November 9, 2012 copyright prof. dr. a. lange 2. Anita, 5 year later. Part I. November 9, 2012 copyright prof. dr. a. lange 4

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1 The International Congress Child Abuse and Neglect Prof. dr Alfred Lange Trauma & Health Research and Dilemmas in online treatment of sexually abused adolescents 18 years old Anita Repeated rape neigbourhood gang No disclosure to parents, relatives and friends Stopped after leaving school / moved to other city Symptoms: Somatic Anxiety Low self- esteem DifGiculty relating to friends November 9, 2012 copyright prof. dr. a. lange 1 November 9, 2012 copyright prof. dr. a. lange 2 Anita, 5 year later Living with boyfriend, John John applies for couple therapy Assessment: administration VST: (Childhood Unwanted Sexual Events) Sexual problems Groucho Marx Syndrom No intercourse possible Part I De VST / Chuse Measure of severity 20 situations increase threatening sexual experiences Part II maximum 3 situations multiple choice questions + explanation responsibility reactions others degree guilt feeling Lange, A. (2004). Vragenlijst Seksuele Trauma's in het Verleden, VST-V. Een anamnestisch instrument voor onderzoek en praktijk. Verantwoording en handleiding (Childhood Unwanted Sexual Experiences, CHUSE). Houten: Bohn Stafleu van Loghum. November 9, 2012 copyright prof. dr. a. lange 3 November 9, 2012 copyright prof. dr. a. lange 4 Severity of sexual trauma and psychopathology Sample of Dutch female population: N = 400 Respondents of sexual unwanted sexual events High response rate Main Gindings: Strong association severity of sexual abuse & psychopathology Main mediating variables No disclosure Degree of responsibility and guilt Problems involving abused adolescents Low rate of disclosure Difficult to engage Pathology related to non-disclosure Need to lower threshold >> online treatment Lange, A.,Beurs, E. de, et al. (1999). Long-term effects of childhood sexual abuse: objective and subjective characteristics of the abuse and psychopathology in later life. Journal of Nervous and Mental Disease, 187(3), Hanneke de Graaf e.a. (2005). SEKS ONDER JE 25e. Seksuele gezondheid van jongeren in Nederland. Eburon, 254 blz November 9, 2012 copyright prof. dr. a. lange 5 November 9, 2012 copyright prof. dr. a. lange 6 1

2 In this presentation Key elements of trauma View general concepts of trauma and treatment Overview protocol online PTSD- treatment: adults Outcome in general population Special adjustments for sexually abused youngsters Outcome of treatment sexual abused adolescents Problems encountered Parental consent & anonimity Ethical Dilemma s Intrusions Avoidance Hyperactivity Secundary: Depression Anxiety November 9, 2012 copyright prof. dr. a. lange 7 November 9, 2012 copyright prof. dr. a. lange 8 Main elements of PTSD treatment Imaginary exposure / self confrontation face- to- face writing assignments Cognitive Reappraisal Social Sharing Take leave ritual Online treatment: From self- help to guided protocols a. Self help / chat: small effects b. Protocolled standardized treatments c. Minimal guidance: medium effects d. Step by step treatment: medium to large effect Lange, A. (2006). Gedragsverandering in gezinnen (Behavioral change within the family; cognitive behavioral- and system therapy). Noordhoff publishers. (650 pg) November 9, 2012 copyright prof. dr. a. lange 9 November 9, 2012 copyright prof. dr. a. lange 10 Structured evidence-based protocols Online Interapy treatment general features Explanation > assignments > feedback >. No but highly protected website Feedback within 1 working day Online screening Acceptance / rejection within hours Direct referral Outcome criteria: Validated and normated self-report questionnaires Behavioral tests pré-post-follow ups November 9, 2012 copyright prof. dr. a. lange 11 Transparancy The general treatment principles Clients keep record of the process and products Integrity of the treatment Active role of patient Awareness: monitoring and writing Self-confrontation Cognitive reappraisal Emphasis on motivating, & self-esteem, therapeutic relationship Power of behavioral change Power of support & compliments Power of increasing socials skills Relapse preventation: toolkit November 9, 2012 copyright prof. dr. a. lange 12 2

