View source for Internet interventions for post-traumatic stress

'''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.<ref name=":8">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.</ref> These limits include lack of resources and residing in small towns or in the countryside.<ref name=":0">Wang, Z., Wang, J., & Maercker, A. (2013). Chinese my trauma recovery, a web-based intervention for traumatized persons in two parallel samples: Randomized controlled trial. Journal of Medical Internet Research, 15(9), 112-125. doi:10.2196</ref> 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.<ref name=":0" /> Additionally, those who live in rural areas may experience more stigma related to mental health issues.<ref name=":0" /> Internet interventions can increase the possibility that those who suffer from [[Posttraumatic stress disorder|PTSD]] can seek help by eliminating these barriers to treatment.<ref name=":0" />

Most of the internet interventions for PTSD currently being studied use [[Cognitive behavioral therapy|Cognitive Behavioral Therapy]] (CBT) tenants to provide treatment.<ref name=":0" /><ref name=":1">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.</ref><ref name=":2">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.</ref><ref name=":3">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.</ref><ref name=":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.</ref><ref name=":5">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.</ref><ref name=":6">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.</ref><ref name=":7">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</ref> Often these internet interventions also pull from [[Cognitive processing therapy|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.<ref name=":0" /> In therapist assisted interventions, patients have access to a live therapist either via video conferencing, instant messenger, or telephone.<ref name=":9">Morland, L., Ruzek, J., & Rosen, C. (2015). Technology and PTSD care: An update. PTSD Research Quarterly, 26(2), 1-10.</ref> Therapists can provide feedback to the patient's assignments, and help them process their trauma.<ref name=":9" /> 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.<ref name=":7" /> Throughout these interventions, patients are given coping skills and resources.<ref name=":9" /> 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.<ref name=":7" /> The resources provided in a self-guided treatment protocol are not a part of the intervention itself.<ref name=":7" />

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,<ref name=":1" /> another study only had therapists for intake and follow-up purposes.<ref name=":4" /> The existing interventions have been shown to be effective in reducing symptoms of PTSD with varying causes such as war in Iraq<ref name=":4" /><ref name=":5" /> or miscarriages.<ref name=":6" /> This effectiveness is consistent across follow-ups up to a year out from the interventions,<ref name=":2" /><ref name=":6" /><ref name=":3" /> but one randomized control trial does report that more structured and highly therapist-assisted interventions are more effective than purely psychoeducational or inspirational interventions.<ref name=":4" />

== Therapist-assisted internet interventions ==

=== High therapist involvement ===
One example of an internet intervention with a high level of therapist involvement is [https://www.interapy.nl/ Interapy], which was created and named by Alfred Lange and a team of psychologists at the University of Amsterdam in 2003.<ref name=":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.</ref> 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.<ref name=":10" />

The first phase, Self-Confrontation, involves describing the traumatic event in great detail within the writing assignment.<ref name=":10" /> 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.<ref name=":10" /> The second phase, Cognitive Reappraisal, helps the participant to instill new views concerning the traumatic event.<ref name=":10" /> 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.<ref name=":10" /> 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.<ref name=":10" />

Therapists are highly involved in the entire process of Interapy.<ref name=":10" /> 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.<ref name=":10" /> 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.<ref name=":1" /><ref name=":5" /><ref name=":10" />

=== 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.<ref name=":2" /> The intervention was a ten-week interactive program that guides the participant through a different module each week.<ref name=":2" />

The first module focuses on psychoeducation about trauma and trauma responses (including stress and anxiety).<ref name=":2" /> Modules 2 and 3 are directed at anxiety and stress reduction tools, such as deep breathing and progressive muscle relaxation.<ref name=":2" /> 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.<ref name=":2" /> Lastly, the tenth module gives information and tools to prevent relapse into the trauma response.<ref name=":2" />

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.<ref name=":2" /> 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.<ref name=":2" /> Although PTSD Online is no longer live, it showed promising effects early on, with positive treatment effects found at a 3-month follow-up.<ref name=":2" />

=== 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.<ref name=":3" /> The intervention is an eight-week text-based intervention that delivers a different module to participants each week.<ref name=":3" />

Within the first module, participants are given psychoeducation about PTSD and are invited to commit to change through a treatment contract.<ref name=":3" /> The second module is focused on anxiety coping skills such as controlled breathing or relaxation.<ref name=":3" /> 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.<ref name=":3" />

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.<ref name=":3" /> 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.<ref name=":3" />

== Self-guided internet interventions ==
One intervention under development is Coming Home and Moving Forward.<ref name=":7" /> This treatment protocol has not been implemented for public use.<ref name=":7" /> It was utilized as a randomized control trial (RCT) to investigate if it would be a feasible tool for reducing PTSD symptoms in veterans.<ref name=":7" /> This intervention is meant to treat veterans who have recently moved back home from deployment, and have been using excessive amounts of substances.<ref name=":7" /> 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.<ref name=":7" /> Therefore, primary care providers can recommend it to their patients.<ref name=":7" /> 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.<ref name=":7" />

The study in which this intervention was implemented utilized veteran feedback 6 months after they completed the protocol.<ref name=":7" /> Veterans felt this intervention was ideal for individuals who had been home from deployment for a period of 3–4 months.<ref name=":7" /> 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.<ref name=":7" /> 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.<ref name=":7" /> Due to issues related to stigma, veterans are wary of seeking help.<ref name=":7" /> Those who engaged in this online intervention felt it could decrease this stigma and enable veterans to feel comfortable enough in seeking psychological services.<ref name=":7" />

Veterans’ feedback regarding Coming Home and Moving Forward was not all good: there were some downsides to this intervention as well.<ref name=":7" /> 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.<ref name=":7" /> Veterans were afraid their identifying information such as their demographics, and their responses to homework assignments would be leaked somehow.<ref name=":7" /> Due to this fear, some veterans who participated in the online intervention admitted that they were dishonest throughout some aspects of it.<ref name=":7" /> These veterans believed that other Vets participating in this intervention would do the same based on their fears.<ref name=":7" />

== References ==
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[[Category:Psychotherapy by type]]
[[Category:Internet culture]]