International Society for Traumatic Stress Studies

Trauma Treatment in the Digital Age

Posted 26 November 2013 in StressPoints by Matthew Price, PhD

Technology is increasingly used as a means to address significant barriers in the delivery of trauma-focused mental health treatment. These barriers include limited access to a subset of providers who treat traumatic stress, transportation to treatment, access to stimuli needed for exposure therapies, and poor treatment adherence. The following review examines the evidence related to the efficacy of several prominent technology-based approaches in trauma-focused work.

Internet-based approaches

The Internet offers a new way to deliver behavioral interventions to patients in their own homes and on their own time. The potential reach of these interventions has grown tremendously in recent years, given that the overwhelming majority of American adults (85%) and American teenagers (95%) routinely use the Internet (Koepsell, Zatzick, & Rivara, 2011; Pew Internet and American Life Project, 2013). Several studies have evaluated self-help and therapist-assisted Internet-based treatments for PTSD and trauma related disorders (e.g., depression, panic disorder; Amstadter, Broman-Fulks, Zinzow, Ruggiero, & Cercone, 2009).

Approaches can also add additional therapist support through e-mail to provide personal recommendations to navigate difficulties and remind patients to complete activities. This research is still relatively new as most of these studies are described by the authors as preliminary or pilot trials (Litz, Engel, Bryant, & Papa, 2007; Ruggiero et al., 2006; Steinmetz, Benight, Bishop, & James, 2012). Among studies that evaluated efficacy, sample sizes ranged from n=22 to n=56. Results suggested that Internet-based treatments are superior to waitlist control groups (Hirai & Clum, 2005; Knaevelsrud & Maercker, 2007; Lange et al., 2003) and Internet-based supportive counseling (Litz et al., 2007).

These preliminary findings suggest that further work across several areas is needed. Areas for future study include trials examining the efficacy of trauma-based interventions administered to a population. Given that a unique strength of Internet-based treatments is their capacity for rapid deployment to a large population, an examination at “scale” is needed.

For example, a disaster-exposed population could provide an ideal setting with which to test the effectiveness and dissemination of an Internet-based trauma treatment. Second, work is needed to identify the best practices for addressing attrition in these studies. Attrition poses a significant threat to their effectiveness (Kiluk et al., 2011), as users do not access treatments or prematurely discontinue Internet-based interventions (Christensen, Griffiths, & Farrer, 2009; Donkin et al., 2011; Price, Gros, McCauley, Gros, & Ruggiero, 2012). Third, it is unclear how Internet-based interventions compare to traditional in-person treatments or other technology-based strategies such as telehealth.

Comparative effectiveness research would help identify where these strategies fall with regards to efficacy and how to best integrate them into the care continuum. For example, Internet-based treatments may be helpful as an initial, low-intensity, treatment modality in a stepped-care treatment model (Draper & Ghiglieri, 2011).

Telehealth

Telehealth, the use of televideo services to provide face-to-face treatment remotely, has rapidly expanded in recent years. This increased accessibility is important, as telehealth provides a method of delivering high-quality treatment to clients who are unable to attend in-person sessions (Gros et al., 2013).

There is a strong evidence base supporting telehealth as a means to deliver trauma-focused treatment, with a recent review identifying n=8 studies examining this approach (Gros et al., 2013). The majority (n=6) of these studies used samples greater than 30 participants. Overall, these findings support telehealth as an effective method to deliver care for PTSD and related disorders. Of note, there was a discrepancy in effect sizes among studies that used exposure therapy such that the effects for in-person exposure were noticeably larger than those obtained via telehealth.

This difference was not observed in studies that used non-exposure based treatments. A meta-analysis also reported similar findings, in that telehealth was superior to waitlist control groups, and comparable to in-person treatment for depression symptoms, but inferior to in-person treatment for PTSD symptoms (Sloan, Gallagher, Feinstein, Lee, & Pruneau, 2011). Despite this limitation, telehealth appears to be a valuable option, especially for patients who could not otherwise receive treatment.

Given the strong support for the efficacy of telehealth, future work should focus on barriers towards the implementation of telehealth treatment. Policies regarding the scope of practice are a critical barrier towards the increased adoption of telehealth (Yuen, Goetter, Herbert, & Forman, 2012).

For example, state licensure boards have varied in permitting psychologists to treat remotely patients who reside in other states. In rural areas where access to providers is often limited, restrictions on interstate delivery of telehealth may further reduce the availability of treatment. Future work is also needed to determine if there are specific components of existing interventions that are more efficacious when conducted in-person as compared to telehealth.

Identifying such components could result in hybrid treatments in which portions (e.g., coping strategies and relaxation) are delivered via telehealth and others in-person (e.g., exposure) to maximize the efficacy and efficiency of treatment delivery.