3 General exclusion criteria Extreme psychopathology Psychosis Dissociation Suicidality Bipolarity Medication Neuroleptica Hard drugs / severe alcohol abuse Another prevailing disorder Age: < 16 year Psychosis List, PL Somatic Dissociation Questionnaire,SDQ Suicide-Risk-List November 9, 2012 copyright prof. dr. a. lange 13 Interapy based trauma studies Randomized Controlled trials Between effects Intention-to treat analyses Primary and secundary measures Long-term follow-ups Virtual Clinic: routine outcome Lange, A., Rietdijk, e.a. (2003). INTERAPY. A controlled randomized trial of the standardized treatment of posttraumatic stress through the Internet. Journal of Consulting and Clinical Psychology, 71(5), November 9, 2012 copyright prof. dr. a. lange 14 Study N Intrusion Avoidance Depression Anxiety Lange et al. (2001) Lange et al. (2003) Wagner et al. (2007) * Knaevelsrud et al.(2007) Kersting et al. (2011) * Knaevelsrud et al.subm) d <.2 no effect.2 < d <.5 weak effect.5 < d <.8 medium effect d >.8 large effect * Pathological Grief November 9, 2012 copyright prof. dr. a. lange 15 Meta-Analysis" Van Emmerik et al Controlled studies of writing therapy online and face-to-face Both are highly effective compared to control groups. Online at least as effective Emmerik et al. (in press). Writing therapy for posttraumatic stress: a meta-analysis. Psychotherapy and Psychosomatics. DOI: / November 9, 2012 copyright prof. dr. a. lange 16 Content Analyses Functional Coping Increase functional coping 4,5 10 most improved vs 10 least improved (out of n = 101) Blind raters Training raters Interrater reliabilities Criterion: Impact of Event Scale November 9, 2012 copyright prof. dr. a. lange ,5 3 2,5 2 1,5 1 0,5 0 essay 1 essay 3 essay 8 essay 10 Most improved Least improved F(3,54 = 40.1 P =.0000 Cohen s d = 3.3 Lange, A., Van de Ven, J-P., & Schrieken, B. (2003). Interapy: Treatment of Post-traumatic Stress via the Internet. Cognitive Behaviour Therapy, 32(3), November 9, 2012 copyright prof. dr. a. lange 18 3

4 Routine Clinical Practice 1500 patients Decrease in time Virtual clinical Same procedure as in trials, no control group Same measures: pre-post-follow-up 478 PTSD patients 361 completers 117 dropouts: 24% &" %#" %" $#" $" #" 78*(5+9,8" :;,9<=8>)" " '()*)+*" ',+-)+*"./0"1,22,3456" November 9, 2012 copyright prof. dr. a. lange 19 November 9, 2012 copyright prof. dr. a. lange 20 Effects in clinic even better than in randomized trials Routine Practice" Satisfaction with treatment Feature Score SD Yes No Satisfaction with therapists (1-10) 8.5 1,5 Would recommend this online treatment Online treatment effective 90% 4 % 78 % 6 % Did you miss face- to-face contact? 29 % 61 % Ruwaard, J., Lange, A., Schrieken, B., Dolan, C.V. & Emmelkamp, P. (2012). The effectiveness of online cognitive behavioral treatment in routine clinical practice. PLoS ONE, 7(7): e doi: /journal.pone November 9, 2012 copyright prof. dr. a. lange 21 November 9, 2012 copyright prof. dr. a. lange 22 Back to the beginning Anita and other sexually abused adolescents Pilot study Rutgers Nisso" Group / Interapy Background: > 20% of youngsters (12-25 years) victims of sexual abuse Very few come into treatment Very often: no disclosure Aim of the project: creating and testing online treatment Based on Interapy protocol Uncontrolled Pilot Cooperation: Interapy / UvA (Psychology and Medical Faculty) November 9, 2012 copyright prof. dr. a. lange 23 November 9, 2012 copyright prof. dr. a. lange 24 4

