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European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2024 Oct 24;15(1):2408960. doi: 10.1080/20008066.2024.2408960

The effectiveness of a remote intensive trauma-focused treatment programme for PTSD

Eficacia de un programa de tratamiento intensivo remoto centrado en el trauma para el TEPT

Nienke Ellenbroek 1, Mae D Nuijs 1, Suzy J M A Matthijssen 1,CONTACT
PMCID: PMC11504181  PMID: 39446983

ABSTRACT

Background: Limited research has addressed the efficacy of remote intensive trauma-focused treatment programmes.

Objective: This study aims to assess the effectiveness of a remote intensive treatment programme in reducing symptoms of Post-Traumatic Stress Disorder (PTSD), general psychiatric symptoms, symptoms of depression, and the interference of PTSD symptoms in daily life among individuals diagnosed with PTSD.

Method: A cohort of 26 patients diagnosed with PTSD underwent a six-day remote treatment programme, which included prolonged exposure, Eye Movement Desensitisation and Reprocessing (EMDR), physical activity, and psycho-education. PTSD symptoms, general psychiatric symptoms, symptoms of depression, and interference of PTSD symptoms in daily life were assessed at screening, pre-treatment, post-treatment, 1-week, 4-week, and at 6-month follow-up.

Results: A significant decrease in PTSD symptoms, measured by the CAPS-5 and PCL-5, was observed from screening to 4-week follow-up (respectively, d = 1.42, d = 1.15), and sustained improvements were noted at 6-month follow-up (respectively, d = 1.70, d = 1.29). Additionally, a significant decrease in general psychiatric symptoms (d = 1.18), symptoms of depression (d = 0.85), and interference of PTSD symptoms in daily life (d = 0.92) was found from pre-treatment to 4-week follow-up. At 4-week follow-up, 56% of the participants no longer met the criteria for PTSD according to the CAPS-5, 73.1% showed improvement, and no patients worsened based on the Reliable Change Index.

Discussion: The results of this study demonstrate that a remote intensive trauma-focused treatment was effective in reducing PTSD symptoms and secondary outcomes in individuals with PTSD due to multiple traumatic experiences. To enhance the robustness of these findings, future studies should incorporate controlled designs, larger sample sizes, and extended follow-up durations.

KEYWORDS: PTSD, online, intensive trauma-focused treatment, remote treatment, prolonged exposure, EMDR

HIGHLIGHTS

  • Intensive trauma-focused treatment can be performed remotely.

  • Remote intensive trauma-focused treatment is successful in reducing PTSD symptoms.

  • Remote intensive trauma-focused treatment is successful in reducing general psychiatric symptoms, symptoms of depression, and interference of PTSD symptoms in daily life.

  • Symptom decrease was maintained at 4-week and 6-month follow-up.

1. Introduction

After experiencing a traumatic event, one can develop a posttraumatic stress disorder (PTSD). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PTSD is characterised by intrusions, avoidance behaviours, negative mood or cognitions, and increased arousal (American Psychiatric Association [APA], 2013). PTSD is associated with psychiatric comorbidity and is frequently characterised by a chronic course, resulting in a significant clinical burden for the individual (Pietrzak et al., 2012) and a significant economic impact on society (Davis et al., 2022; Watson, 2019). There are several in-person evidence-based treatments recommended or suggested for treating PTSD (APA, 2017; Bisson et al., 2019; International Society for Traumatic Stress Studies; ISTSS, 2018), such as Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), Prolonged Exposure (PE), and Eye Movement Desensitisation and Reprocessing therapy (EMDR). Although most of these treatments have been investigated extensively when delivered in-person, less studies have been conducted on providing these treatments remotely.

The COVID-19 pandemic increased the demand for remote psychotherapy due to restrictions on in-person therapy (Fernández-Álvarez & Fernández-Álvarez, 2021). Remote psychotherapy is a form of psychotherapy in which therapists meet with their patients via telephone, e-mail, videoconferencing or other electronic media (Mitchell, 2020). Meta-analyses have shown that remote psychotherapy for PTSD can be effective in reducing PTSD symptoms and symptoms of depression from pre  – to post-treatment (e.g. Lewis et al., 2019; Olthuis et al., 2016). Additionally, remote CBT proved more effective compared to waitlist control conditions and as effective as in-person CBT in reducing PTSD symptoms, without altering treatment protocols (Lewis et al., 2019; Olthuis et al., 2016; Turgoose et al., 2018). Nevertheless, the results of these studies must be interpreted with caution due to high heterogeneity across studies in terms of the study sample (e.g. veterans vs. victims of rape), treatment method, duration of treatment, and amount of therapist contact.