Virtual Reality

Virtual Reality Exposure (VRE) involves exposing individuals to a feared stimulus in a virtual world; a useful approach given that many traumatic stimuli (e.g., firearms, combat scenarios) can be difficult to recreate (Krijn, Emmelkamp, Olafsson, & Biemond, 2004). VRE permits a stimulus to be tailored to the specific fears of an individual.

For example, recreating the specific type of intersection in which a car accident took place is likely to elicit greater fear during an exposure session than using a dissimilar intersection. Similar to in-person exposure, evidence is accumulating that suggests tailoring a virtual stimulus to an individual’s actual feared stimulus may enhance the efficacy of exposure (Price & Anderson, 2007; Price, Mehta, Tone, & Anderson, 2011). VRE has been evaluated in the treatment of PTSD in 10 studies, the majority of which involved Veterans (Gonçalves, Pedrozo, Coutinho, Figueira, & Ventura, 2012; Motraghi, Seim, Meyer, & Morissette, 2013). Although VRE resulted in significant reductions in PTSD symptoms compared to wait-list control (Difede et al., 2007), these conclusions must be viewed as preliminary given that most studies involved small sample sizes (n’s=10-32).

Larger trials in which VRE is compared to other exposure-based conditions and wait-list control groups are needed. A search on clinicaltrials.gov identified 10 currently active clinical trials using VRE for PTSD, indicating that this research is underway. Another challenge in the use of VRE to treat PTSD is the creation of virtual worlds that are salient to a given patient. A flexible system, EMMA’s world, attempts to address this issue by offering users an array of objects to construct a virtual trauma-relevant stimulus (Botella et al., 2010). Future work is needed to better understand how adaptive virtual experiences can be used to advance VRE as a treatment for PTSD.

Mobile Applications

The widespread availability of mobile devices offers a range of new possibilities for trauma-focused mental health care (Luxton, McCann, Bush, Mishkind, & Reger, 2011; Price et al., 2013). The United States Department of Defense (DoD) and the United States Department of Veteran’s Affairs (DVA) have been leaders in this area and have developed several mobile phone applications (apps) for trauma-focused treatment. These include the currently available “PTSD Coach”, “Psychological First Aid Mobile”, “T2 Mood Tracker”, “Psychological First Aid Coach”, and “PE Coach”. The majority of these apps are available at no cost and readers are encouraged to review them on their own. They have variable functions and can be used as self-help tools or to facilitate treatment.

For example, PE Coach is designed to facilitate prolonged exposure by reminding patients to complete homework, practice relaxation techniques, and complete regular self-report assessments (Reger et al., 2013). It is anticipated that this tool will improve treatment adherence, and thus, enhance response.

Despite the proliferation of mobile apps, there remains a lack of research as to their efficacy as assessment tools and treatment adjuncts. The lack of evidence is to be expected given that this field is in an early stage, and a number of clinical trials are underway (Labrique, Vasudevan, Chang, & Mehl, 2012). Evaluation is essential given the ease and speed with which apps can be made available to the public. At the time this article was written, a search for the term “PTSD” yields 53 apps on the iTunes app store, all of which claim to have medical benefit. A hurdle in building this evidence base is the large discrepancy between the typical 5-year timeline for treatment evaluation and the 1-6 month timeline in which an app can be rapidly developed and released.

Considerations for Future Research

In an effort to improve research on technology strategies, researchers have strongly advocated for new methodologies that can accommodate the speed of software development to expedite the gathering of evidence (Kumar et al., 2013). Technology-based approaches are made of multiple components (e.g., frequency of reminders, appearance, type of information captured, modular content), each of which can be separately evaluated for efficacy and effectiveness. However, conducting an RCT on each component is impractical and inefficient. Multiphase Optimization Strategies (MOST) is an example of a method to systematically evaluate multiple components of an intervention with a single study (Collins et al., 2011).

Briefly, this approach compares the utility of multiple components within a large factorial structure (component present/absent). The main effect for each component then determines its incremental benefit. An alternative model is the Continuous Evaluation of Evolving Behavioral Intervention Technologies (CEEBIT), which evaluates numerous components or multiple applications simultaneously (Mohr, Cheung, Schueller, Hendricks Brown, & Duan, 2013).

This approach implements applications in successive waves. At the end of each wave, a comparison is made to determine the relative utility of all currently active applications. Those deemed inferior are removed and a new app is added to the evaluation and the process repeats for another wave. This rolling process permits the evaluation of multiple applications in a single study and is immensely useful when seeking an optimal choice from among different available options.

