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Running head: RESEARCH PROPOSAL

Theoretical Research Proposal for Email-based PTSD Intervention


for Male Millennial Combat Veterans
Ian Witherby
Research Methods, Thursday 10:30am
Boston College
Graduate School of Social Work

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Abstract

The following paper is a theoretical research proposal involving a new therapeutic


intervention for male combat veterans from the wars in Iraq and Afghanistan ages 18-30
suffering from Post-Traumatic Stress Disorder (or PTSD).
The proposal begins with a brief discussion of PTSD, including the intersection of the
diagnosis with the military mental health care system. The paper reviews unique characteristics
of the target group (the Millennial generation) and poses a research question and hypothesis
based on that information.
The remainder of the proposal deals with the methodology of the study. An experimental
design is constructed and detailed, and sampling & procedural details are examined.
Consideration is made to ethical details and the use of several common measurement instruments
are discussed.
Finally, hypothetical results are analyzed, inherent limitations of the study are discussed,
and future research avenues are briefly explored.

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Introduction

General medical and therapeutic understanding of the nature of post-traumatic stress


disorder (or PTSD) has increased in recent decades. The American Psychological Association
added PTSD to the DSM-III in 1980, and despite some controversy, the inclusion has proven to
be useful and demonstrably effective in the diagnosis and understanding of post-trauma care
(Friedman, n.d.). Kilpatrick et al. found in 2013 that in their nationwide sample, [m]ost
respondents (89.7%) reported exposure to at least one DSM-5 Criterion A event (that is,
exposure to real or threatened death, injury, or sexual violence). Given the communality of
exposure to one of the DSM-Vs criteria for PTSD diagnosis and the fact that diagnosis of PTSD
is more likely after repeated exposures (which is even more likely in military veterans exposed
through combat theater situations), the discovery and implementation of effective treatment is
paramount.
Military veterans were one of the first populations to be diagnosed with the disorder; use
of PTSD diagnosis was especially important for veterans returning to the United States after
combat deployments.
Keane and associates, working with Vietnam war-zone Veterans, first developed both
psychometric and psychophysiological assessment techniques [used in the diagnosis of
PTSD] that have proven to be both valid and reliable. (Friedman, n.d.)
Military personnel are at heightened risk for PTSD; Kilpatricks study also determined that their
[f]indings were consistent with previous reports that the highest conditional probabilities of
PTSD are associated with events involving interpersonal violence or military
combat (Kilpatrick, 2013, emphasis added).

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The rate of PTSD diagnoses in the military is not only high it is climbing. The
Veterans Administration issued a report in 2005 detailing the increases in expenses related to
PTSD and found that between fiscal years
19992004, the number and percentage of PTSD cases increased significantly. While the
total number of all veterans receiving disability compensation grew by only 12.2 percent,
the number of PTSD cases grew by 79.5 percent, from 120,265 cases in FY 1999 to
215,871 cases in FY 2004. (VA Inspector General, 2005).
The incidence of this diagnosis alone is sufficient incentive to explore additional treatment
options for those veterans suffering from this crippling disorder.
Historically,
[t]he most successful interventions [for PTSD] are cognitive-behavioral therapy (CBT)
and medication. Excellent results have been obtained with CBT approaches such as
prolonged exposure therapy (PE) and Cognitive Processing Therapy (CPT), especially
with female victims of childhood or adult sexual trauma, military personnel and Veterans
with war-related trauma, and survivors of serious motor vehicle accidents.
(Friedman, n.d., emphasis added)
Results of current and past research on the effectiveness of online therapies for PTSD are
inconclusive (as is the efficacy of online therapy generally). Kojima et al. (2010) found that for
depression treatment in office workers, success rates for short-term CBT over email were not
statistically different from traditional therapies for the control group (this study was limited both
in time and in sample size and cannot be generalized).

