Ebook: Internet Use in the Aftermath of Trauma

A while ago, while preparing the conference that led to this book, a public health researcher told me: “Obviously, if everybody who had a health condition went to their doctor, the health system would simply collapse.” This truism really hit the mark as it captured the very notion I was trying to articulate with respect to the future of the Internet as a public health tool: in the aftermath of 9/11, if every New Yorker had gone to their psychologist to vent, or for information and advice, the mental health system would have collapsed. Instead, they turned to a variety of sources of support and information: their doctor, the media, their yoga teacher, their friends...and the Internet. In fact, notwithstanding 9/11, Americans are increasingly turning to the Internet to find health-related information to take better care of themselves and the ones they love. But, the Internet has a lot more to offer than mere information. The Internet offers forums for self-expression. It offers a place for networking with others who share similar concerns. It is also a marketplace where one can access professional help. And, for some of us, the Internet is an object of study as well as a tool for conducting research.

Trauma-related mental disorders are among the most prevalent public health problems on this planet. This book is a testimony to the creativity of a few pioneers who believe the solution to this public health problem includes the Internet. The book is organized into six sections, each addressing the various uses of the Internet in mental health, with a particular emphasis on the issue of traumatic stress.

In Section I (Introduction), John Grohol, a founder of the award-winning PsychCentral (http://psychcentral.com/), offers a historical perspective on how the Internet helped build a mental health social networking community which has radically changed the way people seek information on mental health and find social support. In the same vein, Azy Barak offers an international perspective on the creative ways in which Internet has, since its beginning, provided psychological solace to people affected by mass disasters and tragedies. Celia Boyer and Judith Patterson also describe one solution – the HON code – for what is perhaps the most important pitfall of the Internet: the inconsistent quality of the information and advice that one can find.

Section II addresses how the Internet can foster the creation of virtual social networks that can effectively mitigate the impact of traumatic events. Authors revisit the role the Internet played during and in the aftermath of events such as 9/11 (Spiegel & Butler) and the Haiti earthquake (Herbert & Brunet).

By definition, traumatic events create chaos. This chaos often impedes initiatives to conduct trauma-related research. Section III contains three chapters describing powerful methodological, scientific, and logistical strategies (Schlenger, Litz, & McLean; McLean, Schlenger, & Litz; Ashbaugh, Herbert, Butler, & Brunet) to conducting cost-effective scientific surveys in the aftermath of mass disasters. The fourth chapter (Lewis & Bisson) provides a rare introduction to the health economics of web-based mental health interventions designed to mitigate the impact of trauma.

Section IV presents two very original examples of how the dissemination of information via the Internet is addressing increasingly sophisticated issues. The chapter by Kassam-Adams, Marsac, and Winston describes a site dedicated to parents whose children have been seriously injured (and who may or may not suffer from traumatic stress). The chapter by Josef Ruzek, Director of the Dissemination and Training Division of the National Center for Posttraumatic Stress Disorder (PTSD), explores an initiative designed to disseminate information to mental health practitioners on the best practices for the treatment of PTSD and engage them in adopting such practices.

In Section V, we explore the usefulness of online psychological self-evaluation in the aftermath of trauma. Vetter and Henley present a brief, Internet-based early intervention for injured patients who have been admitted to the emergency department and are at-risk for developing PTSD (Mouthaan, Sijibrandij, & Olff).

Section VI reviews the empirical results of a booming area, that of Internet-based psychotherapies (Andersson; Wagner & Maercker), which can take on a surprising number of forms, including virtual reality exposure therapy for the treatment of PTSD (Rothbaum, Josman, & Malcoun). This section closes with a chapter by Jeffrey Barnett that describes the ethical, clinical, and legal challenges related to providing mental health services online.

There is no doubt that, in the near future, the Internet will be increasingly used to conduct primary, secondary, and tertiary prevention in the area of traumatic stress in ways that we have yet to imagine. I hope the publication of this book will lead to the adoption of the online tools that already exist by an increasing number of mental health professionals, researchers, and policy planners, and foster further developments of this amazing invention.

The Internet has grown exponentially during the past 15 years, providing greater access to a wider and more diverse population than before. Because of this development, how people use the Internet to learn about and engage in mental health interventions has also changed, and the Internet now has the potential to be cost-effective, convenient, and reach a broader population than traditional face-to-face interventions. This chapter reviews and summarizes the past fifteen years of progress in online mental health, beginning with the major milestones in Internet history. As the Web took form and grew in popularity, mental health websites allowed people to share basic mental health information and their own personal stories with one another. The use of the Internet as a means for people to learn and share with one another has led to blogging, online self-help support groups, and online mental health interventions, such as personalized, interactive, cognitive-behavioral self-help programs and professional-led online therapy. Emerging uses of the Internet – including its use at disaster sites to help victims of trauma – are discussed, as well as the growth of Web 2.0 and Health 2.0 components.

