Integrative testimonial therapy: an Internet-based, therapist-assisted therapy for German elderly survivors of the World War II with posttraumatic stress symptoms

Randomized controlled trial of two internet-based written therapies for world trade center workers and survivors with persistent PTSD symptoms

Posttraumatic stress disorder (PTSD) remains prevalent among individuals exposed to the 9/11 World Trade Center (WTC) terrorist attacks. The present study compared an Internet-based, therapist-assisted psychotherapy for PTSD to an active control intervention in WTC survivors and recovery workers with WTC-related PTSD symptoms (n = 105; 75% syndromal PTSD). Participants were randomized to integrative testimonial therapy (ITT), focused on WTC-related trauma, or modified present-centered therapy (I-MPCT), each comprising 11 assigned written narratives. The primary outcome was baseline-to-post-treatment change in PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5). Secondary measures included PTSD symptom clusters, depressive/anxiety symptoms, functioning, and quality of life. A significant main effect of time was observed for the primary outcome (average "large" effect size improvement, d = 1.49). Significant and "moderate-to-large" main effects of time were also observed for all PTSD symptom clusters, depressive symptoms, quality of life, and mental health-related functioning (d range=0.62-1.33). Treatment and treatment-by-time interactions were not significant. In planned secondary analyses incorporating 3-month follow-up measures, ITT was associated with significantly greater reductions than I-MPCT in PTSD avoidance and negative alterations in cognitions and mood, anxiety, and mental health-related functioning. Both therapies significantly lowered PTSD symptoms, suggesting they may benefit hard-to-reach individuals with chronic WTC-related PTSD symptoms.

The efficacy of internet-delivered cognitive-behavioral therapy for posttraumatic stress disorder according to the mean age of patients: a systematic review and meta-analysis

Internet-delivered cognitive-behavioral therapy (I-CBT) is effective in treating post-traumatic stress disorder (PTSD) symptoms, offering enhanced accessibility and cost-effectiveness. However, it's important to note that these technologies may not be suitable for all age groups. Therefore, we conducted a systematic review and meta-analysis to determine if the effectiveness of I-CBT in treating PTSD varies based on the patients' mean age. We conducted a systematic review of the literature, focusing on randomized controlled trials (RCTs) in the ISI Web of Science, PubMed/MEDLINE, and PsycINFO databases. Following this, we performed a meta-analysis and evaluated the risk of bias using the Cochrane risk of bias quality assessment tool. In this study, we examined patient-related factors (civil or military status, age, and gender), clinical characteristics (baseline PTSD severity and type of trauma), and treatment characteristics (type of intervention, synchronous or asynchronous delivery, and the number of sessions) as independent variables. The dependent variable was the reduction in mean PTSD symptoms. Five RCTs out of 1,552 screened studies were included in this review, all of which showed some level of concern regarding potential bias. Our meta-analysis indicates that I-CBT is equally effective regardless of patients' mean age. Since all RCTs included only provide the mean age of the patients, further randomized controlled trials should address the effectiveness of I-CBT among different age groups.

[Differential Effects of an Internet-Based Cognitive-Behavioral Writing Therapy for Reducing PTSD Symptoms after Intensive Care: Results of a Per-Protocol Analysis]

OBJECTIVE

To investigate the differential effects of an internet-based cognitive-behavioral writing therapy (iCBT) on post-traumatic stress disorder (PTSD) symptoms after intensive care in patients and their spouses.

METHODS

This reanalysis of a randomized controlled trial compared PTSD symptom severity (measured by PCL-5) before and after therapy considering potential influencing factors in the per-protocol population.

RESULTS

A significant reduction in post-traumatic symptom severity after iCBT was found. Eleven of the 25 treated participants showed a clinically significant change (PCL-5 difference≥10 points). The number of words written by the participants in the therapy modules had a significant impact on iCBT efficacy.

CONCLUSION

iCBT appears to be a promising option to augment therapy for PTSD, particularly for physically impaired patients following critical illness.

Factors Associated With Treatment Response in an Internet-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement

Internet-based psychological interventions have proven effective in the treatment of prolonged grief disorder (PGD). Yet, some patients do not benefit from treatment in a clinically significant way. We aimed to examine predictors of symptom reduction in an Internet-based intervention for PGD after cancer bereavement, in order to identify possible treatment mechanisms and discern directions for future intervention design. A secondary analysis of data from a randomized wait-list controlled trial on an Internet-based intervention for PGD after cancer bereavement was conducted. Multiple regression models were used (1) to test for the influence of pretreatment PGD, working alliance, avoidance and gender on PGD symptom reduction; and (2) to explore further predictors of treatment success with a best subset selection protocol. The regression models explained 18% (Model 1) and 34% (Model 2) of variance in symptom reduction. Participants with more favorable symptom change had more severe pretreatment PGD scores and better working alliance. Those with lower social support and less posttraumatic growth experienced more PGD symptom change. In conclusion, therapeutic alliance is an important factor that should be monitored and fostered. Findings regarding social support and posttraumatic growth need further replication and clarification.

