Treating posttraumatic stress disorder via the Internet: does 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. 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. 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. 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 al 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 Clum 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 waitinglist controls. However, the generalizability of the study’s results is limited because of the predominantly female college student sample. Litz et al 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 therapistassisted, 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. Klein et al 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. 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. 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. The issue of therapeutic alliance deserves special attention in the treatment of PTSD. Therapeutic alliance is the