Whereas the short-term effects of remote psychotherapy for PTSD seem promising, results of the long-term effects are more mixed. Although studies observed that PTSD symptoms decreased at 3–6 and 7–12 month follow-up assessments for both remote and face-to-face interventions (14 studies, n = 1286; Olthuis et al., 2016), the face-to-face interventions outperformed the remote treatments in terms of PTSD symptom decrease on the long term (5 studies, n = 611; Olthuis et al., 2016). However, other studies demonstrated that there were no differences in effectiveness between remote or in-person CBT at three or 6-month follow-up (Lewis et al., 2019; Turgoose et al., 2018). Thus, it is unclear whether remote trauma-focused therapy is equally efficacious in the long term as in-person therapy.

Another recent development, apart from remote treatment, is to intensify treatment. In intensive trauma-focused treatment programmes a variety of treatment components can be incorporated and delivered within a shorter timeframe (i.e. multiple session per day). So far, a systematic review summarised that these intensive treatment programmes are effective in decreasing PTSD symptoms and PTSD diagnosis in diverse samples (e.g. veterans, service members, adults with multiple trauma types and interpersonal violence), yielding large effect sizes (Sciarrino et al., 2020). For example, an intensive outpatient programme for veterans lasting three weeks (15 days of treatment) (n = 191) resulted in significant reductions in PTSD symptoms (d = 1.12) and had a dropout rate of 7.9% (Zalta et al., 2018). Other studies examined a six or eight-day intensive treatment programme combining PE, EMDR therapy, physical activity and psycho-education (Bongaerts et al., 2017; Matthijssen et al., 2024; Van Woudenberg et al., 2018; Voorendonk et al., 2020). These treatment programmes proved to be effective in reducing PTSD symptoms and diagnosis from pre-treatment to 1-month and 6-month follow-up with low dropout rates. Thus, intensive programmes seem to present a compelling alternative as they yield similar treatment outcomes as non-intensive treatment programmes, while also offering the advantages of accelerated treatment response and high retention rates (Ragsdale et al., 2020).

Less is known about the effects of offering these short intensive treatment programmes remotely. To date, only five studies (Bongaerts et al., 2021, 2022; Held et al., 2021, 2022; Matthijssen & Menses, 2024) have investigated the effectiveness of remote intensive treatment programmes in patients with PTSD. Two case (series) studies, conducted in a sample of veterans (total n = 12), examined the efficacy of a two-week intensive treatment programme based on Cognitive Processing Therapy (CPT; Held et al., 2021, 2022). The programme proved to be effective in reducing PTSD symptoms from pre-treatment to post-treatment and 3-month follow-up. In addition to CPT as the core treatment, additional components as Dialectical Behaviour Therapy (DBT)-based skills groups, mindfulness sessions, trauma-sensitive yoga, and art therapy were offered. Moreover, another case study showed that a six-day remote intensive trauma-focused treatment combining PE, EMDR 2.0 (Matthijssen et al., 2021), physical activity, and psychoeducation was effective in reducing PTSD symptoms from screening to 4-week and 6-month follow-up (Matthijssen & Menses, 2024). The other studies, both conducted at the same clinic, investigated the efficacy of an eight-day remote intensive treatment programme combining PE, EMDR, physical activity, and psycho-education. This programme proved to be effective in reducing PTSD symptoms from pre-treatment to 4-week and 6-month follow-up, yielding large effect sizes (d = 0.92–2.12) and no dropouts. Moreover, 82% of the patients lost their PTSD diagnosis. Taken together, the first results on the effectiveness of remote intensive trauma-focused treatment programmes seem promising. Given that only five studies investigated the effectiveness of remote intensive treatments in patients with PTSD, of which two are case (series) studies using CPT in veterans at the same clinic, two other studies also stem from the same clinic and one being a single case study, it is imperative that more studies are conducted to strengthen the current body of evidence.

