Prof. Dr. Christine Knaevelsrud

Transcrição

Web-based Psychological Interventions for Traumatized Individuals in
Regions of Violent Conflicts
- how ICT improves access to Mental Health Care
Prof. Dr. Christine Knaevelsrud
Freie University, Berlin
German Science Day, 26.05.2016
Overview
•
Introduction
•
Efficacy of internet based interventions
•
Treatment of PTSD through the internet in areas of ongoing violent
conflicts
•
Outlook for future research
Prof. Dr. Christine Knaevelsrud, Freie University Berlin
2
Definition: internet-based therapy
Internet
als... as….
The
internet
Source of information
(Information pages, interactive,
automated programs)
Beratungs-/Therapieansatz
Consulting/
intervention platform
Internet based self-help
(no input from a therapist)
Communication
(Email, Chat, Skype etc.)
Email-/ Chat-/Skypeconsulting/therapy
etc.
(Berger, 2010)
guided self-help
(partly standardized
interventions)
3
Numerous ways of digital
enhancement
Skype (video
counseling)
Video training
Podcasting
Writing Intervention
Serious Games/VR
4
Growing field of research
Guidelines:
National Institute for Health
and Care Excellence
(NICE)
Swedish National Board of
Health and Welfare (2010)
(Hedman et al., 2012)
5
Efficacy (Effect sizes)
•
•
Proof of efficacy for most
mental health disorders (metaanalyses)
high effect sizes for symptom
reduction
NUMBER
CONTROLLED
STUDIES
EFFECT SIZE
Andrews et
al. (2010)
PS, SAD,
GAD k = 16
0.96
Richards &
Richardson
(2012)
Depression
k = 19
0.56
6
Meta-analytical comparison of
guided internet based interventions vs. „faceto-face“-therapy
(Andersson et al., 2014)
7
Specifics of internet based communication
- Mostly text based communication
- No non-verbal signals
- Asynchrony
- / + Anonymity
+ effect of idealization
+ effect of disinhibition
+ adaptation of the communication behavior
8
Therapeutical contact and
intervention effects
No significant differences in regard
to quality of therapeutical
relationship between internet
based and face-to-faceinterventions
(Klasen, Böttche & Knaevelsrud, 2012)
No
contact
Contact
before
Contact
during
Contact
before
and
during
Evaluation of therapeutical
relationship is no consistent
predictor of the intervention
outcome
(Knaevelsrud et al., 2006; Sucala et al., 2012)
→ intervention effects are increasing with increasing amount of
therapeutical contact
(Johannsen et al., 2012)
9
Adherence and Dropout
Rates of internet based and „Face-to-face“-therapies are comparable
(Christensen et al., 2009; Macea et al., 2010)
High variance between different psychiatric conditions → probably rather
condition specific than intervention specific
→ Dropout smaller with
increasing contact
(Richards & Richardson, 2012)
No contact
Administrative contact Constant contact
10
Treatment of PTSD through the Internet in
areas of ongoing violent conflicts
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Internet based CBT for PTSD in
areas of violent conflicts
• Ongoing violence in Arabic conflict areas
• High prevalence rates of psychiatric conditions
• Internet-based interventions for PTSD have been
shown to be effective in Western countries (Lange et al.
2003, Knaevelsrud et al., 2007, Wagner et al., 2006)
• Treatment with Iraqi patients has been shown to be
applicable in a pilot study (Wagner, Schulz, & Knaevelsrud,
2012)
Efficacy of an
Internet-based
intervention in an
unstable conflict
region?
12
Global challenges of mental health
care
Shatha (34). Since her
husband has died she
is responsible for the
Marwan
family.
Grief (28).
and
Survived aimpairs
bomb
hopelessness
herattack.
daily functioning.
He suffers
The
nextnightmares
therapy
from
and
location
75 miles
flashbacks.
Hasim
(74).
A refugee
away.
There
no therapy
from
Iraqisliving
in
Germany.
availableHe
insuffers
his
from
chronic exhaustion
country.
and depression.
He still has difficulties
speaking German, but
seeks help.
13
14
Global challenges of mental health
care
- Global and connected solutions
•
Connection of locations (teams)
•
Connection of data sources