Occasional national and international traumas and disasters may affect large numbers of people worldwide. Well-known incidents in the past decade include the death of Princess Diana, the tsunami in South-East Asia, Hurricane Katrina, the Pakistan-Kashmir earthquake, and the World Trade Center terror attack. In all these incidents, in addition to other, less publicized large-scale disasters, hundreds of millions people went through intense emotions of fear, panic, despair, depression, and anxiety. The Internet – through various channels of online communication – provided many of these people with an effective means of psychological relief. Research conducted on such mass traumas has documented the feasibility and effectiveness of Internet-assisted activities in helping people mentally survive the aftermath of such unusual circumstances. This chapter reviews these interesting research reports and identifies specific types and modalities characterizing the online provision of emotional relief. It is proposed to preemptively construct mass disaster-specific web portals that could be operated at times of need and provide numerous effective services. International organizations – such as the UN and its related agencies (e.g., UNICEF, UNESCO), NATO, the World Bank, the European Commission, Interpol, the Red Cross, and the World Health Organization – should consider the initiation and establishment of such institutionalized infrastructures to harness the Internet’s ability to meet a population’s psychological needs in the event of unpredicted mass-disaster incidents.

More and more people are using the Internet as a source of information on health and mental health issues. Assuring quality and preventing abuse of the medium for the provision of health and mental health information is an increasing concern. This can be particularly important for more at-risk populations, such as people with chronic diseases and mental health concerns. This chapter presents the current situation of the health and medical Internet usage and the actions that have been taken to improve the quality of medical and health information. The chapter will particularly describe the methodology used by Health On the Net Foundation (HON), an international organization that has been certifying medical websites since the beginning of the Internet era. HON’s goal is to guide healthcare consumers and providers on the Internet to sound and reliable medical information. By certifying sites that adhere to its eight ethical guidelines (the HON Code), HON seeks to contribute to better, more accessible healthcare. HON certification is free and thereby available to all, and not subject to conflict of interest concerns that can arise from client-provider relationships. The HON code provides a transparent, flexible, accessible, and reliable methodology that promotes and improves the quality of medical websites worldwide. The success of the HON Code attests to its growing importance and the suitability of its methodology. More than 7,500 websites have been certified in 34 languages from 118 countries; 450 of these websites are related to mental health. In 2007, the French National Health Authority mandated that all health websites in France be certified by HON.

Especially at times of crisis, there is a generally unmet need to help people come to terms with their emotional responses and facilitate ongoing emotional support. Internet-based research, in particular, has tremendous potential to identify needs and provide immediate solace and opportunity for self-reflection. Our experience using the Internet to assess responses after the 9/11 terrorist attacks and that of other similar research will be presented. We highlight key findings in the areas of denial, changes in worldview, growth, and resilience to illustrate the main factors which are predictive of adaptation. Our Internet findings suggest that the ability to express and come to terms with trauma-related emotions, use of effective coping strategies, maintenance of a supportive social environment, and cognitive reorganization and meaning-making can reduce distress in the long run and may lead to higher well-being and posttraumatic growth. We illustrate how the virtual world of the Internet may offer these opportunities.

Social networking sites like Facebook (www.facebook.com) and Twitter (http://twitter.com) have become among the most popular sites on the Internet. People of all ages use them to talk about their lives and keep in touch with friends and acquaintances. In addition, when people have experienced a traumatic event, they often use these sites to seek out others who have had similar experiences, and to find support and information on posttraumatic stress disorder. In the direct aftermath of a disaster, such as the earthquake in Haiti in 2010, especially in the absence of functional telephone and television cables, these sites have been used by survivors to find immediate assistance and resources as well as to inform the rest of the world about what is happening. Mental health professionals have also begun to use such websites to give support to their patients or to network with colleagues from the same area. And so, in the study of the Internet in mental health, the importance of these social networking sites cannot be ignored.

The Internet is an ideal tool for gaining quick access to populations, sometimes even thousands of miles away, who have recently experienced a traumatic event. It is also a cost-effective and powerful tool that can be used to study the effects of trauma. However, although adapting trauma research for the Internet, particularly when using surveys, appears relatively straightforward, there are a number of methodological and technological issues that researchers need to be aware of to ensure that the survey runs smoothly and the data are useful. The purpose of this chapter is to highlight some of the methodological issues, including informed consent, confidentiality, and the representativeness of the sample, that should be considered when conducting studies on the Internet, particularly those involving trauma research. We also briefly discuss some of the technological aspects of conducting an Internet-based survey and highlight potential new applications for Internet-based research in the study of how trauma affects individuals.