It is important to not only investigate the impact of intensive treatment programmes on PTSD symptoms, but also whether trauma-focused treatments reduce secondary outcomes such as depression symptoms or general psychiatric symptoms. Given the high prevalence of comorbid conditions in PTSD patients (Kessler et al., 2013), including secondary outcomes will help gain a more comprehensive and nuanced understanding of how PTSD treatments work and their effects on patients’ lives. Previous studies showed that these programmes effectively reduce symptoms of depression, anxiety, and interference of trauma symptoms in daily life from pre-treatment to 3-month follow-up (e.g. Ehlers et al., 2010; Zalta et al., 2018). Despite the findings of Matthijssen and Menses (2024), whose case study demonstrated that their patient did not exhibit depression or general psychiatric symptoms at 6-month follow-up, no studies have yet investigated the effects of remote intensive trauma-focused treatment on secondary outcomes. Therefore, in this study we investigated whether decreases in PTSD symptoms are accompanied by decreases in comborbid symptoms.

This study investigated the effectiveness of a remote trauma-focused intensive treatment programme in patients with PTSD due to multiple traumatisation. In addition to PTSD symptoms, depression and general psychiatric symptoms were assessed at screening, pre-treatment, post-treatment, 4-week follow-up, and at 6-month follow-up. We hypothesised that the remote intensive treatment programme would be effective in decreasing PTSD symptoms, general psychiatric symptoms, symptoms of depression, and interference of PTSD symptoms in daily life, and would lead to a loss of PTSD diagnosis. Furthermore, we hypothesised that this decrease in symptoms would be maintained at 4-week and 6-month follow-up.

2. Methods

2.1. Participants

Between January 2020 and November 2021, 37 patients diagnosed with PTSD were treated with a remote variant of an intensive outpatient trauma-focused treatment programme at the Altrecht Academic Anxiety Centre, Utrecht, the Netherlands. Data of these patients was collected as part of routine outcome monitoring. Data of 11 patients was excluded due to early drop-out (n = 2), following the treatment for a second time (n = 4), partial in-person treatment (n = 3), and invalid responses (n = 2). The final sample included 26 participants (Mage = 33.54; SD = 9.05), of which four identified as male and 22 as female.

To tailor the programme to individuals who have experienced multiple traumatic events, only patients with an established PTSD diagnosis (according to the DSM-5) were eligible for treatment. Furthermore, they have to had a history of at least six traumatic memories (of which at least four A-criterion traumatic events). In this study, patients predominantly sought treatment for traumatic experiences involving physical and sexual abuse. Sedative medication was, in consultation with a psychiatrist, minimised as much as possible, and alcohol and drug use were prohibited during treatment and for four weeks afterward. Exclusion criteria included acute suicide risk, lack of Dutch language competency, severe psychiatric issues impairing trauma therapy, and inability to participate remotely.

2.2. Measurements

2.2.1. LEC-5

The Dutch version of the Life Events Checklist for DSM-5 (LEC-5; Boeschoten et al., 2014b; Weathers et al., 2013b) was used to assess the type of traumatic events that participants experienced. This self-report questionnaire assesses exposure to 16 potentially traumatic events (e.g. physical violence) and an ‘additional’ open item, which can be manually filled in by the respondent in case the traumatic event is not listed. There was no predetermined ‘level of exposure’ (e.g. happened to me or witnessed it) required for participant inclusion.

2.2.2. CAPS-5

To establish a PTSD diagnosis and measure the severity of symptoms, the Dutch version of the Clinical Administered PTSD Scale for DSM-5 (CAPS-5), a semi-structured diagnostic interview, was administered as the primary outcome measure (Boeschoten et al., 2014a, 2018; Weathers et al., 2013a). The severity of each symptom is rated on a 5-point Likert scale ranging from 0 (absent) to 4 (extreme or incapacitating), with a summed total score ranging from 0–80. Psychometric qualities of the Dutch month version of the CAPS-5 are adequate, with good internal consistency (α = .90; Boeschoten et al., 2018). The Dutch weekly version of the CAPS-5 has not yet undergone validation. Table 1 illustrates that both the weekly and monthly versions of the CAPS-5 were administered at each time point, except for the 1-week follow-up. The CAPS-5 assessments were administered by trained clinicians who were also part of the treatment team.

