journal of consulting and clinical psychology, 71(5), 901.
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