Conducting methodologically rigorous, community epidemiologic studies of the outcomes of large-scale potentially traumatic events (PTEs) presents extraordinary challenges. The primary scientific and logistical challenges of conducting such studies, however, result primarily from the fundamental unpredictability of the exposures of interest (i.e., the fact that disasters typically occur with little or no warning). Most of the important design problems arise from two unavoidable factors: the necessarily observational nature of the studies, and the need for the studies to be implemented quickly. In this chapter, we describe how using the Internet can enhance the design of these studies, focusing on three critical design features: probability sampling; psychometrically sound assessment of outcomes and other postexposure factors; and the use of prospective, longitudinal designs. We also describe recently developed methods for conducting Internet-based community epidemiologic studies, including prerecruited participant panels and multiple mode designs. We conclude that the Internet can be a valuable tool in conducting these studies, but that it will not be feasible as an assessment mode for some kinds of PTEs. Rather, Internet-based assessment is best understood as one of many tools that investigators will need in their tool kit for conducting scientifically sound, cost-efficient community epidemiologic studies of outcomes associated with large-scale PTEs.

Web-based mental health interventions have been developed with the aim of reaching a large population of people cost-effectively. An understanding of the principles underlying health economics is therefore essential to those designing, implementing, and delivering web-based interventions. This chapter describes what is meant by health economics, provides instruction on how to carry out an economic evaluation, and reviews existing evidence for the cost-effectiveness of web-based interventions aimed at mitigating the effects of trauma.

Injury is a common experience for children worldwide. Over 80% of children develop some traumatic stress symptoms in the month following injury. Regardless of injury severity, 15 to 20% of injured children develop persistent and impairing posttraumatic stress symptoms (PTSS), including 5 to 10% who develop posttraumatic stress disorder (PTSD). (Similar rates of symptoms are observed in the parents of injured children.) PTSS are a key predictor of child functional outcomes post-injury. Parents are the most important resource for acutely injured children, and yet are often unaware of how best to help their child. The Internet can provide easily accessible and quick information and tools to a wide range of parents of injured children. This chapter describes the development process for the After the Injury website (www.aftertheinjury.org) from concept to execution, including initial efforts to evaluate the website’s utility and acceptability to parents. After the Injury aims to prevent persistent PTSS and PTSD through a web-based information and psychoeducational intervention. The development of this site highlights several important principles: 1) selecting evidence-informed objectives and content; 2) utilizing user-centered design to guide the site’s look, design, and functionality, and help ensure parent engagement; and 3) incorporating evaluation throughout the process of site development and implementation.

The task of assisting health and mental health providers to deliver care for trauma survivors in ways that are consistent with current understanding of best practices in posttraumatic stress disorder assessment and treatment is an important public health priority. However, these providers face significant challenges in learning evidence-based interventions, keeping their knowledge current, and locating resources useful to their work. The Internet can provide a crucial element of more comprehensive training in empirically-supported practices and offer a useful means of shaping provider behavior and ensuring delivery of best practices. Dissemination is aided by effective training, ongoing consultation and coaching, monitoring of implementation, facilitative administrative support, and systems interventions; and the Internet can be used, to a greater or lesser extent, to support these various aspects of systematic implementation and knowledge management. Online training methods can offer many of the components of effective training, achieve some important instructional goals, and increase the cost-effectiveness and efficiency of in-person training. In addition, websites can support communities of practice, assist with preparation for dissemination projects, facilitate measurement of practitioner needs, preferences, and practices, make evidence-based practices easier to use, create better-informed clients, and enable clinicians and managers to more rapidly and efficiently locate the information they require.

An Internet-based self-screening instrument for assessing psychological stress reactions was created in the aftermath of the 2004 tsunami affecting the countries around the Indian Ocean. Named the Online Self Evaluation Tool (ONSET), it permitted any affected subjects to self-evaluate whether further clinical assessment by trained mental health professionals was needed. This chapter outlines all experiences and existing scientific evidence guiding the development of ONSET, reports the results of the use of this instrument for the tsunami victims, and discusses why early screening after disasters is important. From the entire sample of ONSET users, 45% of respondents reported possible posttraumatic stress disorder symptoms, 24% reported possible depression, 19% potentially had anxiety disorders, and 27% reported an increased use of psychotropic substances. Additionally, a total of 18% of ONSET users reported experiencing suicide ideations. Findings support the recommendation that future research on mental health issues should put more emphasis on the importance of early monitoring and assessment to detect early PTSD and other reactions in the wake of natural disasters.