Table 1.

Means scores and standard deviations of all outcome measures.

  Screening Pre-treatment Post-treatment 1-week follow-up 4-week follow-up 6-month follow-up
Questionnaire n M SD n M SD n M SD n M SD n M SD n M SD
CAPS-5 M 26 44.62 9.97                   25 21.84 17.96 11 18.55 19.64
CAPS-5 W 26 44.73 10.10             25 23.16 15.55 24 22.00 18.01 11 18.18 19.15
PCL-5 13 58.69 11.26 26 57.65 13.29 24 35.29 21.34 24 29.17 21.23 24 30.63 23.72 10 27.40 27.79
VAS 13 87.15 10.00 25 79.36 19.66 24 49.17 28.64 24 43.96 27.07 24 41.96 33.03 10 33.40 38.73
BSI 13 2.33 .71 26 2.27 .81 24 1.32 1.13 24 1.26 .91 24 1.31 1.13 10 1.22 1.33
BDI-II 13 36.08 10.85 26 35.92 11.95 24 21.92 14.22 24 21.83 14.24 24 22.29 16.60 10 16.90 19.06
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Note: M: Month-version; W: Week-version; CAPS-5: Clinical Administered PTSD Scale for DSM-5; PCL-5: PTSD Checklist for DSM-5; VAS: Visual Analogue Scale; BSI: Brief Symptom Inventory; BDI-II: Beck Depression Inventory Second Edition.

2.2.3. PCL-5

To measure self-reported PTSD symptom severity, the Dutch week version of the PTSD Checklist (PCL-5; Boeschoten et al., 2014c; Weathers et al., 2013c) was used. The PCL-5 assesses the DSM-5 diagnostic criteria for PTSD with 20 items rated on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely), with a total score ranging from 0–80. The internal consistency of the month version of the PCL-5 is suggested to be excellent (α = .93; van Praag et al., 2020).

2.2.4. VAS

To assess to what extent patients suffered from their PTSD symptoms in daily life, a Visual Analogue Scale (VAS; Crichton, 2001) ranging from 0 (not at all) to 100 (extremely bothered) was used. Patients were asked to indicate to what extent they are currently experiencing distress in their daily lives due to their trauma symptoms.

2.2.5. BSI

To assess self-reported general psychiatric symptoms, the Dutch version of the Brief Symptom Inventory (BSI; de Beurs, 2006; Derogatis & Melisaratos, 1983) was used. The BSI is a self-report questionnaire that consists of 53 items covering 9 symptom dimensions: Somatisation, Obsession-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. On a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely), patients indicated the intensity of distress during the past 7 days. The internal consistency of the Dutch BSI is excellent (α = .96; de Beurs & Zitmann, 2006).

2.2.6. BDI-II-NL

To assess symptoms of depression, the Dutch version of the Beck Depression Inventory Second Edition (BDI-II-NL; Beck et al., 1996; van der Does, 2002) was used. The BDI-II is a self-report questionnaire that consists of 21 items that evaluate key symptoms of depression during the past 7 days on a 4-point Likert scale ranging from 0 (symptoms absent) to 3 (severe symptoms). Total scores range from 0 to 63, with higher scores indicating higher levels of depression. The internal consistency of the BDI-II-NL is excellent (α = .95; Roelofs et al., 2013).

2.3. Treatment programme

The six-day intensive trauma-focused programme, adapted for remote delivery (see Matthijssen et al., 2024), extended over two weeks with three consecutive treatment days in each week. Patients stayed at home and some in a private space at an inpatient clinic. Each treatment day began with a 90-minute PE session, followed by a 15-minute break and an hour of physical activity (e.g. walking). After lunch, patients had a 90-minute EMDR session followed by a pre-recorded psycho-education video (for a more elaborate description of the programme see Matthijssen et al., 2024). At the end of the day, a daily therapist phone call addressed questions or comments patients might have about the psycho-education or the treatment in general. All treatment components were delivered by different therapists (see ‘therapist rotation’ in van Minnen et al., 2018), all of whom were psychologists trained in trauma treatment. However, the number of therapists per modality varied over time, making it difficult to determine the exact number who conducted PE or EMDR in any given month.