(smartphones, wearables)
•
Connection of disciplines (especially
math and computer science)
15
Lead partner in Work Package 6: ePM+
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Methods: Ilajnafsy treatment
principles
Based on the Interapy treatment protocol for PTSD and depression (Lange et al.,
2003)  translated (arabic) and culturally adopted
Structured treatment protocol
• cognitive-behavioral writing therapy
• Exclusively internet based
Duration of treatment: :
• 10 sessions (5-6 weeks)
• Weekly basis, each 45 minutes
-
Patient plans the writing sessions ahead of
each treatment phase
Therapist provides feedback within 48 hours
17
Online Assessment
Male, 29 years, Irag, Baghdad,
„...They killed my friend in front of my eyes, I will never forget that
moment, I saw him bleeding until he died. He died in front of my eyes
just like that. I also saw also a car which was bombed. All the people
inside were burned. I was injured too.“
18
Therapists
Team Alexandria Egypt
Team Berlin, Germany
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Overview of the treatment
Self-confrontation
Module 1 (4 Essays)
Cognitive
Reappraisal
Module 2 (4 Essays)
Social Sharing
Module 3
(2 Essays)
• Describing of the most
painful moment,
memories, feelings
including sensory
perceptions
• First person
• Present tense
• Writing an encouraging
letter to a fictive friend
who experienced a
similar event (change
of perspective).
• Questioning
dysfunctional irrational
thoughts
•
•
Sharing and
symbolic farewell
ritual
Style, spelling and
grammar
important
(dignified
document)
20
Sociodemographics
TG
n = 79
CG
n = 80
Sex n (%)
Female
60 (76)
55 (69)
Age M (SD)
29.11 (8.20)
27.15 (6.48)
53 (68)
20 (26)
45 (56)
30 (37)
17 (22)
56 (71)
28 (35)
38 (48)
Marital Status
Single
Married
Education
High school
University
21
Traumatic events
Number of traumatic events:
• TG: M = 3.67, SD = 3.01
• CG: M = 3.03, SD = 2.61
Murder of family member
39
40
War/Torture
27
26
Other (i.e. kidnapping)
Behandlungsgruppe
20
18
Sexual violence
(war-related sexual violence,
Sexual abuse)
14
16
0
Kontrollgruppe
20
40
60
80
100 %
22
Reliable Change at the end
of treatment
*
*
*
*p<.001
23
Conclusion
• Significant symptom reduction could
be found, despite unsafe and violent
environment;
• Effect sizes had the same magnitude
as reported in Western samples;
• New communication technologies can
be used to provide mental health care
services in regions of ongoing conflict
24
How our understanding of mental health
benefit from digital supported data collection
• Heterogenous courses of mental disorders
• Prediction of relapse
• Prediction of treatment (non-)response
25
Understanding mechanisms of change
Potential of online-based interventions
Extensive potential of
objectively tracking therapy-relevant behavior
all (written-)
communication
is recorded
Patient behavior
within the sessions
Therapist behavior
within the sessions
All tasks are digitally
recorded
(with timestamp)
Compliance with
homework
assignments
26
Enhanced assessment
Assessment of symptom severity and symptom change
Self-/
External rating
Laboratoy
assessment
physiologicalvegetative
behavioral
interpersonal
cognitive/emotional
27
Online-therapy and technical innovation
unobtrusive,
flexible assessments
ambulatory
assessment
physiologicalvegetative
behavioral
interpersonal
cognitive/emotional
28
Such as:
• localisation (i.e. GPS)
• movement (i.e. steps)
• Heart rate
• Sleep tracking
• Smartphone-usage (i.e. calls, social apps)
• Usage of therapeutic tools
(Login-duration, content etc.)
29
„Conventional“ data collection
Pre
INTERVENTION
Post
3 Mon.
6 Mon.
12 Mon.
Collection of behavioral data
Online - platformLogin/Usage/content
Meta-App
Tracking
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How our understanding of mental health
benefit from digital supported data collection



Processes of change
Predictors
Active treatment variables
31
Contact: [email protected]
32

Prof. Dr. Christine Knaevelsrud

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