Feasibility of a Digital Storytelling Intervention for Hematopoietic Cell Transplant Patients

Patients undergoing hematopoietic cell transplantation (HCT) are at risk for psychological and social impairment given the rigors and multiple sequelae of treatment. The purpose of this pilot study was to test the feasibility of a digital storytelling (DS) intervention for HCT patients, and to examine limited efficacy of the intervention relative to control arm on psychological distress and perceived social support. Adult HCT patients (n = 40, M age = 59.2 years) were enrolled immediately post-HCT and randomly assigned to either DS intervention or information control (IC). DS participants viewed four 3-min personal, emotionally rich digital stories, and IC condition participants viewed four videos containing information about post-HCT care. Feasibility regarding recruitment, enrollment efforts, and change scores from pre- to post-intervention (Δs) on depression, anxiety, and perceived social support were tracked. Fifty-four (51.4%) of 105 eligible patients consented. Forty (74%) patients completed the intervention. All but one completed the post-intervention assessments demonstrating that HCT patients can be recruited and retained for this intervention. On average, perceived social support increased for the DS group (Δ = 0.06) but decreased for the IC group (Δ = - 0.05). Anxiety and depression improved over time in both conditions. Viewing digital stories with content evoking emotional contexts similar to one's own health challenges may improve perceptions of social support among HCT patients. How DS can improve perceived social support for both short-term and longer-term sustained effects in a longitudinal study is an area ripe for additional investigation.

Where Are They Now: The Narratives of Children Who Lost a Parent on 9/11

There is a paucity of literature examining the experiences of children who lost a parent on 9/11. The primarily quantitative research has not allowed for a deeper understanding of how children who lost a parent on 9/11 make meaning of their experiences, especially in the context of a national tragedy. This study investigates how eight children who were between the ages of 5 and 12 when they lost a parent on 9/11 developed a personal narrative about this loss in the context of the collective narrative about 9/11. Using narrative inquiry, cases demonstrated patterns of narrative development about grief, tragedy, and collective themes of American exceptionalism, patriotism, triumph, and resiliency. These cases highlight de-personalized narratives of grief, tension between the grand narrative provided to them and their personal story of loss, and distance between the reality of their loss and the collective meaning-making of the tragedy. This study extends Bronfenbrenner's (1977) ecological systems theory by highlighting how a lack of bidirectionality between larger social and cultural systems and the individual negatively impacts personal experiences of grief and loss.

Psychosocial modification of general self-efficacy in older adults: A restricted review

OBJECTIVES

In recent years, the concept of general self-efficacy has increased in popularity. General self-efficacy is positively associated with quality of life and has the potential to act as a psychological buffer against adverse events and circumstances. However, due to the long-term influences that are said to shape general self-efficacy beliefs, they may be resistant to intervention, particularly within the older population. This restricted review aimed to explore whether psychosocial interventions could improve the general self-efficacy of older adults. Aspects of intervention design associated with improvements were also investigated.

METHODS

A restricted review was undertaken. This included a keyword search of four major health databases (PubMed, CINAHL, PsycINFO and AgeLine). Search terms focused on general self-efficacy and the commonly used measures of this concept and were limited to the older adult population.

RESULTS

In total, 848 articles were screened, with 20 studies proceeding to data extraction. The modification of general self-efficacy in older adults appears possible, with 7 out of the 20 included studies reporting improvements postintervention. Despite issues relating to the quality of included studies and the generalisability of their results, several aspects of intervention design coincided with intervention success, including intervention duration, and employing sufficiently-qualified staff.

CONCLUSIONS

Future research must address the generalisability issues identified in this review. Studies comparing the effectiveness of individual- and group-based interventions, the efficacy of remote delivery platforms and the possibility for long-term transfer of any improvements are needed to contribute the high-quality data required for policy and practice decisions in this area.

Internet-based cognitive-behavioural writing therapy for reducing post-traumatic stress after severe sepsis in patients and their spouses (REPAIR): results of a randomised-controlled trial

OBJECTIVES

To investigate the efficacy, safety and applicability of internet-based, therapist-led partner-assisted cognitive-behavioural writing therapy (iCBT) for post-traumatic stress disorder (PTSD) symptoms after intensive care for sepsis in patients and their spouses compared with a waitlist (WL) control group.

DESIGN

Randomised-controlled, parallel group, open-label, superiority trial with concealed allocation.

SETTING

Internet-based intervention in Germany; location-independent via web-portal.

PARTICIPANTS

Patients after intensive care for sepsis and their spouses of whom at least one had a presumptive PTSD diagnosis (PTSD-Checklist (PCL-5)≥33). Initially planned sample size: 98 dyads.

INTERVENTIONS

ICBT group: 10 writing assignments over a 5-week period; WL control group: 5-week waiting period.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome: pre-post change in PTSD symptom severity (PCL-5).

SECONDARY OUTCOMES

remission of PTSD, depression, anxiety and somatisation, relationship satisfaction, health-related quality of life, premature termination of treatment. Outcomes measures were applied pre and post treatment and at 3, 6 and 12 months follow-up.

RESULTS

Twenty-five dyads representing 34 participants with a presumptive PTSD diagnosis were randomised and analysed (ITT principle). There was no evidence for a difference in PCL-5 pre-post change for iCBT compared with WL (mean difference -0.96, 95% CI (-5.88 to 3.97), p=0.703). No adverse events were reported. Participants confirmed the applicability of iCBT.

