Internet-mediated, protocol-driven treatment of psychological dysfunction

Exploring the use of AI text-to-image generation to downregulate negative emotions in an expressive writing application

Conventional writing therapies are versatile, accessible and easy to facilitate online, but often require participants to self-disclose traumatic experiences. To make expressive writing therapies safer for online, unsupervised environments, we explored the use of text-to-image generation as a means to downregulate negative emotions during a fictional writing exercise. We developed a writing tool, StoryWriter, that uses Generative Adversarial Network models to generate artwork from users' narratives in real time. These images were intended to positively distract users from their negative emotions throughout the writing task. In this paper, we report the outcomes of two user studies: Study 1 (N = 388), which experimentally examined the efficacy of this application via negative versus neutral emotion induction and image generation versus no image generation control groups; and Study 2 (N = 54), which qualitatively examined open-ended feedback. Our results are heterogeneous: both studies suggested that StoryWriter somewhat contributed to improved emotion outcomes for participants with pre-existing negative emotions, but users' open-ended responses indicated that these outcomes may be adversely modulated by the generated images, which could undermine the therapeutic benefits of the writing task itself.

Patient evaluation of a smartphone application for telehealth care of opioid use disorder

Background

People with opioid use disorder (OUD) face barriers to entering and remaining in life-saving treatment (e.g., stigma, detrimental interactions with health care, and privacy concerns). Telehealth and related technology can reduce barriers to entering and staying in care. Patient feedback is critical to the development of these newer treatment approaches to ensure they are usable and do not inadvertently recreate treatment barriers.

Purpose

Evaluate the perceived usability of existing and planned features of a mobile application (app) that facilitates delivery of OUD treatment via telehealth.

Methods

People with current or prior experience with OUD treatment were eligible for the study. Participants (n = 31; 55% women) provided feedback on an interactive prototype demonstration via individual qualitative interviews and completed a quantitative survey on the app’s perceived usability. Descriptive statistics summarized the usability survey. We analyzed qualitative interview transcripts to elicit common themes.

Results

Participants were primarily white (77%) with a mean age of 42.2 years (range 22–69). Participants rated the six major features of the current app as helpful (median response 5 out of 5) and appreciated the flexibility of conducting a visit from a place of their choosing. Participants regarded the five proposed components of the app, such as daily affirmations and medication treatment-related reminders (e.g., pick up medication at pharmacy, medication schedule), as useful features with medians 5 out of 5, and reported they would recommend the app to others for OUD care. Participant qualitative interviews provided additional information on perceived usability of existing and proposed app features.

Conclusion

Our study suggests that an appealing, easy-to-use app—with tools and features that effectively support care—could circumvent existing barriers and foster sustained recovery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00331-4.

Psychotherapists' perception of their clinical skills and in-session feelings in live therapy versus online therapy during the COVID-19 pandemic: a pilot study

During the coronavirus disease 2019 (COVID-19) pandemic, many psychotherapists who were used to seeing their patients in face-toface setting adapted to providing therapies online. In the present pilot study, we investigated therapist current experiences of online therapy compared to live therapy. Twenty-nine therapists completed Clinical Skills, Difficulties in Practice, and in-sessions feelings of Flow, Boredom and Anxiety of the Trainee Current Progress Report, giving a score for each item in two different conditions: Live Therapy and Online Therapy. Compared to Live Therapy, in Online Therapy therapists reported significantly less Clinical Skills, whereas Difficulties in Practice did not differ in the considered conditions. With regard to in-sessions feeling, therapists reported significantly lower scores of Boring and higher scores of Flow in Live Therapy compared to Online Therapy, whereas Anxiety did not differed in the considered conditions.

A qualitative study exploring the experience of psychotherapists working with birth trauma