It should be noted that both of these strategies, as well as other approaches, require novel analytic strategies that require oversight from experts. Technology based strategies often result in “data tsunamis”, a deluge of information that can be difficult to parse with more traditional practices that appear in the literature. Such methods include the Dynamic P-Technique (DPT; Little, Boviard, & Slegers, 2006), an approach that evaluates variation across the densely collected repeated measures that can be obtained from a mobile app. Collaboration with colleagues from the complementary areas that specialize in such techniques, including bioinformatics, physics, mathematics, and computer science is strongly encouraged. Such collaboration at the start of a project will inform the design of these applications and the resulting data that is collected.

In sum, there is considerable evidence to support the integration of technology into trauma-focused treatment. However, only research on telehealth has moved beyond preliminary evaluations. There is a clear a need for definitive studies on these topics within the area of traumatic stress. Researchers are encouraged to continue to explore issues of efficacy, implementation, and dissemination in all of these approaches. By accumulating new evidence, technology-based strategies will continue to improve the quality and reach of clinical care for trauma-related disorders.

About the Author

Matthew Price, PhD, is an assistant professor in the Department of Psychology at the University of Vermont. He conducts research on how technology-based interventions reduce the psychological distress caused by traumatic events. He has conducted work with mobile, web-based, virtual reality, and televideo approaches.

References

Amstadter, A. B., Broman-Fulks, J., Zinzow, H., Ruggiero, K. J., & Cercone, J. (2009). Internet Based Interventions for Traumatic Stress-Related Mental Health Problems: A Review and Suggestion for Future Research. Clinical psychology review, 29(5), 410–420. doi:10.1016/j.cpr.2009.04.001

Botella, C., García-Palacios, A., Guillen, V., Baños, R. M., Quero, S., & Alcaniz, M. (2010). An Adaptive Display for the Treatment of Diverse Trauma PTSD Victims. Cyberpsychology, Behavior, and Social Networking, 13(1), 67–71. doi:10.1089/cyber.2009.0353

Christensen, H., Griffiths, K. M., & Farrer, L. (2009). Adherence in Internet interventions for anxiety and depression: Systematic review. Journal of medical Internet research, 11(2), e13.

Collins, L. M., Baker, T. B., Mermelstein, R. J., Piper, M. E., Jorenby, D. E., Smith, S. S., … Fiore, M. C. (2011). The Multiphase Optimization Strategy for Engineering Effective Tobacco Use Interventions. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 41(2), 208–226. doi:10.1007/s12160-010-9253-x

Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., … Hoffman, H. G. (2007). Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. The Journal of clinical psychiatry, 68(11), 1639–1647.

Donkin, L., Christensen, H., Naismith, S. L., Neal, B., Hickie, I. B., & Glozier, N. (2011). A Systematic Review of the Impact of Adherence on the Effectiveness of e-Therapies. Journal of Medical Internet Research, 13(3), e52. doi:10.2196/jmir.1772

Draper, C., & Ghiglieri, M. (2011). Post-traumatic stress disorder. Computer based stepped care: Practical applications to clinical problems. In Stepped care and e-health (pp. 77–97). Springer.

Gonçalves, R., Pedrozo, A. L., Coutinho, E. S. F., Figueira, I., & Ventura, P. (2012). Efficacy of Virtual Reality Exposure Therapy in the Treatment of PTSD: A Systematic Review. PLoS ONE, 7(12), e48469. doi:10.1371/journal.pone.0048469

Gros, D. F., Morland, L. A., Greene, C. J., Acierno, R., Strachan, M., Egede, L. E., … Frueh, B. C. (2013). Delivery of Evidence-Based Psychotherapy via Video Telehealth. Journal of Psychopathology and Behavioral Assessment, 1–16. doi:10.1007/s10862-013-9363-4

Hirai, M., & Clum, G. A. (2005). An Internet-based self-change program for traumatic event related fear, distress, and maladaptive coping. Journal of Traumatic Stress, 18(6), 631–636. doi:10.1002/jts.20071

Kiluk, B. D., Sugarman, D. E., Nich, C., Gibbons, C. J., Martino, S., Rounsaville, B. J., & Carroll, K. M. (2011). A methodological analysis of randomized clinical trials of computer-assisted therapies for psychiatric disorders: toward improved standards for an emerging field. The American Journal of Psychiatry, 168(8), 790–799. doi:10.1176/appi.ajp.2011.10101443

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. doi:10.1186/1471-244X-7-13

Koepsell, T. D., Zatzick, D. F., & Rivara, F. P. (2011). Estimating the Population Impact of Preventive Interventions from Randomized Trials. American Journal of Preventive Medicine, 40(2), 191–198. doi:10.1016/j.amepre.2010.10.022

Krijn, M., Emmelkamp, P. M. G., Olafsson, R. P., & Biemond, R. (2004). Virtual reality exposure therapy of anxiety disorders: A review. Clinical Psychology Review, 24(3), 259–281.