5 Therapeutic procedure Adjustment in protocol S T A R T Screening Biographic data Informed Consent pretest Module 1 Self-confrontation Most painful elements 4 times writing 2 weeks Module 2 Somatic symptoms Info Monitoring Advice 1 week Module 3 Cognitive Reappraisal 4 times writing 2 weeks Adjustment in psycho-education Specific info-pages on specific topics Somatic issues Adjustment of language Dealing with anonimity Social sharing E X I T Worthy letter Posttest Evaluation Follow-up 2 times writing November 9, 2012 copyright prof. dr. a. lange 1 week 25 November 9, 2012 copyright prof. dr. a. lange 26 Specific exclusion criteria Recruitment / pré-treatment withdrawal pilot < 14 years Publicity Journals / TV 997 hits on the website 90 started screening > 18 years No parental consent No informed consent Ongoing incest 6 no inf. consent 8 females started treatment 30 excluded 7 completed treatment 46 stopped screening November 9, 2012 copyright prof. dr. a. lange 27 November 9, 2012 copyright prof. dr. a. lange 28 Measure pre - post Effect size Cohen s d Strength d = 1.4 Invalidation d = 1.2 The effects in the pilot Conclusions pilot a. ± 90% pré-treatment withdrawal (PTW) b. Probable causes Obligation to inform parents Biographical data PTSD symptoms (IES-Ch / SVL-K) d = 1.1 Depression d = 0.7 Satisfaction with therapists & treatment (1-10) Score 7-9 Understanding effect sizes d <.2 no effect.2 < d <.5 weak effect.5 < d <.8 medium effect d >.8 large effect November 9, 2012 copyright prof. dr. a. lange 29 For the treated participants: Only 1 dropout Very high positive effects De Haas, S., Höing, M., Schrieken, B., Tsagana, A., Wijnker, C., Michels, C., & Lange, A. (2009). Behandeling via het Internet voor jeugdige slachtoffers van seksueel geweld: een pilotstudie. Maandblad Geestelijke Volksgezondheid, 64 (11), November 9, 2012 copyright prof. dr. a. lange 30 5

6 Aims of the second study Changes Controlled study Reduction Pre Treatment Withdrawal Adjustment Design: from RCT to within controlled: Pre-test > screening > baseline > test > treatment > test Adjustment Screening: Only the most necessary biographical questions Biographical questions later in screening /dispersed Choice telephone interview / online chat Age of participants: November 9, 2012 copyright prof. dr. a. lange 31 November 9, 2012 copyright prof. dr. a. lange 32 Outcome measures Primary measures a. SVL Schokverwerkingslijst : intrusion / avoidance b. Monitoring after each module (1 10) Feeling strength Feeling invalidation c. Clinical Interview CIDI Secundary measure: Depression (subscale SCL-90) Flow chart of participation Application: n = 155 Not started: n = 37 Screening: n = 118 Screening withdrawal: n=40 Interview: n = 78 Excluded: n = 49 Included: n = 29 No Inf.Consent: n = 5 Baseline period: n = 24 No start treatment: n = 1 Treatment: n = 23 Treatment drop out: n = 4 Posttest: n = 24 No follow-up test: n =5 Follow-up 1 year: n = 19 November 9, 2012 copyright prof. dr. a. lange 33 November 9, 2012 copyright prof. dr. a. lange 34 Types of sexual intimidation Conclusions Screening Forced to undress Being touched Oral sex Rape Mostly one perpetrator Most many times 25 % pré-screening withdrawal Screening in 21 steps: 34% withdrawal 3 steps biographical questions 49% withdrawal during these 3 steps Age years: 87 % PTW started treatment, n = 1 Age years: 75% PTW started treatment, n = 4 Age years: 54% PTW started treatment, n = 19 November 9, 2012 copyright prof. dr. a. lange 35 November 9, 2012 copyright prof. dr. a. lange 36 6

7 Conclusions PTW Total PTW: 77 % Crucial: parental consent and anonimity Total treatment dropout: 16% Drop out from posttest 0 % November 9, 2012 copyright prof. dr. a. lange 37 Depression SCL-90 Invalidation 1-10 Strength 1-10 Effects of treatment Screening Pré Baseline Interpretation effect size Cohen s d: d <.2 no effect.2 < d <.5 weak effect.5 < d <.8 medium effect d >.8 large effect End Baseline End Treatment Follow up 1 year M M M d M d M d November 9, 2012 copyright prof. dr. a. lange 38 Repeated Measures Clinical change Time After baseline periode 17 % clinical recovered After treatment 71 % clinically recovered Follow- up year later 68 % clinically recovered CIDI, diagnostic interview before treatment 79 % PTSD CIDI, after one year 14 % PTSD November 9, 2012 copyright prof. dr. a. lange 39 November 9, 2012 copyright prof. dr. a. lange 40 Evaluation by participants Feature Score % Yes Satisfaction with treatment modules (1-10) Stage 1: Exposure 8.1 Stage 2: Body 6.7 Stage 3: Cognitive Reappraisal 7.3 Stage 4: Social sharing, take leave 6.8 Satisfaction with therapist (1-10) 8.6 Missed face-to-face contact 22% Find Internet treatment effective 87 % Will recommend the treatment to others 91% Summary findings Large Pre- treatment withdrawal Extremely high committment during and satisfaction during treatment Extremely large and lasting effects Adjustment in design and screening worked: PTW down to 77%) General online treatment: PTW ± 50% Lange, A., & Ruwaard, J. (2010). Ethical Dilemmas in online research & treatment of sexual abused adolescents. Journal of Medical Internet Resrearch, 12 (2010): e58 November 9, 2012 copyright prof. dr. a. lange 41 November 9, 2012 copyright prof. dr. a. lange 42 7