CONCLUSIONS

ICBT was applied to reduce PTSD symptoms after intensive care for sepsis, for the first time addressing both patients and their spouses. It was applicable and safe in the given population. There was no evidence for the efficacy of iCBT on PTSD symptom severity. Due to the small sample size our findings remain preliminary but can guide further research, which is needed to determine if modified approaches to post-intensive care PTSD may be more effective.

TRIAL REGISTRATION NUMBER

DRKS00010676.

What Factors are Associated with Posttraumatic Growth in Older Adults? A Systematic Review

OBJECTIVES

Posttraumatic growth (PTG) is of increased theoretical and clinical interest. However, less is known about PTG in older adults specifically. This systematic review aimed to identify domains where PTG is studied for older adults; investigate factors associated with PTG in older adults; consider how these might differ between historical and later life traumas.

METHODS

Online databases were searched for quantitative studies examining PTG outcomes in adults aged ≥ 60 years.

RESULTS

15 studies were subject to a narrative synthesis.

CONCLUSIONS

Older adults can experience substantial levels of PTG, from traumas during later life or across the lifespan, and historical wartime traumas. Traumas can be diverse, some studies found equivalent levels of PTG from different traumas across the lifespan. Social processes may be a key variable for older adults. Additional psychosocial factors are found; however, diverse findings reflect no overall model, and this may be consistent with variations found in other PTG literature.

CLINICAL IMPLICATIONS

Clinical considerations are discussed. As diverse studies, findings may not be widely generalizable and directions for further research are highlighted. PROSPERO: CRD42020169318.

Review of Grief Therapies for Older Adults

Purpose of Review

The objective of this review is to provide background on common theories of grief, describe the impact of grief on older adults and to introduce various modalities that are currently used and/or being researched for treatment. The objective is also to condense information and identify what has been found beneficial versus what has been found lacking. A brief examination of overlap of other disorders is done. It also will suggest what further research is necessary on this subject, and highlight what research is being done during the COVID-19 Pandemic.

Findings

The latest research of grief primarily involves refining the definitions of grief. More concrete definitions of grief will help for better screening tools, and thus target interventions more appropriately. There is considerable need for applying it to the unique and real-world COVID-19 pandemic.

Summary

Grief disorders are relatively common and the symptoms overlap other disorders. Since the treatments differ, identifying grief disorders is important, especially in the elderly who are more susceptible to grief disorders. Therapy improves grief better than medications, but medications will help with any co-occurring disorders. No clear superior therapy has been identified but research continues. The pandemic has highlighted the need to refine the definitions of grief disorders and to treat them effectively.

Responsible Relations: A Systematic Scoping Review of the Therapeutic Alliance in Text-Based Digital Psychotherapy

Introduction: Developing a good therapeutic alliance is considered essential for the responsible delivery of psychotherapy. Text-based digital psychotherapy has become increasingly common, yet much remains unclear about the alliance and its importance for delivering mental health care via a digital format. To employ text-based digital therapies responsibly, more insight is needed into the type and strength of the therapeutic alliance online. Methods: A systematic scoping review was performed searching four databases: Scopus, PsycINFO, Web of Science, and Wiley Online Library. A total of 23 studies were selected and data was extracted and tabulated to explore the characteristics of studies on text-based psychotherapy, measurements of the therapeutic alliance and associations of the alliance with treatment outcome. Results: The therapeutic alliance in text-based digital interventions was studied with a variety of client groups, though mostly for clients diagnosed with anxiety and/or depression issues. Treatment modalities were predominantly internet-based cognitive behavioral therapy (ICBT) and tailored platforms for distinct client groups (e.g., PTSD). Almost all treatments used asynchronous text-based communication, such as e-mails and integrated messaging functions, which were mainly used to give feedback on tasks. For measurements, a version of the Working Alliance Inventory (WAI) was used in most studies. Measurements with the WAI or WAI- short form indicated a good therapeutic alliance with a weighted mean score of 5.66 (on a scale of 1 to 7) and a weighted standard deviation of 0.84. Relations between the therapeutic alliance and treatment outcomes were mostly positive, with many studies reporting significant associations (n = 8 out of 10) or significant effects of the therapeutic alliance on treatment outcomes (n = 5 out of 6). Discussion: Our scoping review suggests that a good therapeutic alliance can be established in digital psychotherapy through text-based communication, and shows support for a positive relationship between the alliance and treatment outcomes. These findings illustrate that text-based online psychotherapy can be a responsible treatment option as far as the establishment of the therapeutic alliance is concerned. However, current measures of the therapeutic alliance might miss important aspects of the alliance in digital treatment, such as the presence of empathy or compassion.

Ambient assisted living technology-mediated interventions for older people and their informal carers in the context of healthy ageing: A scoping review

BACKGROUND AND AIMS

There is a growing demand for health and social care services to provide technology-mediated interventions that promote the health and well-being of older people with health or care needs and of their informal carers. The objectives of this study were to scope and review the nature and extent of prior intervention studies involving ambient assisted living technology-mediated interventions for older people and their informal carers, and how and in what ways (if any) the goals and aims of these interventions reflected the domains of the World Health Organization framework for healthy ageing.