2.3.1. Remote trauma-focused treatment

PE and EMDR were used as the trauma-focused treatments. For the remote variant of PE in this intensive treatment programme, Karify Pro, Google Meet, or Starleaf were used to establish a secure video call. During the PE, therapists made sure they had a good view of the patients, which allowed them to control whether patients were keeping their eyes closed, were not fidgeting or showing self-harming behaviours. In addition, exposure in vivo assignments could be added (e.g. opening the curtains or turning the lights on or off).

The application MOOVD D-EMDR (Moovd, 2020), a protected application in which secure video calls are established, was used to provide the remote EMDR, utilising the Dutch EMDR protocol (ten Broeke et al., 2021 based on Shapiro, 2001). To tax the working memory, the programme provided a response task in which patients were asked to react swiftly to a moving ball by means of a key response. The ball's speed adjusted in response to the patients’ reaction times, ensuring that they faced an optimal level of working memory taxation. Additionally, an auditory task was integrated, necessitating patients to respond promptly to a beep by means of a key response. If these tasks did not sufficiently tax were the working memory, they could be complemented by extra tasks, such as identifying colours. An error buzzer could be activated to provide feedback to the patients.

2.4. Procedure

During a first screening appointment, patients completed the LEC-5, and clinicians administered the CAPS-5 to assess PTSD criteria. If the criteria were met, patients completed the following questionnaires online: PCL-5, BSI, BDI-II-NL, and a VAS. These questionnaires were administered again at the beginning and end of the treatment, and at 1-week, 4-week, and 6-month follow-up. To evaluate eligibility for treatment, a treatment plan was set up, outlining the six traumatic memories that would be addressed during the six treatment days. The traumatic memories were ranked from most to least distressing using a scale ranging from 0 to 10, with the most distressing memory addressed on the first day. On each treatment day, one memory was addressed. Additionally, the following topics were evaluated prior to treatment: Motivation for treatment, avoidance and safety behaviours, suicidality, and self-harming behaviours. During an appointment with a therapist to formulate a treatment plan, these crucial aspects were addressed. In consultation with the patient, agreements were established (e.g. alternatives to self-harming behaviours or discussing suicidal thoughts/plans if they arise during treatment) and incorporated into the treatment plan. Significant avoidance and safety behaviours were outlined for each memory, with the aim of addressing and modifying these with exposure in vivo during treatment. Prior to treatment, patients received an information booklet about the treatment, which also included psycho-education slides and corresponding forms with exercises.

2.5. Data analyses

All analyses were conducted using SPSS 28 (IBM SPSS). Paired samples t-tests were used to investigate whether CAPS-5 month scores decreased from screening to 4-week and 6-month follow-up. To investigate changes in CAPS-5 week scores, a repeated-measures ANOVA was conducted with Time (screening, 1-week, and 4-week follow-up) as the independent variable and total CAPS-5 week scores as the dependent variable. Significant effects were further examined using paired-sample t-tests for each time point comparison. For PTSD symptoms (PCL-5) and secondary outcomes (VAS, BSI, and BDI-II), repeated-measures ANOVAs were performed with Time (pre-treatment, post-treatment, 1-week, and 4-week follow-up) as the independent variable and total scores on the outcome variables as the dependent variable. Significant effects were followed up by paired-sample t-tests comparing pre-treatment with each follow-up assessment. Furthermore, to investigate whether PTSD symptoms (PCL-5) and secondary outcomes decreased from pre-treatment to 6-month follow-up, paired sample t-tests were used. The Reliable Change Index (RCI) was calculated by dividing the difference between pre-treatment and post-treatment scores by the standard error of this difference, using Cronbach’s alpha values of .90 for the CAPS-5 (Boeschoten et al., 2018) and .93 for the PCL-5 (van Praag et al., 2020). RCI values above 1.96 indicated reliable changes (Jacobson & Truax, 1991).

