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BACKGROUND: Previous studies have shown that Internet-based interventions for posttraumatic stress disorder are feasible. However, little is known about how therapeutic process factors impact online interventions in war and conflict regions. OBJECTIVE: This study aims to assess the quality of the working alliance at midtreatment and posttreatment and its relationship with therapy outcome in an Internet-based cognitive-behavioral intervention for Arabic-speaking traumatized patients. METHODS: A trial was conducted from January 2009 to August 2011 with patients recruited specifically in Iraq. Fifty-five participants with posttraumatic stress symptoms completed the Working Alliance Inventory (WAI) after at least session 4. Participants' mean age was 27.7 years (SD = 6.9); 78% of participants were females. Participants received two weekly 45-min Internet-based cognitive-behavioral interventions over a 5-week period. The main outcome measures were the Posttraumatic Diagnostic Scale (PDS) and the WAI. RESULTS: High ratings of the therapeutic alliance were obtained early in treatment, and results remained stable from sessions 4 to 10, indicating that it was possible to establish a positive and stable online therapeutic relationship. The working alliance at both assessment points predicted treatment outcome for posttraumatic stress symptoms. CONCLUSIONS: Despite the instability of the settings and patients' ongoing exposure to human right violations through war and dictatorships, it was possible to establish a stable online therapeutic relationship.
Wagner et al. (Thu,) studied this question.