To the Editor: We appreciate Dr. Markowitz’s queries pertaining to the role of interpersonal contact in our Internet-based program. He raises a number of questions about our article, which he states “emphasized technology and downplayed human contact.” It is important to note that our self-management cognitive behavioral therapy (CBT) intentionally reduces the role of human contact with the objective that more people will receive the care they need. The model is germane because many people 1) are reluctant to seek traditional services, 2) live in remote regions where expert care is unavailable, and 3) are unable to access services because the demand exceeds the resources. In an ideal world, there would be no barriers to care, but it is imperative to recognize the sobering reality that most survivors of trauma do not receive evidence-based mental health services (1). Telehealth therapies may be less efficacious because they do not provide intensive human connection and oversight, but there is an unequivocal public health need to overcome barriers to care through alternative methods of therapy delivery.
Dr. Markowitz suggests that a supportive counseling program should provide “interpersonal warmth.” Our supportive counseling program followed previous psychotherapy trials by ensuring that it 1) did not contain active CBT skills and 2) involved the same therapist contact time (2). The issue concerning the telephone and e-mail contacts with patients in the respective conditions is an important one, and our analyses indicate that there were no significant differences between patients in the two conditions in terms of the total number or length of phone calls or e-mail messages. It should also be noted that the supportive counseling program resulted in a pre-/posttreatment effect size of 1.1, which is actually larger than most supportive counseling programs offered in traditional therapy formats (3). This suggests that the supportive counseling program was a change agent and provided a reasonable Internet-based analog to a supportive psychotherapy comparison group for our trial.
1.Zayfert C, Deviva JC, Becker CB, Pike JL, Gillock KL, Hayes SA: Exposure utilization and completion of cognitive behavioral therapy for PTSD in a “real world” clinical practice. J Trauma Stress 2005; 18:637–6452.Bryant RA, Sackville T, Dang ST, Moulds M, Guthrie R: Treating acute stress disorder: an evaluation of cognitive behavior therapy and counseling techniques. Am J Psychiatry 1999; 156: 1780–17863.Bradley R, Greene J, Russ E, Dutra L, Westen D: A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry 2005; 162:214–227
Dr. Litz’s disclosures accompany the original article.
This letter (doi: 10.1176/appi.ajp.2007.07121853r) was accepted for publication in December 2007.