The Internet has proven to be an effective medium for delivering curative interventions for a range of psychological disorders, including posttraumatic stress disorder (PTSD). For the prevention of PTSD, e-health solutions have so far been scarce, even though the interactivity and accessibility of the Internet medium could be extremely beneficial in offering these types of interventions early after trauma. In this article, we present Trauma TIPS, our interactive e-health intervention for an injured trauma population. Trauma TIPS is aimed at the reduction of acute distress and acute arousal resulting from a traumatic injury, and the prevention of long-term symptoms of PTSD. In the six steps of the program, several cognitive behavioural techniques are presented including: psychoeducation, modeling, relaxation and in vivo exposure, and the use of various audiovisual features. The main emphasis is placed on the patient building resilience after traumatic injury and regaining control over his or her life. Since most single-session interventions that were offered to victims of psychological trauma have shown to be ineffective or are even associated with an increased risk for symptoms of PTSD, we considered that careful testing of this treatment’s efficacy is warranted. Currently, a randomised controlled trial is being carried out to test the efficacy of Trauma TIPS.

More than half of a given population will be exposed to a traumatic event in their lifetime, and, although most individuals will recover on their own, a salient minority will go on to develop posttraumatic stress disorder (PTSD) or other serious threats to wellness and quality of life. Without treatment, PTSD tends to be chronic, and is associated with considerable personal and public health costs. Unfortunately, most individuals with PTSD do not get the care they need because there are a variety of barriers to treatment-seeking (e.g., stigma) and treatment access, including a shortage of well-trained professionals, a scarcity of professionals who provide evidence-based treatment, and the unavailability of expert care outside of city centers. In this chapter, we review the key challenges associated with providing evidence-based treatment to individuals who have experienced trauma, and highlight ways in which Internet-based approaches can be used to overcome these challenges. Next, we describe several existing Internet-based treatment programs for PTSD, and the efficacy of these treatments. Last, we suggest some important considerations for future research that may impact the effectiveness of Internet-based treatments for PTSD.

Several independent research groups have adapted cognitive behavioral treatments for anxiety disorders in order to deliver them via the Internet. These include treatments for posttraumatic stress disorder (PTSD), panic disorder, social phobia, and generalized anxiety disorder. In this chapter, the evidence from several randomized controlled trials is reviewed. Overall, findings suggest that Internet-delivered treatments are effective when minimal therapist support is provided via e-mail or telephone. In addition, effects tend to be close to or equivalent to face-to-face treatments. A recent development in the field of Internet treatment is to use a tailored approach in which patients are prescribed a treatment program according to their clinical profile as assessed in a structured psychiatric interview. Preliminary findings of such an approach show promising outcomes. This development may be fruitful in the treatment of PTSD as comorbidity between the different anxiety disorders is common.

In the last decade, psychological treatment for posttraumatic stress disorder (PTSD) has become available over the Internet. An Internet-based therapy for trauma victims (Interapy) that combines manual-based cognitive behavioral writing therapy with Internet technology has been pioneered. Three randomized controlled studies have shown that Interapy is effective, producing large reductions in symptoms of PTSD. This chapter describes the treatment rationale, presents individual treatment modules, and discusses specific aspects of the online therapeutic relationship. Finally, it presents Ilajnafsy, a culturally adapted version of Interapy for PTSD patients in Iraq.

Posttraumatic Stress Disorder (PTSD) is a chronic, debilitating, psychological condition that occurs in a subset of individuals who experience or witness life-threatening traumatic events. This chapter describes the underlying theoretical foundations and existing research on virtual reality exposure therapy (VRE), a recently emerging treatment for PTSD. Three virtual reality scenarios used to treat PTSD in combat veterans and survivors of terrorism – Virtual Vietnam, Virtual Iraq, and BusWorld – are presented, along with a case study of an individual treated using BusWorld. The future of VRE and its potential for use with telemedicine and the Internet for treatment of PTSD are also discussed.

As the use of the Internet increases worldwide, mental health services are frequently being accessed on this medium. In addition, more Internet media are being used for establishing and maintaining relationships and as a primary and timely means of communication. Following a review of the history and range of various technologies used for mental health services, the role of the Internet in the provision of these services is described in lights of its clinical, ethical, and legal challenges and implications. Also discussed are the opportunities that arise as a result of the unique features of the Internet such as ease and speed of access, and the application of various Internet technologies to natural disasters and emergency situations. The significant potential of the Internet for enhancing the ability to more rapidly respond to these situations is introduced. Implications for the future of the Internet in the provision of mental health services and for responding to emergencies and natural disasters are addressed.