8 Dilemma s May PTW be lowered further? To which price? No parental consent? Providing full anonimity? Provide self- help format instead of therapy- format? Some propositions Do not refrain totally from identigication but use few as possible biographical questions Might lower the threshold, but.. Might be dangerous / irresponsible Damages scientigic studies Obtain dispensation for parental consent in specigic populations Involve trust- persons November 9, 2012 copyright prof. dr. a. lange 43 November 9, 2012 copyright prof. dr. a. lange 44 Final reflection Sexual abuse exists world-wide. Therapists, medics, social workers should focus on situations and circumstances in which they have a chance to succeed. Even if this only helps part of the victims. The studies we discussed give rise to optimism since their tools show surprisingly strong positive effects in the participants. Let us continue to improve these protocols. Let us try to interest authorities to make use of them and make them available to as many victims as possible, without compromising our clinical and scientific integrity. Time for discussion and questions November 9, 2012 copyright prof. dr. a. lange 45 November 9, 2012 copyright prof. dr. a. lange 46 References Lange, A. (2006). Gedragsverandering in gezinnen (Behavioral change within the family; cognitive behavioral- and system therapy). Groningen: Groningen: Noordhoff publishers. (650 pag.) Lange, A. (2004). Vragenlijst Seksuele Trauma's in het Verleden, VST- V. Een anamnestisch instrument voor onderzoek en praktijk. Verantwoording en handleiding (Childhood Unwanted Sexual Experiences, CHUSE). Houten: Bohn StaGleu van Loghum. Spence, J., Titov, N e.a. (2011). Randomied controlled trial of internet delivered cognitive behavioral therapy for posttraumatic stress disorder. Depression and anxiety, 28, Wagner, C. Knaevelsrud, and A. Maercker, Internet- based cognitive- behavioral therapy for complicated grief: a randomized controlled trial. Death Studies 30 (2006): C. Knaevelsrud and A. Maercker, Internet- based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC Psychiatry 7 (2007): 13. November 9, 2012 copyright prof. dr. a. lange 47 References " Lange, A., Ruwaard, J., Schrieken, B., de Haas, S., Broeksteeg, J., Renteria Agirre, A., & Kuyper, A. (2011). Online behandeling van seksueel misbruikte adolescenten: Ethische dilemma's en resultaten van een geprotocolleerde trial. Directieve Therapie, 31(3), Lange, A., & Ruwaard, J. (2010). Ethical Dilemmas in online research & treatment of sexually abused adolescents. Journal of Medical Internet Resrearch, 12 (2010): e58 Lange, A., Rietdijk, e.a. (2003). INTERAPY. A controlled randomized trial of the standardized treatment of posttraumatic stress through the Internet. Journal of Consulting and Clinical Psychology, 71(5), Lange, A., Van de Ven, J- P., & Schrieken, B. (2003). Interapy: Treatment of Post- traumatic Stress via the Internet. Cognitive Behaviour Therapy, 32(3), Ruwaard, J., Lange, A., Schrieken, B., Dolan, C.V., & Emmelkamp, P. (2012). The effectiveness of online cognitive behavioral treatment in routine clinical practice. PLoS ONE 7(7): e doi: /journal.pone [ full- text article at journal site ] Lange, A.,Beurs, E. de, Dolan, C., Lachnit, T., Sjollema, S., & Hanewald, G. (1999). Long- term effects of childhood sexual abuse: objective and subjective characteristics of the abuse and psychopathology in later life. Journal of Nervous and Mental Disease, 187(3), November 9, 2012 copyright prof. dr. a. lange 48 8