METHODS

We conducted a scoping review. Data were collected between June and October 2018 with an updated search in October 2020. A total of 85 articles were eligible for inclusion.

RESULTS

Nine categories described the aims and content of the included studies. The healthy ageing domain "Ability to meet basic needs" was mirrored in four categories, whereas "Ability to contribute to society" was not addressed at all.

CONCLUSION

The ways in which domains of healthy ageing are mirrored suggest that there is an emphasis on individual factors and individual responsibility, and a lack of attention given to broader, environmental factors affecting healthy ageing. Only a few of the studies used a dyadic approach when assessing health outcomes concerning older people and their informal carers.

Life review therapy for holocaust survivors (LRT-HS): study protocol for a randomised controlled trial

BACKGROUND

The Holocaust was one of the most traumatic catastrophes in recorded human history. Survivors seeking psychotherapeutic help today, now in their seventies and older, often show symptoms of a posttraumatic stress disorder (PTSD), depression, or prolonged grief disorder. Established psychological treatments for PTSD (e.g. cognitive behaviour therapy, psychodynamic therapies) have been tested and assessed mainly with young and middle-aged adults; only very few studies examined them in old age. There is no therapy outcome study known to us for any treatment mode for Holocaust survivors. Moreover, there is a need for an age group-specific treatment of PTSD and other stress-related mental disorders. A narrative approach including life-review and narrative exposure seems to meet very well the natural need of older people to review their lives and is highly effective. However, most studies on the efficacy of life review therapy (LRT) focus on late-life depression. There is a lack of efficacy studies evaluating the effect of LRT on PTSD symptoms in older individuals that have experienced traumatic events.

METHODS

The main goal of this study is to evaluate the effect of LRT for Holocaust survivors (LRT-HS) on symptoms of PTSD and related mental health problems (depression, anxiety, prolonged grief), compared to a supportive control group. A secondary goal is to identify the characteristics of participants that seem to especially benefit from the treatment. The proposed study is a randomised, controlled follow-up trial including Holocaust survivors with one or more trauma-related disorders. The LRT treatment consists of 20-25 sessions. Before and after the treatment phase, participants in both conditions will be assessed. Follow-up will take place 6 months after the treatment. A sample size of 80 is required (drop-out rate included).

DISCUSSION

Efficacious treatments for trauma-related disorders in older people are of high importance, also because the probability of traumatisation and loss increases with age. Because this study is conducted with this specific group of multiply traumatised people, we are convinced that the results can easily transfer to other samples.

TRIAL REGISTRATION

ISRCTN, ISRCTN12823306. Registered 31 March 2018 - Retrospectively registered (first participant 22 December 2017).

From fragments to identity: reminiscence, life review and well-being of holocaust survivors. An integrative review

Objectives: Survivors of the Holocaust have reached an age during which it is common for them to look back on their lives. Previous research has shown that reminiscence can take on either adaptive ('self-positive') or detrimental ('self-negative') forms, which in turn are differently linked to psychological well-being. Thus, the question of "why" and "how" Holocaust survivors recall their autobiographical memories may hold important information about the underlying coping processes at play. This review aims to give insight into the current state of research on these questions.Method: A systematic literature search was conducted, looking for articles reporting quantitative and qualitative research on reminiscence and narrative styles, life review and well-being of Holocaust survivors. A methodological quality assessment was undertaken.Results: 23 articles met the criteria for inclusion. These articles focused either on reminiscence functions or on content and structure of life narratives. Such autobiographical reports were shaped by the experience of Holocaust. However, actual well-being was particularly determined by positive life events. Studies found evidence for resilience and ongoing effort to integrate the past into a coherent review. The link between reminiscence and health remains stable even after massive trauma. Contextual influences (such as culture) and age are discussed as possible covariates.Conclusions: The results show that Holocaust survivors are able to use reminiscence in a functional way, though they are increasingly more vulnerable as they reach very old age. The link between past suffering and present well-being gets stronger with age. Other stressful life experiences after the Holocaust must be considered as exacerbating factors. This review also presents the implications for therapy and open research questions are discussed.

Long-Term Psychological Consequences of World War II Trauma Among Polish Survivors: A Mixed-Methods Study on the Role of Social Acknowledgment

Background

The research on the psychological consequences of World War II (WWII) trauma has predominantly focused on concentration camp and Holocaust survivors. Only a few studies have been undertaken among civilian survivors of WWII.

Objectives

The purpose of this study was to examine the association between perceived social acknowledgment of WWII trauma and the level of post-traumatic stress disorder (PTSD) and depressive symptoms among Polish survivors of WWII by employing a mixed-methods design (i.e., a quantitative analysis supported by qualitative interviews).

Method

In the quantitative part, 123 participants filled out: the list of WWII-related traumatic events, the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), the shortened version of the Geriatric Depression Scale (GDS), and the Social Acknowledgment Questionnaire (SAQ). In the qualitative part, an interpretative phenomenological analysis (IPA) of participants’ reminiscences of WWII was examined.

