Treating Posttraumatic Stress Disorder via the Internet: Title and subTitle BreakDoes Therapeutic Alliance Matter?

Mass violence—whether intentional attacks or the result of natural disasters—adversely affects survivors and often causes widespread disruption, displacement, and disability. Epidemiological studies have reported posttraumatic stress disorder (PTSD) or symptoms of PTSD in almost one-third of communities affected by mass violence.¹ Evidence-based psychological therapies used to treat PTSD are available, but obstacles such as a shortage of mental health care professionals and patient stigma toward treatment often limit accessibility to these therapies. Posttraumatic stress disorder is associated with significant socio-occupational dysfunction; therefore, an imperative need exists for approaches that enhance access to treatment while preserving effectiveness of important factors such as the therapeutic relationship between patients and mental health care professionals.

One approach that has been evaluated recently is use of the Internet to deliver therapist-assisted treatment to trauma survivors.^{2 - 9} Such Web-based approaches may be worth considering for the treatment of PTSD symptoms for 2 reasons. First, in contrast to other mental health disorders, a traumatic event is an identifiable etiological factor and, hence, may be more amenable to being treated via a less-intensive Internet-based mode. Second, a single traumatic event, as in the case of the recent Japanese tsunami or the September 11 terrorist attacks in the United States, can be the cause of PTSD in thousands of individuals, rendering the Internet a potentially useful mode via which treatment can be provided on a large scale.

Research has shown that Internet-based interventions for trauma survivors are feasible.² The course of treatment typically occurs over several weeks and includes key components of trauma-focused therapy such as exposure, cognitive reappraisal, and writing assignments. Lange et al⁶ developed a protocol-driven, therapist-assisted online treatment program in which patients work mostly independently and therapists provide regular feedback via e-mail. In a randomized controlled trial conducted in a community sample, significant improvements occurred among those who used the protocol compared with waiting-list controls. A notable limitation of that trial was the significant number of participants who dropped out of treatment. Hirai and Clum⁸ studied the efficacy of an online self-help treatment for patients with subclinical posttraumatic distress. Although the therapist role was minimal, consisting only of prompting participants to take assessments, study participants reported a significant reduction in avoidance behavior, intrusive symptoms, and anxiety compared with waiting-list controls. However, the generalizability of the study's results is limited because of the predominantly female college student sample.

Litz et al⁴ tested use of an Internet-based treatment program in a sample of US service members with clinically diagnosed PTSD related to combat or the September 11 attacks on the Pentagon. The study compared therapist-assisted, Internet-based, self-management cognitive behavioral therapy (CBT) vs Internet-based supportive counseling in an 8-week module. Those in the former group made significantly more clinical gains than those receiving supportive counseling alone. Of note, this study involved an in-person initial evaluation by a therapist and planned telephone conversations through the treatment course.⁴ Klein et al⁵ assessed use of a 10-week Internet CBT intervention in a sample with clinically significant PTSD and therapist support offered via e-mail only. Although the results suggested a significant reduction in PTSD symptom severity that was maintained at 3-month follow-up, the study was limited by the absence of a control group.^{5 ,9}

Current evidence for the effectiveness of Web-based interventions for PTSD treatment is limited by a lack of comparisons with the gold standard of face-to-face therapy, a predominance of small sample sizes, significant dropout rates, and lack of follow-up data to assess whether positive outcomes were sustained over time.^{4 - 6 ,8 - 9} Furthermore, issues related to Internet availability and use of smartphones, a digital divide based on socioeconomic status and age, and user privacy, confidentiality, and safety are important concerns associated with Internet-based treatment that have yet to be fully addressed.²

The issue of therapeutic alliance deserves special attention in the treatment of PTSD. Therapeutic alliance is the development of a bond of trust, acceptance, and confidence between patient and therapist and has been demonstrated, in meta-analytic review, to be integral to positive patient outcomes.¹⁰ Mental health treatment traditionally involves a patient being seen face-to-face by a professional and care takes place under close supervision. Such care is synchronous in time and includes verbal and nonverbal communication and the sharing of the same physical space for the duration of the visit. All of these factors facilitate the establishment of therapeutic alliance. In contrast, interventions delivered via the Internet tend to be asynchronous in time and share no physical space, with face-to-face communication replaced by e-mails³ and the role of clinicians often marginalized to assisting patients with working through the online treatment modules.^{2 - 5} This raises the key question of whether Web-based interventions that marginalize the role of the therapist provide the adequate therapeutic alliance necessary for long-lasting, positive outcomes for patients with PTSD.

Some early investigation has started to address this question.^{3 ,7} In a study using the protocol developed by Lange et al,⁶ investigators specifically sought to evaluate the quality of the online therapeutic relationship. Overall, they found evidence to suggest that a stable and positive online therapeutic relationship can be established via the Internet. Eighty-six percent of the sample described their Internet clinician experience as being personal and 60% reported that they did not miss face-to-face communication.³ However, this sample consisted largely of young, well-educated women with a range of PTSD symptoms, which limits the generalizability of these results. Furthermore, follow-up analyses found only a modest association between the quality of the therapeutic alliance and treatment outcome in online PTSD treatment.⁷ This finding is in contrast to studies of face-to-face interventions in which therapeutic alliance exerts a consistently moderate influence on positive outcomes for patients with mental health disorders.¹⁰ Such discrepancy raises many as yet unanswered questions about PTSD therapy delivered via the Internet. For example, is there a selection bias among those willing to try online treatment that makes therapeutic alliance less relevant to outcome? Or is the mechanism of change with this modern mode distinctly different from that observed in face-to-face interventions (eg, does the inherent visual anonymity promote higher levels of patient self-disclosure and openness and, hence, improvement via a separate mechanism of action)?⁷

In sum, Internet-based approaches for the treatment of PTSD appear to have intriguing potential. Care via the Internet may hold some potential advantages over traditional care. For example, geographic distance or lack of patient mobility no longer hinder access,² reduced demands on clinician time may facilitate clinicians' availability to meet the needs of more patients, and Web-based treatments can be tailored to meet the needs of diverse patients, as content can be presented in different languages. Even though the evidence to date is not sufficient to recommend Internet-based approaches as first-line treatment, one option might be to use this approach after an initial evaluation by a clinician to assess the degree of underlying symptoms and impairment and then to select patients for whom Internet-based ongoing care most likely would be appropriate. Furthermore, such treatments may facilitate a stepped-care approach to dealing with the psychological aftermath of a wide-scale traumatic event.⁶ Based on current studies, these Web-based interventions may be most useful for those with subsyndromal traumatic symptoms. Using a mode such as the Internet may ensure wider access for those who need help when demands are high. This can leave mental health care professionals with more time to treat patients with PTSD that requires medication or hospitalization or is complicated by other psychiatric comorbidities. Such individuals will likely require more traditional interventions delivered face-to-face, close monitoring, and the experience of a strong therapeutic alliance before they can heal from the psychological trauma of mass violence.