Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans: Quasi-experimental Comparison Study

Abstract

Background Blended models of therapy, which incorporate elements of both internet and face-to-face methods, have been shown to be effective, but therapists and patients have expressed concerns that fewer face-to-face therapy sessions than self-guided internet sessions may be associated with lower therapeutic alliance, lower program completion rates, and poorer outcomes. Objective A multisite quasi-experimental comparison study with a noninferiority design implemented in routine clinical care was used to assess webSTAIR, a 10-module blended therapy derived from STAIR (skills training in affective and interpersonal regulation) for trauma-exposed individuals delivered with 10 weekly therapist sessions (termed Coach10) compared to 5 biweekly sessions (Coach5). It was hypothesized that Coach5 would be as good as Coach10 in a range of outcomes. Methods A total of 202 veterans were enrolled in the study with 101 assigned to Coach5 and 101 to Coach10. Posttraumatic stress disorder (PTSD) symptoms, depression, emotion regulation, interpersonal problems, and social functioning measures were collected pre-, mid-, and posttreatment, and at a 3-month follow-up. Noninferiority analyses were conducted on symptom outcome measures. Comparisons were made of continuous and categorical measures regarding participant and therapist activities. Results Participants reported moderate to severe levels of baseline PTSD, depression, or both. Significant reductions were obtained in all symptom measures posttreatment and at the 3-month follow up. Coach5 was not inferior to Coach10 in any outcome. Therapeutic alliance was at an equivalently high level across the 2 treatment conditions; completion rates and web usage were similar. Total session time was substantially less for the Coach5 therapists than the Coach10 therapists. Both programs were associated with a low, but equal number of therapist activities related to scheduling and crisis or motivational sessions. Conclusions A blended model delivered with 5 sessions of therapist support was noninferior to 10 sessions in individuals with moderate to severe symptoms. Future studies identifying patient characteristics as moderators of outcomes with high versus low doses of therapist support will help create flexible, technology-based intervention programming.

Supporting equitable engagement and retention of women patients in a trauma-informed virtual mental health intervention: Acceptability and needed adaptations.

“…Data for this study were drawn from the comparative webSTAIR trial (Cloitre et al, 2022). All coaches were VA-employed, licensed mental health staff (e.g., clinical psychologists, social workers), and trained in webSTAIR and the videoconferencing platform.…”

“…The comparative trial enrolled 202 veterans via clinical or self-referral from rural-serving VA facilities. Detailed webSTAIR eligibility and exclusion criteria were previously published (Cloitre et al, 2022). Fifty-nine women veterans completed baseline assessments and identified as belonging to at least one racial or ethnic minority group.…”

“…Two open trial studies reported significant symptom reduction from baseline to 3-month follow-up in PTSD and depression, and improvements in emotion regulation, social functioning, and interpersonal problems with large to moderate effect sizes across all outcomes (Bauer et al, 2021; Fletcher et al, 2021). A third trial assessed the impact of number of coaching sessions on treatment outcome (Cloitre et al, 2022). Veterans completed 10 modules independently supported by sessions with their coach over a videoconferencing platform.…”

STAIR und STAIR/NT zur Behandlung der Posttraumatischen Belastungssymptomatik: Ein systematischer Übersichtsartikel

“…In einer weiteren kontrollierten Studie wurden positive Effekte der STAIR-Adaptation vom Prä-zum Post-Messzeitpunkt in der Interventionsgruppe, nicht aber in der aktiven Kontrollbedingung gefunden (Gruppenunterschiede inferenzstatistisch nicht abgesichert) [Trappler und Newville, 2007]. Drei weitere kontrollierte Studien (eine davon an Jugendliche gerichtet) konnten keine Effekte von STAIR/-Adaptationen im Vergleich zu einer aktiven und einer passiven Kontrollbedingung sowie im Vergleich zu STAIR in internetbasierter Kurzform auf die PTB-Symptomatik feststellen [Gudiño et al, 2016;Tripodi et al, 2020;Cloitre et al, 2022]. [Weiss et al, 2018] berichtet, jedoch könnte die Präzision der Effektstärke aufgrund der nicht-signifikanten inferenzstatistischen Testung eingeschränkt sein.…”

“…Im Vergleich zu einer passiven Kontrollbedingung wurde ein mittlerer Effekt der STAIR-Adaptation auf die interpersonelle Problematik zum Post-Messzeitpunkt berichtet (d = 0,65 [KI nicht angegeben]) [Gudiño et al, 2016]. Im Vergleich zu aktiven Kontrollbedingungen zeigte sich sowohl ein großer Effekt vom Prä-zum 3-Monats-Folgemesszeitpunkt (g = 0,81 [KI nicht angegeben]) [Jain et al, 2020] wie auch ein Nulleffekt zum Post-Messzeitpunkt (d = 0,03 [KI nicht angegeben]) [Cloitre et al, 2022].…”