Results

Although we observed a direct positive association between the number of WWII-related traumatic events and the intensity of PTSD and depressive symptoms, these relationships changed when we entered the social acknowledgment construct into the model. Specifically, we found that perceived social acknowledgment (general disapproval) was a mediator of the relationship between the number of WWII traumatic events and the intensity of PTSD symptoms only, and not of depressive symptoms. In the qualitative part, three themes relating to traumatic reminiscences emerged among the participants: parental efficacy, parental betrayal, and support from the invader.

Conclusion

Our study showed the significance of the general social acknowledgment in the long-term mental consequences of the WWII trauma in Poland. In addition, the results of our study may be an adjunct to the discussion on the long-term impact of WWII trauma in Poland and the factors that hindered its social recognition.

Posttraumatic Stress Disorder in Older Adults: A Conceptual Review

Objectives: We provide a review of the literature on posttraumatic stress disorder (PTSD) in older adults, focusing largely on older U.S. military veterans in two primary areas: 1) assessment and diagnosis and 2) non-pharmacological treatment of PTSD in late life. Methods: We performed a search using PubMed and Academic Search Premier (EBSCO) databases and reviewed reference sections of selected papers. We also drew on our own clinical perspectives and reflections of seven expert mental health practitioners. Results: Rates of PTSD are lower in older compared with younger adults. The presence of sub-syndromal/partial PTSD is important and may impact patient functioning. Assessment requires awareness and adaptation for potential differences in PTSD experience and expression in older adults. Psychotherapies for late-life PTSD appear safe, acceptable and efficacious with cognitively intact older adults, although there are relatively few controlled studies. Treatment adaptations are likely warranted for older adults with PTSD and co-morbidities (e.g., chronic illness, pain, sensory, or cognitive changes). Conclusions: PTSD is an important clinical consideration in older adults, although the empirical database, particularly regarding psychotherapy, is limited. Clinical Implications: Assessment for trauma history and PTSD symptoms in older adults is essential, and may lead to increased recognition and treatment.

Understanding Resilience and Preventing and Treating PTSD

Resilience is defined as the dynamic ability to adapt successfully in the face of adversity, trauma, or significant threat. Some of the key early studies of resilience were observational studies in children. They were followed by research in adults, studies testing interventions to promote resilience in different populations, and a recent upsurge of studies on the underlying genomic and neurobiological mechanisms. Neural and molecular studies in preclinical models of resilience are also increasingly identifying active stress adaptations in resilient animals. Knowledge gained from animal and human studies of resilience can be harnessed to develop new preventive interventions to enhance resilience in at-risk populations. Further, treatment interventions focused on enhancing potentially modifiable protective factors that are consistently linked to psychological resilience can enrich currently available treatment interventions for individuals with posttraumatic stress disorder (PTSD). Translating our expanding knowledge of the neurobiology of resilience additionally promises to yield novel therapeutic strategies for treating this disabling condition. This review summarizes the vast field of resilience research spanning genomic, psychosocial, and neurobiological levels, and discusses how findings have led and can lead to new preventive and treatment interventions for PTSD.

Does prolonged grief treatment foster posttraumatic growth? Secondary results from a treatment study with long-term follow-up and mediation analysis

OBJECTIVES

Prolonged grief disorder (PGD) is a persistent and disabling kind of grief reaction that can be treated effectively with psychotherapeutic interventions. There has been limited investigation of whether these interventions can also enhance positive outcomes of bereavement, such as posttraumatic growth or benefit finding.

DESIGN

As part of secondary analyses in a randomized controlled trial evaluating integrative cognitive-behavioural therapy for PGD (PG-CBT), the posttraumatic growth trajectories in 51 outpatients with clinically relevant prolonged grief symptoms were followed up from baseline up to 1.5 years.

METHODS

Immediate treatment effects on posttraumatic growth in comparison with a waiting list control group were evaluated with univariate ANCOVA. Using mediation analysis, we examined the relation between symptom reduction and the short-term treatment effect on posttraumatic growth. For evaluating long-term outcome stability, the immediately treated group and the delayed treatment group were pooled.

RESULTS

PG-CBT significantly fostered growth in patients suffering from PGD, with a controlled medium effect size of Cohen's d = 0.60 (completer analysis). This effect remained stable up to the 1.5-year follow-up. Grief symptom reduction mediated short-term treatment effects on posttraumatic growth. However, growth also partially mediated treatment effects on prolonged grief symptoms.

CONCLUSIONS

Taken together, PG-CBT was effective in enhancing the participants' perception of posttraumatic growth, but the definite interaction between symptom reduction and posttraumatic growth remains unclear, as both seemed to influence each other's trajectory in the course of treatment.

PRACTITIONER POINTS

Integrative CBT for prolonged grief disorder also fostered posttraumatic growth. Post-treatment and 1.5-year follow-up effect sizes for posttraumatic growth were moderate. Whether growth-enhancing techniques are useful in grief treatment needs further research.

Internet-based grief therapy for bereaved individuals after loss due to Haematological cancer: study protocol of a randomized controlled trial

BACKGROUND

Approximately 10% of the individuals experiencing the death of a loved one develop prolonged grief disorder (PGD) after bereavement. Family members of haematological cancer patients might be particularly burdened since their loss experience is preceded by a very strenuous time of disease and aggressive treatment. However, support needs of relatives of cancer patients often remain unmet, also after the death of the patient. Therapeutic possibilities are enhanced by providing easily available and accessible Internet-based therapies. This study will adapt and evaluate an Internet-based grief therapy for bereaved individuals after the loss of a significant other due to haematological cancer.