Kumar, S., Nilsen, W. J., Abernethy, A., Atienza, A., Patrick, K., Pavel, M., … Swendeman, D. (2013). Mobile Health Technology Evaluation: The mHealth Evidence Workshop. American Journal of Preventive Medicine, 45(2), 228–236. doi:10.1016/j.amepre.2013.03.017

Labrique, A., Vasudevan, L., Chang, L. W., & Mehl, G. (2012). H_pe for mHealth: More “y” or “o” on the horizon? International journal of medical informatics. doi:10.1016/j.ijmedinf.2012.11.016

Lange, A., Rietdijk, D., Hudcovicova, M., Van De Ven, J. P., Schrieken, B., & Emmelkamp, P. M. G. (2003). Interapy: A controlled randomized trial of the standardized treatment of posttraumatic stress through the internet. Journal of Consulting and Clinical Psychology, 71(5), 901–909.

Little, T. D., Boviard, J. A., & Slegers, D. W. (2006). Methods for the analysis of change. In: Mroczek D K, Little T D, editors. Handbook of personality development (pp. 181–211). Mahwa, NJ: Erlbaum.

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.

Luxton, D. D., McCann, R. A., Bush, N. E., Mishkind, M. C., & Reger, G. M. (2011). mHealth for mental health: Integrating smartphone technology in behavioral healthcare. Professional Psychology: Research and Practice, 42, 505.

Mohr, D. C., Cheung, K., Schueller, S. M., Hendricks Brown, C., & Duan, N. (2013). Continuous Evaluation of Evolving Behavioral Intervention Technologies. American Journal of Preventive Medicine, 45(4), 517–523. doi:10.1016/j.amepre.2013.06.006

Motraghi, T. E., Seim, R. W., Meyer, E. C., & Morissette, S. B. (2013). Virtual Reality Exposure Therapy for the Treatment of Posttraumatic Stress Disorder: A Methodological Review Using CONSORT Guidelines. Journal of Clinical Psychology, n/a–n/a. doi:10.1002/jclp.22051

Pew Internet and American Life Project. (2013). Trend Data. Trend Data (Adults). Retrieved October 5, 2013, from http://pewinternet.org/Trend-Data-(Adults)/Whos-Online.aspx

Price, M., & Anderson, P. (2007). The role of presence in virtual reality exposure therapy. Journal of anxiety disorders, 21(5), 742–751.

Price, Matthew, Gros, D. F., McCauley, J. L., Gros, K. S., & Ruggiero, K. J. (2012). Nonuse and dropout attrition for a web-based mental health intervention delivered in a post-disaster context. Psychiatry, 75(3), 267–284. doi:10.1521/psyc.2012.75.3.267

Price, Matthew, Mehta, N., Tone, E. B., & Anderson, P. L. (2011). Does engagement with exposure yield better outcomes? Components of presence as a predictor of treatment response for virtual reality exposure therapy for social phobia. Journal of Anxiety Disorders, 25(6), 763–770. doi:10.1016/j.janxdis.2011.03.004

Price, Matthew, Yuen, E. K., Goetter, E. M., Herbert, J. D., Forman, E. M., Acierno, R., & Ruggiero, K. J. (2013). mHealth: A Mechanism to Deliver More Accessible, More Effective Mental Health Care. Clinical Psychology & Psychotherapy. doi:10.1002/cpp.1855

Reger, G. M., Hoffman, J., Riggs, D., Rothbaum, B. O., Ruzek, J., Holloway, K. M., & Kuhn, E. (2013). The “PE coach” smartphone application: An innovative approach to improving implementation, fidelity, and homework adherence during prolonged exposure. Psychological Services, 10(3), 342–349. doi:10.1037/a0032774

Ruggiero, K. J., Resnick, H. S., Acierno, R., Coffey, S. F., Carpenter, M. J., Ruscio, A. M., … Roffman, R. A. (2006). Internet-based intervention for mental health and substance use problems in disaster-affected populations: a pilot feasibility study. Behavior therapy, 37(2), 190–205.

Sloan, D. M., Gallagher, M. W., Feinstein, B. A., Lee, D. J., & Pruneau, G. M. (2011). Efficacy of Telehealth Treatments for Posttraumatic Stress-Related Symptoms: A Meta-Analysis. Cognitive Behaviour Therapy, 40(2), 111–125. doi:10.1080/16506073.2010.550058

Steinmetz, S. E., Benight, C. C., Bishop, S. L., & James, L. E. (2012). My Disaster Recovery: a pilot randomized controlled trial of an Internet intervention. Anxiety, stress, and coping, 25(5), 593–600. doi:10.1080/10615806.2011.604869

Yuen, E. K., Goetter, E. M., Herbert, J. D., & Forman, E. M. (2012). Challenges and opportunities in internet-mediated telemental health. Professional Psychology: Research and Practice, 43(1), 1–8. doi:10.1037/a0025524