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A larger study
of the treatment outcome of 1,500 patients showed that effects [of online therapy] in
clinical practice are similar to those observed in the controlled trials, and comparable to
selected benchmarks of naturalistic studies of face-to-face CBT. The accumulated
evidence provides compelling support for the efficacy and effectiveness of online CBT.
(Ruwaard, 2011)
Ruwaards findings are much more generalizable than Kojimas (the sample size is much larger,
for example), but Ruwaard did not work specifically with sufferers of PTSD.
Additionally, Steenkamp (2014) found that
rather than being highly effective for most veterans who receive them, in clinical trials,
PE and CPT [two common forms of CBT] do not sufficiently or reliably meet the
treatment needs of many veterans, and their incremental value over non-trauma-focused
therapies remains unclear. Although PE and CPT are useful and important for clinicians
to learn, even if the dissemination is highly successful, a significant portion of veterans
with PTSD will require alternative or additional treatment.
In contrast, some past research has shown that online therapy can be effective for PTSD (see
Bush, 2010; and Kojima, 2014); however,
much less attention has been paid to the use of telehealth technologies to diagnose
veterans with PTSD for both treatment and/or disability compensation purposes, in spite
of the need for such services. The literature evaluating the use of video teleconferencing
methods in the assessment of PTSD is limited; to [Litwacks] knowledge, only 1 previous
study has been published. (Litwack, 2014)

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The study that Litwack refers to is Bush et al. (2014), wherein


five of six [veteran] participants who completed [online] extended measures of
educational function showed significant improvements from enrollment to
postintervention. Among secondary outcomes, more than 80% of those taking part said
they would recommend the online PTS workshop to a colleague or fellow student with
PTS issues. These preliminary findings show that our online PTS workshop can be
effective in reducing PTS symptoms in some cases, but also suggest that additional
research is needed. (Bush, 2014)
It should be noted that Bushs study utilized an online workshop and not asynchronous emailbased therapy. Based on these two recent studies and Steenkamps critique of current VA
techniques for treating PTSD, the need for additional research is clear.
Finally, it is important to remember for the purposes of this proposal that military
veterans of the wars in Iraq and Afghanistan are younger than their counterparts. In fact, they are
very young, even in relation to the overall population. [M]ore than half [are] between the ages
of 18 and 32. By comparison, about 37 percent of the nonveteran population is over 50, and less
than 29 percent of the nonveteran population is between the ages of 18 and 32 (News21, 2013).
Younger people are often more likely to use the Internet; a Pew research study from earlier in
2014 notes that between 93% and 97% of young adults use the Internet, email, or access the
Internet from a mobile device (Pew, 2014).
Research Question & Hypothesis
Given (1) the growing interest in research involving online and email-based therapies; (2)
the familiarity that Millennials have with the Internet and related technologies; (3) the growing

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need for new and more effective PTSD therapies generally; and (4) the growing need for
alternative PTSD treatments for combat veterans of the wars in Iraq and Afghanistan, this
proposal asks the following question:
Do male combat veterans aged 18-30 from the Iraq and Afghanistan wars diagnosed with
PTSD respond as well to asynchronous therapy conducted over email as their
counterparts who receive similar treatment in VA settings when conducted by the same
clinicians?
From this question, the following hypothesis can be drawn:
Given their predilection to and familiarity with using the Internet and email systems,
male combat veterans will respond as well to (but not better than) email therapy as
traditional therapy.
Methodology
Design
The current study is is an outcome study and is therefore of experimental design. It seeks
to identify linkage between various kinds of therapy and reduction of PTSD symptoms in a very
specific target population. Because volunteers will be randomly assigned to a treatment group,
this study is technically a randomized control trial. According to Tran et al. (2015), benefits of an
RCT include making
the two selected groups not only statistically equivalent to the larger community, but also
statistically equivalent to each other. Random assignment is the key element of
randomized experimental designs. Note that randomization is the process of assigning the
participants or clients into the treatment (or service group) or control group randomly,