METHODS

The efficacy of the Internet-based grief therapy is evaluated in a randomized controlled trial with a wait-list control group. Inclusion criteria are bereavement due to hematological cancer and meeting the diagnostic criteria for PGD. Exclusion criteria are severe depression, suicidality, dissociative tendency, psychosis, posttraumatic stress disorder, substance use disorder, and current psychotherapeutic or psychopharmacological treatment. The main outcome is PGD severity. Secondary outcomes are depression, anxiety, somatization, posttraumatic stress, quality of life, sleep quality, and posttraumatic growth. Data is collected pre- and posttreatment. Follow-up assessments will be conducted 3, 6, and 12 months after completion of the intervention. The Internet-based grief therapy is assumed to have at least moderate effects regarding PGD and other bereavement-related mental health outcomes. Predictors and moderators of the treatment outcome and PGD will be determined.

DISCUSSION

Individuals bereaved due to haematological cancer are at high risk for psychological distress. Tailored treatment for this particularly burdened target group is missing. Our study results will contribute to a closing of this healthcare gap.

TRIAL REGISTRATION

German Clinical Trial Register UTN: U1111-1186-6255 . Registered 1 December 2016.

Turning wounds into wisdom: Posttraumatic growth over the course of two types of trauma-focused psychotherapy in patients with PTSD

BACKGROUND

Treatment studies in PTSD patients have mostly focused on adverse psychopathological outcomes whereas positive outcomes have received less attention. Objectives of this study were to investigate posttraumatic growth in response to two different psychotherapies, to examine the relationship between symptom improvement and growth, and to determine if posttraumatic growth predicted treatment response.

METHODS

Outpatients diagnosed with PTSD after various types of trauma (n = 116) participated in a randomized controlled trial that compared Brief Eclectic Psychotherapy for PTSD (BEP) and Eye Movement Desensitization and Reprocessing therapy (EMDR). Posttraumatic growth was assessed pre- and post-treatment. PTSD severity was measured weekly.

RESULTS

Posttraumatic growth scores significantly increased after trauma-focused psychotherapy, as well as scores in the subdomains personal strength, new possibilities, relating to others, and appreciation of life. Greater self-reported and clinician-rated PTSD decline was significantly related to greater increase in posttraumatic growth. No changes were found between treatment conditions, except for a stronger correlation between PTSD symptom decrease and increase in relating to others in BEP as compared to EMDR. No predictive effects were found.

LIMITATIONS

We were unable to control for time effects because for ethical reasons, no control group not receiving treatment was included, and the stability of the changes could not be determined.

CONCLUSIONS

Findings indicate that increases in posttraumatic growth accompany symptom decline in EMDR and BEP, and that these changes occur independent of whether the treatment specifically addresses posttraumatic growth as therapeutic process. Further research is encouraged to disentangle the contribution of therapeutic elements to growth.

Posttraumatic stress symptoms among Polish World War II survivors: the role of social acknowledgement

Background: There is growing evidence of the important role played by socio-interpersonal variables on the maintenance of PTSD. Many World War II survivors in Poland could, as a result of political circumstances during the aftermath of the war, have experienced a lack of social recognition of their war-related trauma. Objective: The main aim of the study was to examine the association between perceived social reactions and the level of posttraumatic stress symptoms (PTSD) and depression. Method: Participants (N = 120) were aged 71-97 years (M = 82.44; SD = 6.14). They completed a WWII trauma-related questionnaire, the Posttraumatic Diagnostic Scale (PDS), the Impact of Events Scale (IES) and Beck's Depression Inventory (BDI). The Social Acknowledgement Questionnaire (SAQ) was used to measure participants' perception of others' acknowledgement and disapproval of their war trauma. Results: The rate of probable PTSD, diagnosed according to DSM-IV, was 38.3%. PTSD symptoms and General Disapproval were significantly correlated for all three PTSD symptom groups (Pearson's r ranged from .25 to .41). The structural equation modelling results also demonstrated the importance of General Disapproval with regard to the level of PTSD symptoms. It explained both the intensity of PTSD symptoms (13.4% of variance) and the level of depression (12.0% of variance). Conclusion: In addition to confirming the high rate of PTSD among WWII survivors in Poland, the results indicate the importance of social reactions to survivors' traumatic experiences.

