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Keywords:

  • posttraumatic stress disorder;
  • cognitive-behavioral therapy;
  • working alliance;
  • therapeutic relationship;
  • Iraq;
  • Arabic;
  • depression;
  • humanitarian aid

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.