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that is, the selected participants or clients have an equal chance or probability to be
assigned to one or the other group. The randomization process tends to equalize
differences among the selected participants at pretest, making the comparison of the
outcome stronger and more meaningful.
While results of the present study will not be generalizable to the population at large (or even to
all male veterans), randomized grouping will help expand potential applicability to the fullest
possible extent.
This method was chosen for its applicability to treatment outcome. Symptoms of PTSD
are measurable and highly relevant to the chosen population. For a brief insight into treatment
outcome, there is no better design. Because of the nature of the proposed intervention (email
therapy) and its lack of geographical proximity, it is possible to be truly random in group
assignment. The design is therefore purely experimental rather than quasi-experimental.
Sampling
Participants in the study will be male combat veterans of the wars in Iraq and
Afghanistan. Since combat operations in both of those theaters have essentially ceased, service
from any time window will be accepted (that is, it is not required to have been in active combat
inside the last six months or other time period). This flexibility is required because it will
increase the available sample size (and while not generalizable, the results of the study will carry
more validity with an increased n). Given the requirement of Internet literacy necessary for the
alternative hypothesis to be accepted, all study recruits must be between the ages of 18 and 30.
Sampling will be non-probability sampling; specifically, convenience sampling. Since the
treatment group will receive treatment that is independent of physical proximity to the therapist,

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no specific geographic proximity is required for treatment (although recruitment will require a
physical presence). Additionally, the possibly different procedures based on VA location across
the country provide a wide range of comparison data as opposed to comparing treatment
outcomes with only one different methodology. Per Tran et al. (2015), this kind of sampling is
most useful for pilot testing.
In VA hospitals across the country, researchers will place informative flyers advertising
an experimental email-based treatment for PTSD in lobbies and mental health wards. Individual
clinicians from each of these facilities will be informed about the nature of the research and will
be given access to research data and conclusions at the close of the study as incentive (in the
hopes that they will use the data in the improvement of their own practice, whether or not the
intervention is successful in increasing positive treatment outcome). Clinicians will also have the
opportunity to recruit new subjects into the study, with some restrictions1. In order to recruit and
randomize as many veterans as possible, treatment must begin two weeks after the initial posting
of the flyers (there are also ethical concerns in withholding treatment for any period of time).
Procedure
All responders will be screened for previous PTSD diagnosis or for symptoms of the
disorder. Those currently receiving treatment will be excluded from the study, in order to remove
an additional mediating variable (subjects who are currently receiving treatment present difficult
variables which cannot be accounted for in this design; it is necessary to limit our inquiry to
those veterans who are not currently receiving treatment, regardless of their previous or current
diagnoses).

See procedure notes for restrictions on treatment.

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Clinicians at VA facilities will screen in person all those applicants who have not received
a current diagnosis of PTSD for the disorder using standard intake scales2. All participants will
receive the initial screening in person to conduct staff-administered assessments. Additionally,
those responders who already have a PTSD diagnosis will be screened and assessed in the same
manner as the non-diagnosed. Litwack et al. (2014) also believe that an in-person screening is
necessary for PTSD clinical trials;
Those responders who report no diagnosis of PTSD or that do not report sufficient
symptoms for a new diagnosis of PTSD after the face-to-face assessment process will be
excluded from the study.
Responders who after the initial screening and assessment protocols have a current
diagnosis of PTSD will be randomly assigned to two groups; one group (control) receiving
traditional CBT therapy in the VA hospital or outpatient facility, and another group (treatment)
receiving email therapy. This type of group assignment is typical in experimental design.
The control group will be notified that they are on a waiting list for the email therapy but
will still receive the standard level of care (for ethical reasons). Both groups will receive their
specific therapies for six months. Upon completion of the six-month treatment window, subjects
will be assessed at the originating VA facility and treatment group members will begin receiving
traditional therapy. Participants will self-report their symptoms at closure of the email treatment
window and then again six months after their completion dates. Post-treatment follow-up will be
conducted via postal mail or email if the subject is able to digitally send their self-report to the
administering clinician.

See Instruments below for more information about the scales used in this study.