Aliança Terapêutica nas Terapias Cognitivo-comportamentais por Videoconferência: uma Revisão da Literatura

Resumo Nos últimos anos houve um aumento do número de usuários da internet no Brasil e no mundo, enquanto as intervenções por videoconferência surgiram como formas de tratamento para diversos transtornos mentais. Sabe-se que a aliança terapêutica é um componente essencial para se implementar a prática psicoterapêutica, porém, não há um consenso sobre sua formação na psicoterapia por videoconferência. Portanto, o presente artigo teve como objetivo realizar uma revisão de literatura acerca da formação e papel da aliança terapêutica nas Terapias Cognitivo-comportamentais (TCC) por videoconferência. Para isso, foi realizada uma busca em quatro bases de dados, Pubmed, Psycarticles, Lilacs e SciELO, com descritores específicos dos dicionários de cada base. No total, foram encontrados 365 artigos, mas apenas nove preencheram os critérios de inclusão baseados no objetivo deste estudo. Observou-se que a maioria dos artigos indicou que a aliança foi alta no decorrer das sessões de TCC por videoconferência, podendo ser comparada com a aliança formada na terapia presencial, e que poucos artigos avaliaram a aliança como fator preditivo de resultados e de adesão. Apesar deste indicativo, este estudo discute as limitações metodológicas dos artigos e indica a necessidade de estudos que tornem mais claras as evidências sobre a formação da aliança e o o seu papel nesta modalidade alternativa de tratamento.

Transgenerational trauma in a post-conflict setting: Effects on offspring PTSS/PTSD and offspring vulnerability in Cambodian families

We assessed transgenerational effects of maternal traumatic exposure, posttraumatic stress symptoms and posttraumatic stress disorder on trauma-related symptoms in Cambodian offspring born after the genocidal Khmer Rouge Regime. We conducted a randomized cross-sectional study. N=378 mothers from 4 provinces of the country and one of each of their grown-up children were interviewed. Lifetime traumatic exposure was determined using a context-adapted event list. Present posttraumatic stress symptoms and a potential posttraumatic stress disorder were assessed using the civilian version of the Posttraumatic Stress Disorder Checklist. We found no indication of transgenerational effects that were directly related to maternal traumatic exposure, posttraumatic stress symptoms or posttraumatic stress disorder. Instead, a gender-specific moderating effect was found. Individual traumatic exposure had a stronger effect on posttraumatic stress symptoms in daughters, the higher the mother's lifetime traumatic exposure. There is evidence of an interaction between lifetime traumatic exposure of mothers and their offspring that can be interpreted as an increased vulnerability to symptoms of posttraumatic stress in daughters. The mechanisms of transgenerational trauma in the Cambodian context require further research, as learning from previous conflicts will be instructive when addressing the pressing humanitarian needs of today's world.

Efficacy and Feasibility of a Therapist-Guided Internet-Based Intervention for Older Persons with Childhood Traumatization: A Randomized Controlled Trial

OBJECTIVE

Although cognitive-behavioral treatment approaches for post-traumatic stress disorder (PTSD) exist, only a small proportion of older adults seeks psychological treatment. Alternative treatment approaches are thus needed to fill the gap between provision and use of psychological interventions. This study aimed to investigate the efficacy and feasibility of an Internet-based, therapist-guided cognitive-behavioral therapy (Internet-based CBT) for older individuals with PTSD symptoms.

METHODS

Patients with clinically meaningful (i.e., subsyndromal or greater) PTSD symptoms were randomly assigned to a 6-week treatment group of therapist-guided Internet-based CBT (N = 47; treatment group) or a wait-list group (N = 47; WL). The treatment group was assessed pre- and post-treatment as well as at 3-, 6- and 12-month follow-ups.

RESULTS

Linear mixed-effects analyses showed a significant interaction between group (treatment versus WL) and time (pre versus post) for PTSD symptoms with a moderate between-group effect size in favor of the treatment group (d = 0.42). Effects in the treatment group were maintained up to the 12-month follow-up. Findings indicate a significant interaction (group × time) for quality of life (d = 0.39) and self-efficacy (d = 0.38). With regard to the feasibility, attrition rate was very low in both groups (treatment group: 12.8%, WL: 6.4%) and working alliance was very high.

CONCLUSIONS

Results suggest that therapist-guided Internet-based CBT is associated with a substantial reduction in PTSD symptoms, and increase in resource-related variables in older adults with (subsyndromal) PTSD. This Internet-based intervention may offer a promising option in a stepped-care approach for older trauma-affected persons who may otherwise not pursue mental health treatment.

Internet-based cognitive-behavioural writing therapy for reducing post-traumatic stress after intensive care for sepsis in patients and their spouses (REPAIR): study protocol for a randomised-controlled trial

INTRODUCTION

As a consequence of sepsis and intensive care, considerable proportions of patients but also of their spouses develop a post-traumatic stress disorder (PTSD). However, only a very small number receive psychotherapeutic treatment. Internet-based cognitive-behavioural writing therapy (IB-CBWT) has proven to be an effective treatment option for PTSD. It seems to fit the specific needs of this cohort and to overcome treatment barriers. Aim of the REPAIR trial is to examine the efficacy, safety and applicability of IB-CBWT for PTSD in patients and their spouses after intensive care for sepsis.

METHODS AND ANALYSIS

Participants will be assigned randomly either to a treatment or a wait-list (WL) control group. The treatment group receives IB-CBWT for PTSD, actively involving the partners of the participants. IB-CBWT will be guided by a therapist and comprises two written assignments per week over a 5 week period. After completing the assignments, the participants obtain individual responses from the therapist. Participants of the WL control group will receive treatment after a waiting period of 5 weeks. The primary outcome is PTSD symptom severity in self-rated PTSD Checklist for Diagnostic and Statistical Manual Fifth Edition at the end of treatment and waiting time, respectively. Secondary outcomes are remission of PTSD, depression, anxiety, and somatisation measured by the Brief Symptom Inventory-18, marital satisfaction measured by the Relationship Assessment Scale, health-related quality of life measured by the EQ-5D-5L, and the feasibility of IB-CBWT for this cohort (ie, dropout rate). Statistical analysis will be performed according to the intent-to-treat principle.

