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Therapist-assisted Internet-based Writing CBT
for Specific Cohorts with Posttraumatic Stress Disorder
PhD Maria Böttche
Berlin Center for Torture Victims
Freie Universität Berlin
Anxiety and Depression Association of America
April, 11th, 2015
2
Effective Treatment
Components
Traumafocussed Therapy
g = 1.08, K = 27, N = 1310
Cognitive Therapy
g = 1.63, K = 10, N = 585
Narrative Therapy
g = 1.00, K = 4, N = 242
Internet-based Interventions
Effective for PTSD in Western countries (Lange et al. 2003, Knaevelsrud et al., 2006, Wagner et al.,
2006)
3
Advantages of Internet Use
Easy access
Travel problems
Absence of professionals
“Non-visuality” of therapist
Age gap
Feelings of shame and guilt
Stigma
4
Internet-based writing CBT
Based on disorder specific cognitive-behavioral manual (Lange et al., 2003)
culturally adapted
age-specific adaption
Duration of treatment: ca. 5-6 weeks (2 structured assignments / week)
10/11 writing sessions
Individual patient-therapist-relationship – feedback within 24h
Baseline Post Follow-up
5
Integrative Testimonial Therapy
Randomized Control Trial
6
Resource-oriented reconstruction
ITT
Biographical Reconstruction
Integration of traumatic event into biography
Moderate Exposure
Letter to the younger self from
the current perspective
Cognitive Reappraisal
ITT
7
Assessed for eligibility
(n= 333)
Ineligible (n= 239)
Incomplete screening/no response
(n = 161)
Met exclusion criteria
(n = 78)
Randomly assigned to treatment (n= 94)
Allocated to Integrative
Testimonial Therapy
(n= 47)
Completed waiting period
(n= 44)
Completed Intervention
(n= 41)
Allocated to Waitlist control
group
(n= 47)
Completed 3-month follow-up
(n= 38)
Completed 6-month follow-up
(n= 36)
Completed 12-month follow-up
(n=37)
8
Integrative Testimonial Therapy
Randomized Control Trial
Treatment Group Waiting List
n = 47 n = 47
Age (years) M (SD) 70.89 (4.97) 71.91 (4.48)
Women N (%) 35 (74.5) 26 (55.3)
Education (years) M (SD) 11.45 (1.65) 11.70 (1.49)
9
Repeated-measures ANOVA for Intent-to-treat Data
10
0
1
2
3
4
5
6
7
8
9
Pre Post 3-month 6-month 12-month
Intrusion
Hyperarousal
Avoidance
11
Repeated-measures ANOVA for Intent-to-treat Data
12
Dwithin Dwithin Dwithin (preto3
month)
(preto6
month)
(preto12
month)
Anxiety .64 .96 .67
Depression .24 .72 .21
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Pre Post 3-month 6-month 12-month
Brief
Sym
pto
m I
nvento
ry
Anxiety
Depression
13
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Pre Post 3-month 6-month 12-month
Quality of Life
Dwithin Dwithin Dwithin (preto3
month)(preto6month)
(preto12month)
Qualityoflife .46 .50 .55
14
Gesamt
Aufgabe Zi
el
Bindung
1
3
5
7
WAI
Gesamt
Aufgabe
Ziel
Bindung
Dropout-Rate 9.57 % (post)
TG: 12.77%
WL: 6.38%
Feasability
Total Task Goal Bond
Total
Task
Goal
Bond
15
Ilajnafsy
Randomized Control Trial
Ilajnafsy = “psychological help”
www.ilajnafsy.org
www.virtual-traumacenter.org
16
Describing most painful moment
ITT
Self-Confrontation
Encouraging letter to a fictive friend with similar experience
Cognitive Reappraisal
Letter to self/perpetrator/friend
from the current perspective
Social Sharing
Ilajnafsy
17
Assessed for eligibility
(n= 1070)
Ineligible (n= 824)
Incomplete screening/no response
(n = 231)
Met exclusion criteria
(n = 593)
Randomly assigned to treatment (n= 159)
Allocated to Intervention
(n= 79)
Completed waiting period
(n= 47)
Completed Intervention
(n= 47)
Allocated to Waitlist control
group
(n= 80)
Completed follow-up
(n= 28)
No reply to invitation (n= 87)
18
Ilajnafsy
Randomized Control Trial
Treatment Group Waiting List
n = 79 n = 80
Age (years) M (SD) 29.11 (3.01) 27.15 (6.48)
Women n (%) 60 (76) 55 (69)
Education n (%)
Secondary school 17 (22) 28 (35)
University 56 (71) 38 (48)
19
Repeated-measures ANOVA for Intent-to-treat Data
20
0
2
4
6
8
10
12
14
Pre Post 3-month
Intrusion
Hyperarousal
Avoidance
21
Repeated-measures ANOVA for Intent-to-treat Data
22
Dwithin (preto3
month)
Anxiety 1.44
Depression 1.69
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Pre Post 3-month
Anxiety
Depression
23
Dwithin (preto3
month)
Qualityoflife 1.30
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Pre Post 3-month
Quality of Life
24
Gesamt
Aufgabe Zi
el
Bindung
1
3
5
7
WAI
Gesamt
Aufgabe
Ziel
Bindung
Dropout-Rate 41% (post)
TG: 32/79
Feasability
Total Task Goal Bond
Total
Task
Goal
Bond
25
Conclusion Efficacy
Decrease of PTSD symptoms
Increase of Quality of life
Positive therapeutic relationship
Successful adaption for hard-to-reach trauma survivors
26
Challenges
Treatment
Use of media-specific techniques
Circumstances
Technical Problems
Mistrust concerning confidentiality
No adequate treatment alternatives for referrals