As many as 45% of women experience birth trauma. Psychotherapists' knowledgeable insights are largely absent in literature, and therefore the objective of this research is to gain a comprehensive understanding of how psychotherapists in the UK experience the therapeutic process when working with women who have experienced a traumatic birth. Interpretive Phenomenological Analysis (IPA) was employed to examine the data coming from psychotherapists working with birth trauma. Three ostensible areas of focus were revealed: i) Hearing the story: discovering the altered-self, ii) Working with the story: enabling redemption of the altered-self, and iii) Professional challenges and the wider story: advocating for the altered-self. Birth trauma commonly leads to an altered sense of self, intertwined with a perception of loss regarding the birth experience and autonomy. Working with the client's birth story, to enable redemption and restore reasoning, is integral to the therapeutic process. Stabilisation and consideration of the presence of the baby are also significant. Integrating approaches produces positive outcomes. There is a purported gap in NHS services, professionals either lacking knowledge and misdiagnosing, or being limited by the emphasis placed on Cognitive Behavioural Therapy. For the therapeutic process consider: the sense of loss associated with the birth; working with the client's birth story to enable redemption and restore reasoning; the impact of the presence of the baby and the need for stabilisation; birth trauma as unique. For frontline health professionals: implementing existing screening protocols and undergoing training to recognise birth trauma may reduce misdiagnosis.

Peeling Back the Layers: How Expressive Writing about Heterosexist Events Benefits Sexual Minority Adults

Expressive writing exercises, in which participants self-reflect upon a difficult experience, are widely researched interventions. These exercises have been adapted to address a host of concerns, including trauma, mental distress, physical health, and minority stress. Although several theories exist about the mechanisms through which expressive writing yields psychological benefits, the direct perspectives of those who have completed expressive writing exercise has remained unexplored. This study used grounded theory methods to analyze sexual minority adults' interviews about their experience of engaging in various formats of expressive writing exercises about personal heterosexist events. Participants described both what they found helpful and frustrating about the writing process and reflected on how their perspectives shifted throughout the process. These findings contribute to the literature on how change occurs in expressive writing and provide guidance on how to assist sexual minority adults in healing from heterosexism in their lives.

Linguistic Markers of the Emotion Elaboration Surrounding the Confinement Period in the Italian Epicenter of COVID-19 Outbreak

The expressive writing method has rarely been proposed in contexts of large-scale upheavals that affect large populations. In this study this method was applied as an intervention and tool of investigation during the confinement period in the Lombardy region, the Italian Epicenter of COVID-19 outbreak. Sixty-four participants took part in an online expressive writing project, and a total of 167 writings were collected together with some self-report evaluations on emotions and physical sensations. A linguistic analysis through two different sets of computerized linguistic measures was conducted on the collected writings in order to study the linguistic markers of emotion regulation and elaboration. Results indicated that online expressive writing has helped respondents to get more in touch with the intense emotions that were experienced following the upheavals they witnessed. Writing even only once or twice helped, particularly those respondents who had at least one COVID-19 patient among close friends or relatives. Their writings showed an intense emotional involvement together with the ability to reflect and reorganize the personal meaning of the events and emotions experienced. This study shows that expressive writing can be used in the context of a psychological emergency, both as a powerful instrument to investigate and detect the complex psychodynamic processes underpinning the distress, and as a useful intervention to reduce the negative impact of traumatic events.

The efficacy of written exposure therapy versus imaginal exposure delivered online for posttraumatic stress disorder: Design of a randomized controlled trial in Veterans

Adapting evidence-based treatments for online delivery has potential to significantly increase the reach of effective care to Veterans with posttraumatic stress disorder (PTSD). This paper describes the rationale for and methods of a randomized controlled trial comparing the efficacy and efficiency of written exposure therapy versus imaginal exposure for PTSD delivered in a novel online and variable length format. Participants will be 300 Veterans seeking treatment for clinically significant symptoms of PTSD. Participants will be randomly assigned to either written exposure or imaginal exposure via verbal recounting and will complete between 4 and 8 online therapy sessions facilitated by trained peer support specialists. Treatment is terminated before session 8 if the PTSD symptom improvement criterion is met. Assessments will be conducted at baseline, post-treatment, and at 3-month follow-up. The primary hypotheses are that written exposure therapy will be noninferior to imaginal exposure with respect to treatment efficacy and efficiency. Secondary hypotheses relate to identifying and comparing potential mediators of PTSD treatment outcome, including trauma-related cognitions and emotion regulation.

Efficacy of Internet-Delivered Psychodynamic Therapy: Systematic Review and Meta-Analysis

Recent years have seen an increase of internet-delivered interventions based on psychodynamic treatment models. To test the efficacy of internet-delivered psychodynamic therapy (IPDT), we conducted a systematic review and meta-analysis of randomized controlled trials. Following literature searches, we identified seven studies meeting inclusion criteria. The total number of participants was 528 in the treatment group and 552 in the control conditions. We found small effects favoring IPDT compared to inactive control conditions for main outcomes (g = 0.44), depression (g = 0.46), anxiety (g = 0.20), and quality of life (g = 0.40). There was significant heterogeneity between studies for main outcomes and depression. Within-group effects ranged from Hedges's g = 0.32-0.99. The effects of IPDT were maintained or increased at follow-up. Study quality varied but was generally high. No indications of publication bias were found. In conclusion, IPDT is a promising treatment alternative, especially for depression, although the small number of studies limits the generalizability of the findings.