ETHICS AND DISSEMINATION

The study is conducted according to the principles of Good Clinical Practice and has been approved by the ethics committee of the Friedrich-Schiller University Jena, Germany. Results will be disseminated at scientific conferences, published in peer-reviewed journals, and provided to consumers of healthcare.

TRIAL REGISTRATION NUMBER

Pre-results, DRKS00010676.

[Personalized Internet-based treatment services for posttraumatic stress disorder]

Among the most important innovations within the psychotherapeutic care system are the new opportunities in the field of e-mental health. During the past decade, Internet-based and other e-mental health approaches for the treatment of post-traumatic stress disorder and related stress-associated symptoms have been developed in great variety. Solely Internet-based self-help programs are the lowest-threshold approaches in a stepped-care system. By contrast, individualized online psychotherapy and virtual reality programs are at the opposite pole of the spectrum. Approaches in the field of m(obile)-mental health complement these new developments in psychotherapy. The existing evidence supports the clinical efficacy of all the described approaches, although not all have been tested rigorously analog to phase III studies in psychopharmacology. Nonetheless, e-mental health approaches will shape our field more and more in the future.

Understanding resilience: New approaches for preventing and treating PTSD

All individuals experience stressful life events, and up to 84% of the general population will experience at least one potentially traumatic event. In some cases, acute or chronic stressors lead to the development of posttraumatic stress disorder (PTSD) or other psychopathology; however, the majority of people are resilient to such effects. Resilience is the ability to adapt successfully in the face of stress and adversity. A wealth of research has begun to identify the genetic, epigenetic, neural, and environmental underpinnings of resilience, and has indicated that resilience is mediated by adaptive changes encompassing several environmental factors, neural circuits, numerous neurotransmitters, and molecular pathways. The first part of this review focuses on recent findings regarding the genetic, epigenetic, developmental, psychosocial, and neurochemical factors as well as neural circuits and molecular pathways that underlie the development of resilience. Emerging and exciting areas of research and novel methodological approaches, including genome-wide gene expression studies, immune, endocannabinoid, oxytocin, and glutamatergic systems, are explored to help delineate innovative mechanisms that may contribute to resilience. The second part reviews several interventions and preventative approaches designed to enhance resilience in both developmental and adult populations. Specifically, the review will delineate approaches aimed to bolster resilience in individuals with PTSD. Furthermore, we discuss novel pharmacologic approaches, including the N-methyl-d-aspartate (NMDA) receptor ketamine and neuropeptide Y (NPY), as exciting new prospects for not only the treatment of PTSD but as new targets to enhance resilience. Our growing understanding of resilience and interventions will hopefully lead to the development of new strategies for not just treating PTSD but also screening and early identification of at-risk youth and adults. Taken together, efforts aimed at dissemination and implementation of novel interventions to enhance resilience will have to keep pace with the growth of new preventive and treatment strategies.

Predictors of outcome of an Internet-based cognitive-behavioural therapy for post-traumatic stress disorder in older adults

OBJECTIVES

The aim of this study was to evaluate the role of resource-oriented variables such as self-efficacy, locus of control (LOC) and post-traumatic growth (PTG) in predicting treatment response in older adults with post-traumatic stress.

METHODS

Fifty-eight older adults with subsyndromal or greater severity of war-associated post-traumatic stress disorder (PTSD) symptoms completed a randomized controlled Internet-based cognitive-behavioural therapy (CBT) with immediate and delayed treatment groups. Assessments of PTSD severity and resource-oriented variables of self-efficacy, LOC and PTG were conducted at baseline, post-treatment and at a 6-month follow-up.

RESULTS

Results revealed that pre-treatment scores on measures of internal LOC and PTG predicted PTSD symptom severity at post-treatment, even after controlling for initial PTSD. At a 6-month follow-up, internal LOC continued to predict PTSD symptom severity. In addition, repeated-measures analyses of variance revealed that, relative to older adults with low internal LOC and PTG, older adults with high internal LOC and PTG, respectively, did not differ with respect to initial PTSD severity, but they showed a more pronounced response to treatment.

CONCLUSION

These findings suggest that greater locus of control and post-traumatic growth is associated with greater improvement in PTSD symptoms following Internet-based CBT. Assessment of these constructs may be useful in identifying trauma survivors who are most likely to respond to CBT.

PRACTITIONER POINTS

Greater internal locus of control and post-traumatic growth is associated with greater improvement in PTSD symptoms following Internet-based CBT. Older adults with initial high internal locus of control and post-traumatic growth, respectively, did not differ with respect to initial PTSD severity, but they showed a more pronounced response to treatment. It could be assumed that patients with initial functional appraisals could benefit easier and faster from a trauma-focused cognitive-behavioural therapy compared to individuals with lower internal locus of control and post-traumatic growth.