The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 4
4 - Usable
The intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components
Core Components
Guided internet-based CBT with Trauma Focus (i-CBT-T) interventions are CBT-T interventions delivered online for the treatment of PTSD and related conditions in adults. These interventions do not deviate from traditional CBT-T content, hence, they integrate cognitive techniques with behavioural elements that include exposure therapy.
Like the face-to-face CBT-T therapies, the core components of guided i-CBT-T interventions can include;
1) Psychoeducation to provide education about common responses to trauma. This helps patients conceptualise their symptoms as common cognitive and behavioural responses to traumatic experiences. Psychoeducation also helps to enhance understanding of the cognitive model;
2) Stress management to teach patients skills to minimise physiological arousal and promote relaxation;
3) Cognitive restructuring to identify and challenge cognitive distortions and unhelpful thought patterns. These are intended to help patients readdress dysfunctional understanding of the trauma event and of themselves, and to achieve logical, healthy thought patterns; and
4) Exposure therapy involves controlled exposure to traumatic memory or trauma reminders, in order to help patients confront their fears, lessen distorted trauma associations, and reduce avoidance behaviours. Variations of exposure therapy include imaginal exposure (involving systematic, repeated exposure to the trauma memory), and in-vivo exposure (involving repeated engagement with triggers associated with the traumatic fear). The relative input of each of the CBT-T components (i.e. psychoeducation, stress management, cognitive restructuring and exposure therapy) differ with the form of CBT-T.
The main difference between guided i- CBT-T interventions and traditional CBT-T therapies lie in their methods of delivery. Guided i-CBT-T interventions are delivered online (using computers or mobile devices) in formats that include text, video files, audio files, interactive programmes, virtual reality and CBT applications. However, there are also variations in the duration of input from the therapist with remote delivery of CBT-T interventions aiming to reduce demands on therapist’s time. In the same vein, it aims to increase access of psychological therapies that would otherwise have been limited due to shortage of available therapists, patient’s attenuating circumstances, and insufficiencies in available resources for delivery of traditional face-to-face therapies.
Internet-based CBT interventions are reportedly associated with higher risks of discontinuation, partly credited to insufficiently formed therapeutic relationship and measures to mitigate this risk should be considered.
Fidelity
Therapists delivering guided i-CBT-T should be trained and receive ongoing supervision. i-CBT-T interventions should be delivered as per validated treatment manual, and the stipulated content and structure of the intervention should be adhered to in order to ensure consistency in delivery.
Modifiable Components
Guided i-CBT/T interventions are delivered with varying levels of therapist’s assistance. These include
1) Regular assistance from closely involved therapist who provides support with homework assignments (including review and feedback), and advice on how to progress through the treatment;
2) Light assistance from therapist that includes short programme introduction, and periodic check-ins (e.g. via emails or phone calls); and 3) Self-guided or self-help i-CBT-T interventions that require no therapist assistance (e.g. CBT applications like CPT coach, PTSD coach). Delivery methods can include text, telephone call, email, video files, audio files, encrypted website, interactive programmes, simulation technology, and CBT applications (e.g. PTSD coach). Duration of delivery of guided i-CBT-T interventions can vary with the treatment protocol used. In Randomised Controlled Trials (RCTs) that assessed the effectiveness of these interventions, delivery was over 5-14 weeks for therapist guided interventions.
Supports - Rating: 3
3 - Somewhat Supported
Some resources are available to support competency development or organisational development but not both
There is no specific funded NHS Scotland training to support the delivery of i-CBT-T.
Support for Organisation / Practice
Implementation Support
There is no current implementation support known in Scotland.
Start-up Costs
There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations. Other start-up costs for guided i-CBT-T will include costs of developing remotely accessed, stable and secure treatment platform. The platform should allow delivery of the CBT components, interaction with therapists (for therapist guided delivery), assignment of homework, and (if required) have online data collection capacities.
Building Staff Competency
Qualifications Required
Therapist guided internet-based CBT with Trauma Focus (i-CBT-T) interventions involve assistance from professionals who usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and will have completed recognised postgraduate training in CBT (PG Diploma, MSc or Doctoral level).
Training Requirements
Guided Internet-based CBT with Trauma Focus (i-CBT-T) interventions apply the standard principles of CBT and trauma processing. CBT-T training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland (link the names to the programme websites). Additional training in CBT-T is available through the NES Psychology Trauma and CAMHS workstreams.
Supervision Requirements
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). It is recommended that the supervisor has additional training in supervision of CBT-T (https://transformingpsychologicaltrauma.scot/resources/national-trauma-training-programme-online-resources-summary/).
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
Guided Internet-based CBT with Trauma Focus (i-CBT-T) interventions apply the standard principles of CBT and trauma processing and are therefore founded on the same theories that guide CBT-T interventions. These include;
- Emotional processing theory of PTSD poises that PTSD emerges from the development of a fear network in memory of the traumatic event, which in turn elicits avoidance and escape behaviours on exposure to reminders of the trauma. It proposes that enabling patients to repetitively face their traumatic memory and/or triggers would alter elements within the fear network, reduce distorted trauma associations and inhibit fear responses.
- Social cognitive theory of PTSD goes beyond the elicitation of fear networks. It also addresses the development of other related primary emotions (sadness, anger) that are a direct response to the trauma and secondary emotions (e.g. shame, guilt) that develop from misconstrued thoughts and interpretations of the trauma. Social cognitive theory of PTSD therefore focuses on cognitive content, cognitive interpretation and the effects of cognitive misinterpretation on emotions and behaviours.