3. Results

3.1. Descriptive statistics

There were missing values for all of the outcome measures (7.7–61.5%). Due to the small sample size (n = 26), missing data could not be imputed (Jakobsen et al., 2017), resulting in different sample sizes per analysis, see Table 1. Pre-treatment scores were used for analyses on the outcome variables (except for CAPS-5), since a large amount of data at screening was missing and pre-treatment scores were comparable with screening scores (all p’s < .001). For the CAPS-5 analyses screening scores were used. The assumption of sphericity was violated for all of the repeated-measures ANOVA analyses, and thus Greenhouse-Geisser corrected tests are reported, all ϵ’s < 0.75. For mean scores and standard deviations of all outcome measures, see Table 1.

3.2. Treatment effects

3.2.1. CAPS-5 Month Version

A significant decrease in PTSD symptoms from screening to 4-week follow-up was found on the CAPS-5, t(1, 24) = 7.29, p < .001, d = 1.46. According to the CAPS-5, four weeks after treatment 56% of the patients (14 out of 25 patients) did not meet the criteria for PTSD. The RCI of the CAPS-5 indicated that 76.9% of the patients improved, with no patients worsening from screening to 4-week follow-up, see Table 2. Moreover, a significant decrease in PTSD symptoms from screening to 6-month follow-up was found on the CAPS-5, t(1, 10) = 5.87, p < .001, d = 1.70. After 6 months, 54.5% of the patients did not meet the criteria for PTSD (6 out of 11 patients). Of the patients (n = 14) who no longer met the diagnostic criteria for PTSD at the 4-week follow-up, 6 patients remained free of PTSD at the 6-month follow-up assessment, 1 patient had a recurrence of PTSD, and data was missing for 7 patients. Furthermore, of the patients (n = 11) who continued to meet the criteria for PTSD at the 4-week follow-up assessment, 5 patients still met the criteria for PTSD at the 6-month follow-up assessment, while the 8 patients had missing data.

Table 2.

Reliable change index.

Instrument No change (%) Improved (%) Worsened (%)
CAPS-5 M 5 (19.2%) 20 (76.9%) 0 (0.00%)
PCL-5 5 (19.2%) 18 (69.2%) 1 (3.8%)
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Note: For the Clinical Administered PTSD Scale for DSM-5 (CAPS-5 Month version) screening scores and 4-week follow-up scores were used to calculate the Reliable Change Index (RCI). For the PTSD Checklist (PCL-5) pre-treatment scores and 4-week follow-up were used.

3.2.2. CAPS-5 Week Version

Results indicated that PTSD symptoms significantly changed over time, F(22, 1.42) = 43.67, p < .001, ηp2 = .655. Follow-up paired sample t-tests (simple contrasts) showed that PTSD symptoms significantly decreased from screening to 1-week follow-up, t(1, 24) = 6.69, p < .001, d = 1.34 and from screening to 4-week follow-up, t(1, 24) = 7.22, p < .001, d = 1.45, see Figure 1. Moreover, a paired sample t-test showed that PTSD symptoms significantly decreased from screening assessment to 6-month follow-up, t(1, 10) = 6.04, p < .001, d = 1.82.

Figure 1.

Figure 1.

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Mean scores of the clinical administered PTSD scale for DSM-5 (CAPS-5) across the four assessment points.

Note: Error bars represent standard errors. FU: follow-up.

3.2.3. PCL-5

Results indicated that self-reported PTSD symptoms significantly changed over time on the PCL-5, F(1.92, 40.37) = 22.69, p < .001, ηp2 = .519. Follow-up paired sample t-tests (simple contrasts) showed that self-reported PTSD symptoms significantly decreased from pre-treatment to post-treatment, t(1, 23) = 5.23, p < .001, d = 1.07, 1-week follow-up, t(1, 23) = 6.50, p < .001, d = 1.33, and 4-week follow-up, t(1, 23) = 5.62, p < .001, d = 1.15, see Figure 2. The RCI of the PCL-5, showed that 69.2% of the patients improved and one patient worsened from pre-treatment compared to 4-week follow-up (see Table 2). Moreover, a paired sample t-test showed that PTSD symptoms significantly decreased from pre-treatment to 6-month follow-up, t(1, 9) = 4.07, p = .001, d = 1.29.

Figure 2.

Figure 2.

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Mean scores of the PTSD checklist for DSM-5 (PCL-5) across the five assessment points.