Off-hours use of a smartphone intervention to extend support for individuals with schizophrenia spectrum disorders recently discharged from a psychiatric hospital

INTRODUCTION

Technology-delivered healthcare interventions may enhance dissemination of evidence-based treatments in low-resource areas. These interventions may be accessed 'on-demand,' including after hours. Patients with schizophrenia do engage with technological aids but when/how they would utilize these tools is not known.

METHODS

We conducted a large, prospective, ten-site, longitudinal study of four technology-assisted interventions for patients with schizophrenia spectrum disorders within 60 days of psychiatric hospital discharge, a high risk period. One tool employed was a smartphone intervention called 'FOCUS,' which could be used by patients as needed, providing help in five content areas: medications, mood, social, sleep and voices. Each login was date- and time-stamped as occurring during normal clinic hours, or 'off-hours,' and the pattern of use described.

RESULTS

347 of 368 patients utilized FOCUS during the 6-month study. There were a total of 75,447 FOCUS logins; 35,739 (47.4%) were self-initiated and 38,139 (50.6%) were off-hours. 18,450 of the logins during off-hours were self-initiated (24.5%). No differences in average usage per month were found based on race/ethnicity. A subset of 'high utilizers' (n = 152, 43.8%) self-initiated use of all five FOCUS modules both on- and off-hours. They tended to be women, >35 years old, and had a high school diploma or greater.

CONCLUSION

Most patients with schizophrenia spectrum disorders recently discharged from the hospital utilized a smartphone intervention targeted to address troublesome residual symptoms. One quarter of the total smartphone utilization was self-initiated off-hours, indicating the potential utility of this tool to extend support for patients during periods of elevated risk.

Emotional and physical health benefits of expressive writing

Writing about traumatic, stressful or emotional events has been found to result in improvements in both physical and psychological health, in non-clinical and clinical populations. In the expressive writing paradigm, participants are asked to write about such events for 15–20 minutes on 3–5 occasions. Those who do so generally have significantly better physical and psychological outcomes compared with those who write about neutral topics. Here we present an overview of the expressive writing paradigm, outline populations for which it has been found to be beneficial and discuss possible mechanisms underlying the observed health benefits. In addition, we suggest how expressive writing can be used as a therapeutic tool for survivors of trauma and in psychiatric settings.

Evaluation of an internet-based aftercare program to improve vocational reintegration after inpatient medical rehabilitation: study protocol for a cluster-randomized controlled trial

Background

Mental disorders are the main reasons for rising proportions of premature pension in most high-income countries. Although inpatient medical rehabilitation has increasingly targeted work-related stress, there is still a lack of studies on the transfer of work-specific interventions into work contexts. Therefore, we plan to evaluate an online aftercare program aiming to improve vocational reintegration after medical rehabilitation.

Methods

Vocationally strained patients (n = 800) aged between 18 and 59 years with private internet access are recruited in psychosomatic, orthopedic and cardiovascular rehabilitation clinics in Germany. During inpatient rehabilitation, participants in stress management group training are cluster-randomized to the intervention or control group. The intervention group (n = 400) is offered an internet-based aftercare with weekly writing tasks and therapeutic feedback, a patient forum, a self-test and relaxation exercises. The control group (n = 400) obtains regular e-mail reminders with links to publicly accessible information about stress management and coping. Assessments are conducted at the beginning of inpatient rehabilitation, the end of inpatient rehabilitation, the end of aftercare, and 9 months later. The primary outcome is a risk score for premature pension, measured by a screening questionnaire at follow-up. Secondary outcome measures include level of vocational stress, physical and mental health, and work capacity at follow-up.

Discussion

We expect the intervention group to stabilize the improvements achieved during inpatient rehabilitation concerning stress management and coping, resulting in an improved vocational reintegration. The study protocol demonstrates the features of internet-based aftercare in rehabilitation.

