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

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Thanks for your attention

Maria Böttche, PhD

m.boettche@bzfo.de