- Ehlers and Clark (2000) cognitive model of PTSD which suggests that PTSD persists when individual’s processing of trauma produces a sense of serious, current threat. This sense of threat is believed to be a consequence of 1) exaggerated negative distortions of the trauma event, and 2) nature of the trauma memory. The sense of threat is subsequently maintained by 3) behavioural and cognitive coping strategies that are intended to mitigate it. This cognitive model therefore targets these three maintaining factors for PTSD in order to reduce the patient’s symptoms.
Therapist’s understanding of these theories facilitates more effective application of CBT-T treatment strategies.
Research Design & Number of Studies
Internet-based CBT with Trauma Focus (i-CBT-T)
Effectiveness of internet-based CBT with trauma focus (i-CBT-T) interventions (including therapist guided and self-guided/ self-help) in adults with PTSD diagnosis has been assessed in meta-analyses. Complete information on studies included in the meta-analyses, and detailed results from the meta-analyses can be found in the Cochrane Database of Systematic Reviews (Lewis et al, 2018) https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011710.pub2/full
Outcomes achieved for i-CBT-T
Eight Randomised Controlled Trials (RCTs) compared i-CBT-T to wait-list control or treatment as usual. The following outcomes were observed;
- Significantly reduced PTSD symptoms at post-treatment
- Significantly reduced symptoms of depression and anxiety at post-treatment and for follow-up less than 6-months
- Significantly improved quality of life at post-treatment
Therapist guided i-CBT-T interventions
With specific focus on therapist guided i-CBT-T interventions, the best available evidence in adults with PTSD diagnosis comes from five Randomised Controlled Trials (RCTs). The first study included 80 male and female US war Veterans (Engel et al, 2015). The second study included 62 Swedish adults (18 years and older). The third study included 159 war-traumatized Arab patients (Knaevelsrud et al, 2015). The fourth study included 42 adults (18 years and older) in Wales (Lewis et al, 2017). The fifth study included 42 adult (18 years and older) Australian residents (Spence et al, 2011).
Outcomes achieved for therapist guided i-CBT/T interventions
Compared to wait-list control or treatment as usual, the following outcomes were observed;
- Significantly reduced PTSD symptoms at post-treatment (Lewis et al, 2017; Engel et al, 2015; Knaevelsrud et al, 2015; Ivarsson et al, 2014, Spence et al, 2011), sustained at 1-month follow-up (Lewis et al, 2107), 3-months follow-up (Engel et al, 2015; Knaevelsrud et al, 2015; Spence et al, 2011), and 1-year follow-up (Ivarsson et al, 2014)
- Significant reversal of PTSD diagnosis at post-treatment (Knaevelsrud et al, 2015; Ivarsson et al, 2014)
- Significantly reduced depression and anxiety symptoms at post-treatment (Lewis et al, 2017; Knaevelsrud et al, 2015; Ivarsson et al, 2014, Spence et al, 2011), sustained at 1-month follow-up (Lewis et al, 2017), 3-months follow-up (Knaevelsrud et al, 2015; Spence et al), and 1-year follow-up (Ivarsson et al, 2014)
- Significantly improved quality of life/ life satisfaction at post-treatment (Knaevelsrud et al, 2015; Ivarsson et al, 2014), sustained at 3-months follow-up (Knaevelsrud et al, 2015), and 1-year follow-up (Ivarsson et al, 2014)
- Significantly improved somatisation at post-treatment, sustained at 3-months follow-up (Knaevelsrud et al, 2015)
- Significantly reduced functional impairment at post-treatment, sustained at 1-month follow-up (Lewis et al, 2017)
Need
Comparable Population
The effectiveness of guided i-CBT-T interventions in PTSD was mostly assessed in adults living in developed countries (including Australia, Sweden, UK and USA). Specific studies that included children, refugees, asylum seekers and people with disabilities were not found.
Desired Outcome
Therapist guided internet-based CBT-T interventions have been shown to effectively reduce symptoms of PTSD, depression, anxiety, and functional impairment. They have also been shown to reverse PTSD diagnosis, and improve quality of life and somatisation. The effects have been maintained at follow-up.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Guided internet-based CBT with Trauma Focus (i-CBT-T) interventions are CBT-T interventions delivered online, for the treatment of PTSD and related conditions in adults. These interventions do not deviate from the traditional CBT-T content, hence, they integrate cognitive techniques with behavioural elements that include exposure therapy.
Priorities
The core components of guided i-CBT-T interventions can include psychoeducation, stress management, cognitive restructuring and exposure therapy. These interventions are delivered online, using a variety of multi-media methods, with varying levels of therapist’s assistance. This online delivery method aims to increase access to therapy and reduce demands on therapist’s time.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
Guided i-CBT-T interventions are delivered with varying levels of therapist’s assistance, e.g. regular assistance, light assistance and no assistance (for self-guided delivery). Therapy assistance can be provided by professionals who hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).
Technology Support
Access to the internet and other information technology (e.g. phone, video recorder, camera, laptop with integrated camera, and Wi-Fi) will be needed to support therapist delivery of and patient access to guided i-CBT-T interventions. Delivery of these interventions will also require the development of a remotely accessed, stable and secure treatment platform.
Administrative Support
Internet-based CBT interventions are reportedly associated with higher risks of discontinuation. Administrative support is needed to manage appointments (for therapist guided interventions), collate and input outcome measures and process written reports.
Financial Support
Scottish Government/NES Psychology routinely funds training programmes in CBT, supervisor training and additional CPD on CBT with TF. Training is available from other organisations at a cost. Other start-up costs will include costs of developing remotely accessed, stable and secure treatment platform.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