Trial registration

International Standard Randomised Controlled Trial Number Register (ISRCTN:ISRCTN33957202)

Expressive writing and positive writing for participants with mood disorders: an online randomized controlled trial

INTRODUCTION

Expressive writing--writing about traumatic, stressful or emotional events--often leads to improvements in physical and psychological health in non-clinical and clinical populations. Recent studies have shown that positive writing may also be beneficial. Research has not yet investigated whether either expressive writing or positive writing offers benefits for people with mood disorders.

METHOD

Participants were recruited online and were randomly allocated to expressive writing, positive writing or control writing. The following questionnaires were completed online: Centre for Epidemiological Studies-Depression Scale (CES-D), Depression Anxiety Stress Scales (DASS), Pennebaker Inventory of Limbic Languidness (PILL), overall health questions, Temperament and Personality Questionnaire (TPQ) and COPE Inventory (COPE). Participants then wrote for 20 min on 4 occasions, and then completed follow-up questionnaires.

RESULTS

Linear mixed models with custom contrasts were conducted to assess differences between groups and over time. All 3 groups showed significant improvements over time on mental health and some physical health outcomes. There were no significant differences between groups and no significant group by time interactions. These results were not moderated by demographic factors, personality subtypes or coping styles.

CONCLUSION

The expressive writing, positive writing and time management control writing groups all reported significantly fewer mental and physical symptoms for at least 4 months post-writing. When expressive and positive writing groups were combined, the resulting `emotional writing group' showed significantly lower scores on the DASS stress subscale than the control writing group at all time-points. Potential reasons are discussed and areas of further study identified.

The effectiveness of telemental health applications: a review

OBJECTIVE

To review the evidence of benefit from use of telemental health (TMH) in studies that reported clinical or administrative outcomes.

METHOD

Relevant publications were identified through computerized literature searches using several electronic databases. Included for review were scientifically valid articles that described controlled studies, comparing TMH with a non-TMH alternative, and uncontrolled studies that had no fewer than 20 participants. Quality of the evidence was assessed with an approach that considers both study performance and study design. Judgments were made on whether further data were needed to establish each TMH application as suitable for routine clinical use.

RESULTS

Included in the review were 72 papers that described 65 clinical studies; 32 (49%) studies were of high or good quality. Quality of evidence was higher for Internet- and telephone-based interventions than for video conferencing approaches. There was evidence of success with TMH in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive-compulsive disorder were less convincing. Further study was judged to be necessary or desirable in 53 (82%) of the studies.

CONCLUSION

Evidence of benefit from TMH applications is encouraging, though still limited. There is a need for more good-quality studies on the use of TMH in routine care. The emerging use of Internet-based applications is an important development that deserves further evaluation.

E-mail: a new technique for forming a therapeutic alliance with high-risk young people failing to engage with mental health services? A case study

This article describes e-mail therapy with a teenager whom professionals found difficult to communicate with and understand. Anne had a 4-year history of low mood and unpredictable self-harming behaviour that in the past had led to admission to a secure unit. Therapy involved weekly e-mails over a 3-month period and ended when she was transferred to adult services. The article focuses on how e-mail enabled engagement to occur. The therapeutic relationship allowed Anne to explore and understand past experiences, and start resolving present problems. Diagnosis also became clearer.

What do young adults expect when they go online? Lessons for development of an STD/HIV and pregnancy prevention website

We used participatory research to develop a theoretically based online STD/HIV and pregnancy prevention intervention that would be entertaining and captivating for 15-25 year olds while delivering key messages about condom use. We conducted six focus groups with 15-25 year olds attending reproductive health clinics and completed a content analysis with focus group data. Youth had expectations that websites contain features such as graphics and flash technology. They would participate in research online if their confidentiality was assured and if they could receive an instant incentive. Limited access to high-end bandwidth capability requires use of compressed graphics and music to reach diverse audiences. Youth suggested approaches to frame role-model delivered messages about HIV/STD and pregnancy risk, condom attitudes, norms and self-efficacy for negotiation. These data allowed for development of a dynamic, interactive and relatively low bandwidth site that retains fidelity to key theoretical constructs in STD/HIV and pregnancy prevention.

Online therapy for addictive behaviors

Clinicians working in the field of addictive behaviors cannot afford to ignore the Internet. Psychological advice, help, and treatment for addicts are no exceptions, with both counseling and psychotherapy entering the computer age. This paper reviews the main issues in the area and approaches the discussion acknowledging that online therapy has to be incorporated within the overall framework of the need for clinical assistance. The paper also provides brief overviews of some websites as illustrative examples of what types of online therapy are available.