Note: Error bars represent standard errors. FU: follow-up.

3.2.4. VAS

Results indicated that the extent to which patients suffered from their PTSD symptoms in daily life significantly differed over time on the VAS, F(1.99, 39.87) = 20.01, p < .001, ηp2 = .50. Follow-up paired sample t-test (simple contrasts) showed that self-reported PTSD symptoms significantly decreased from pre-treatment to 1-week and 4-week follow-up, p’s < .001, and from pre-treatment to 6-month follow-up, p = .004, see Table 3.

Table 3.

Pairwise comparisons of pre-, post-treatment and follow-up scores.

        Paired samples t-tests
Questionnaire n Mdifference SDdifference t df p Cohen’s d
VAS              
Pre-treatment to post-treatment 23 −31.78 30.99 4.92 22 <.001 1.03
Pre-treatment to 1-week FU 23 −34.96 32.27 5.20 22 <.001 1.08
Pre-treatment to 4-week FU 23 −39.04 33.24 5.63 22 <.001 1.18
Pre-treatment to 6-month FU 9 −40.78 34.89 3.51 8 .004 1.17
BSI              
Pre-treatment to post-treatment 24 -.95 .88 5.27 23 <.001 1.08
Pre-treatment to 1-week FU 24 -.98 .81 5.92 23 <.001 1.17
Pre-treatment to 4-week FU 24 -.95 1.12 4.15 23 <.001 0.85
Pre-treatment to 6-month FU 10 −1.14 1.10 3.26 9 .005 1.03
BDI-II              
Pre-treatment to post-treatment 24 −14.29 12.97 5.40 23 <.001 1.10
Pre-treatment to 1-week FU 24 −13.46 12.08 5.46 23 <.001 1.11
Pre-treatment to 4-week FU 24 −13.38 14.59 4.49 23 <.001 0.92
Pre-treatment to 6-month FU 10 −17.00 12.87 4.18 9 .001 1.32
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3.2.5. BSI

Results indicated that self-reported general psychiatric symptoms significantly differed over time on the BSI, F(1.67, 34.97) = 15.36, p < .001, ηp2 = .42. Follow-up paired sample t-test (simple contrasts) showed that self-reported general psychiatric symptoms significantly decreased from pre-treatment to 1-week and 4-week follow-up, p’s < .001, and from pre-treatment to 6-month follow-up, p = .005, see Table 3.

3.2.6. BDI-II

Results indicated that self-reported symptoms of depression significantly differed over time on the BDI-II, F(1.99, 41.84) = 15.42, p < .001, ηp2 = .42. Follow-up paired sample t-test (simple contrasts) showed that self-reported symptoms of depression significantly decreased from pre-treatment to 1-week and 4-week follow-up, p’s < .001, and from pre-treatment to 6-month follow-up, p = .005, see Table 3.

4. Discussion

This study investigated whether a remote intensive trauma-focused treatment would be effective in decreasing PTSD symptoms and would lead to a loss of PTSD diagnosis in patients with PTSD due to multiple traumatisation. As hypothesised, we observed that the remote treatment was successful in reducing PTSD symptoms. This decrease in PTSD symptoms was sustained over a follow-up period of four weeks and six months. Furthermore, on the CAPS-5 76.9% of the patients showed a reliable change in PTSD symptoms four weeks after treatment and no patients worsened. However, on the PCL-5, one person did report an increase in PTSD symptoms from pre-treatment to 4-week follow-up. Moreover, a substantial portion of patients no longer fulfilled the diagnostic criteria for PTSD four weeks after treatment (56%) and continued to exhibit this trend at 6-month follow-up (54.5%). Note, though, that the effects at 6-month follow-up should be interpreted with caution due a high percentage of missing data. In addition, as hypothesised, we observed that the intensive treatment was effective in reducing general psychiatric symptoms, symptoms of depression, and interference of PTSD symptoms in daily life and that this decrease in symptoms was sustained over a follow-up period of four weeks and six months.