Interapy: treatment of post-traumatic stress via the internet

This paper describes the theoretical background and procedures (including psycho-education, screening, treatment protocol and outcome measurement) involved in a protocol-driven internet treatment of post-traumatic stress and grief in a group of people who have suffered from mild to relatively severe trauma. The paper examines the results of 3 outcome and process studies, which were carried out initially in a student population and subsequently in the general population of highly traumatized people. In the latter study, participants in the experimental condition (n = 69) improved significantly more than participants in the waiting list control condition (n = 32), with respect to trauma-related symptoms and general psychopathology. The effect sizes were large. More than 50% of the participants treated showed reliable change and clinically significant improvement after treatment for avoidance and depression. Treatment proved most beneficial for participants who had suffered from intentional trauma and those who had not previously discussed the traumatic events with significant others. Content analysis of the publications indicates a remarkable increase in cognitive coping during treatment. The possibilities for future research into internet-driven treatment of post-traumatic stress symptomatology are discussed, including the proposal to study the effects of sending a final written letter to a significant other person.

Technological innovations in clinical assessment and psychotherapy

In this paper the application of computer technology and the use of the Internet in mental health care are critically reviewed. A number of on-line screening devices have been developed for anxiety disorders, mood disorders, and substance abuse disorders, with great potential for clinical practice. On line assessment is generally equivalent to clinical assessment. A number of studies have shown that self-help treatment programmes on stand-alone computers are as effective as routine clinical care. The Internet enhances the therapeutic possibilities of computers by offering feedback of therapists and more tailor-made treatment. A number of randomized clinical trials (RCTs) have shown that Internet-based treatment is more effective than no-treatment and as effective as face-to-face treatment. Research so far has been limited to anxiety disorders, burn-out, depression, headache, insomnia, tinnitus and obesity. Further, exposure through virtual reality has been found effective in a number of RCTs in specific phobias, but results with respect to the effects of the use of virtual reality techniques to other disorders are inconclusive. It is concluded that computer-driven assessment and treatment has many advantages and few disadvantages. A number of reasons are discussed which will preclude large-scale implementation of computer-driven assessment and therapy in the near future.

Internet-Based Mental Health Interventions

Following recent reviews of community- and practice-based mental health interventions, an assessment of Internet-based interventions is provided. Although relatively new, many Internet mental health interventions have reported early results that are promising. Both therapist-led as well as self-directed online therapies indicate significant alleviation of disorder-related symptomatology. The number of studies addressing child disorders lags behind those of adults. More research is needed to address methodological issues of Internet-based treatments.

A meta-analysis of the effects of written emotional disclosure on the health outcomes of clinical populations

A meta-analysis was conducted to examine the effects of the written emotional disclosure paradigm on health outcomes of people with physical or psychiatric disorders. After nine studies were meta-analyzed, it was determined that expressive writing significantly improved health (d = .19; p < .05). However, this positive relationship (r = .10) was not moderated by any systemic variables because of the nonsignificant test of homogeneity (Qw = 5.27; p = .73). Nonetheless, a planned contrast illustrated that expressive writing is more effective on physical (d = .21; p = .01) than on psychological (d = .07; p = .17) health outcomes (Qb > 10.83; p < .001). One explanation for the small effect size (ES) results and the nonsignificant test of homogeneity may be the small and heterogeneous samples used in some of the studies within this research synthesis. Future research with expressive writing should be tested with randomized controlled trials to increase the likelihood of detecting a larger treatment effect.

Interapy: A controlled randomized trial of the standardized treatment of posttraumatic stress through the internet

Online therapy offers many advantages over face-to-face therapy. Interapy includes psychoeducation, screening, effect measures, and a protocol-driven treatment via the Internet for people suffering from posttraumatic stress. The present article reports the results of a controlled trial on the Internet-driven treatment of posttraumatic stress and grief in a group of people who manifested mild to relatively severe trauma symptoms. Participants in the treatment condition (n=69) improved significantly more than participants in the waiting-list control condition (n=32) on trauma-related symptoms and general psychopathology. The effect sizes were large. On most subscales, more than 50% of the treated participants showed reliable change and clinically significant improvement, with the highest percentages being found for depression and avoidance.