In line with recent studies (Bongaerts et al., 2021, 2022; Held et al., 2021, 2022; Matthijssen & Menses, 2024), this study shows that remote intensive trauma-focused treatment is an effective treatment for patients with PTSD. The current findings are also in line with a meta-analysis (Ehring et al., 2014) and a review (van Minnen et al., 2015) demonstrating that effective trauma-focused treatment can exert positive effects on comorbid conditions and symptoms. Improving the dissemination of remote trauma therapy requires not only offering effective treatment programmes but also investigating whether they are equally or more effective than in-person therapy. Although the present study did not make these comparisons, effect sizes of this study can be compared to effect sizes of studies delivering similar in-person intensive programmes. Specifically, a study (Matthijssen et al., 2024) providing the same intensive treatment programme in-person, observed a comparable effect size (d = 1.13) in terms of PTSD symptom reduction compared to the current study (d = 1.46). This is in line with another study (Bongaerts et al., 2022), which observed similar effect sizes when delivering their more extensive intensive treatment programme remotely (d = 1.61) compared to the in-person variant (d = 1.51; Bongaerts et al., 2022; Voorendonk et al., 2020). In sum, remote intensive treatments seem to be at least just as effective as in-person intensive treatments.

The findings of the current study have important clinical implications. First, increased use of remote treatment may reduce mental healthcare costs. For example, a review assessing videoconferencing psychotherapy in diverse psychiatric samples, showed that remote treatment is related to reduced travel and intervention costs (Backhaus et al., 2012). Furthermore, it saves therapist costs and time to eliminate therapist-administered components such as psychoeducation. Given that in our study the psychoeducation and physical activity sessions were provided through pre-recorded videos or an instructional manual, the remote treatment programme might reduce both therapist time and costs by removing the need for therapist-administered components. Note, though, that in future research, cost-effectiveness between remote and in-person PTSD treatments should be investigated. Second, increased use of remote treatment may also enhance patient accessibility to healthcare and reduce barriers related to distance, mobility, and treatment modalities, which might be particularly important for individuals residing in rural or low-income areas (e.g. Collins et al., 2004). In addition, a study found that remote therapy can enhance feelings of security and trust in patients with PTSD (Chen et al., 2021). For example, the physical distance can serve as a protective barrier for patients who may feel overwhelmed by in-person treatment or who have concerns about secondary traumatisation. In sum, in light of promising outcomes of remote intensive trauma-focused treatments and the potential benefits, future studies should assess feasibility of broader implementation and cost-effectiveness to inform guidelines.

There are several limitations of this study. First, there was no control group and hence, no randomisation to ensure that the results can be attributed to the intervention and not to spontaneous recovery. Therefore, future studies should compare the current remote treatment to either a waitlist condition or in-person treatment. However, given that in the current study there are no differences between the scores at screening and pre-treatment, the observed results are unlikely attributable to spontaneous recovery. Second, due to a high percentage of missing data at the 6-month follow-up assessment, we can only draw tentative conclusions regarding long-term symptom reduction. Consequently, future studies should incorporate a more extensive follow-up period to examine long-term effects. Thirdly, the study has a small sample size mainly consisting of people who identify as female, thereby potentially impeding the generalizability of the findings. There are also several strengths of the study. First, besides self-report questionnaires, clinical interviews were used to test treatment effects, ensuring reliability of the treatment outcomes and enhancing the generalizability of the results. Second, this remote target group, which requires specialised care (e.g. characterised by limited benefits from previous treatments), does not appear to differ from the in-person target group based on baseline scores on the CAPS-5 (M = 44.62; SD = 9.97, current study) and the in-person version (M = 43.41; SD = 9.73; Matthijssen et al., 2024). This offers promising potential for generalising the findings to a target group with less complex symptoms.

In conclusion, the present study suggests that remote intensive trauma-focused treatment is effective in reducing PTSD symptoms and secondary treatment outcomes in both the short-term and the long-term. The results highlight the potential benefits of delivering remote intensive trauma-focused treatment, as it might reduce mental healthcare costs and can enhance accessibility for underserved patients. To test whether remote trauma-focused treatment can be more widely disseminated, future studies should conduct randomised controlled trails with larger sample sizes and longer follow-up periods.

Disclosure statement

Suzy Matthijssen provides courses on how to design and structure an intensive treatment programme. The other authors do not have competing interests.

Data availability statement

The data is available on request.

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Data Availability Statement

The data is available on request.

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