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Both in-person assessments and a self-report are utilized in this study in order to generate
as much data as possible in the hopes of increasing internal validity. Differences and similarities
between clinicians and participants scores could provide additional information on the efficacy
of non-traditional (as well as standard) treatment.
Instruments
Four total instruments will be used to measure key constructs of the study. It is beyond
the scope of this study to measure associated or co-morbid signs of associated mental health or
illness; the key constructs used in measuring outcome will therefore be limited to the diagnostic
Criteria set forth in the DSM-V for PTSD: exposure, re-experience, avoidance of stimuli,
increased arousal, duration, and distress.
Clinician-administered. The following tests will be administered in person at initial
screen and close-of-treatment by a trained clinician.
The Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire.
This scale will be used because the study involves veterans who are (or who plan to be) actively
involved in the Veterans Administration health care network. (Department of Veterans Affairs,
n.d.). The scale is widely used in the veteran network, but reliability and validity could not be
assessed independently.
Clinician-Administered PTSD Scale (CAPS). The gold standard of PTSD scales, the
CAPS has been in active use for several decades. In 2001, Weathers et al. conducted a ten year
review of the instrument and found extremely high reliability and validity, both internal and
external. Test-retest correlations ranged from .86 to .87 for frequency, .86 to .92 for intensity,
and .88 to .91 for severity. The study also yielded robust estimates of reliability, with intraclass

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correlations of .91 for total frequency, .91 for total intensity, and .92 for total severity.
Additionally, alphas for all 17 items were .93 for frequency, .94 for intensity, and .94 for
severity. Weathers also cited additional evidence for interrater reliability.
PTSD Symptom Scale - Interview (or PSS-I). This scale is designed to be used in a faceto-face interview. It was developed in 1993 and has been extensively evaluated for reliability and
validity. Internal consistency of the PSS-I as measured by Cronbachs Alpha is extremely high
at .85. Additionally, test-retest reliability is high at .80, and alpha coefficients for clusters are: reexperiencing = .69, avoidance = .65, and arousal - .71. (Witherby, 2014)
Self-reported. The study will utilize a self-reported measure in addition to the clinicianadministered tests. The Penn Inventory for Post-traumatic Stress Disorder has been widely used
since 1992. Hammarberg (1992) reported that
The Penn Inventory has been demonstrated to have very good to excellent internal
consistency (changes from .78 to .94) across a variety of clinical and community
samples Additionally. test-retest over an average of 5.2 days ranged from .87 to .93.
The Penn Inventory has the added advantage of not being keyed to a specific traumatic event.
Subjects self-reporting with the Penn Inventory are reporting on their emotions and reactions
generally, as opposed to their reactions to the specific trauma which prompted them to originally
seek treatment. Because this study is not specifically designed to measure broad outcome (but is
understandably interested in such), a nonetheless wider measure of PTSD symptoms at close of
treatment is preferable.
This instrument will be the only scale used at six-month follow-up. No clinician will be
present for its administration.

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Intervention
This study attempts to examine the efficacy of a therapeutic intervention in an individual
(not group) context namely, asynchronous email-based CBT. As noted above, very little
research has been devoted to using online interventions with veterans, and none have studied
email-based therapies.
A standardized email-based treatment model will be developed and utilized by VA
clinicians; the same clinicians will work with both control and treatment groups in order to
eliminate several variables. The intervention will draw both from standardized methods of CBT,
including PE (prolonged exposure) and CET (channel exposure therapy), as well as exercises in
changing thought patterns.
Participant Protection
According to Tran et al. (2015), three key strategies in protecting research subjects are:
1. voluntary informed consent;
2. assurance of anonymity and confidentiality;
3. no harm and distress to participants.
The Veterans Administration maintains its own Informed Consent form which all participants
would be required to sign. The form covers all standard research and experimental information
required to be supplied for informed consent. Records kept by researchers will be stripped of
personally identifying information. In addition, all participants will receive immediate treatment
by the same trained professionals, regardless of which group they are a part.
Treatment-group participants will also be notified that the treatments they will undergo
are research-based and have not been proven (that is, there is no significant evidence base to

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justify their use). Because of the experimental nature of the treatment, participants will be
informed that they may leave the email group at any time and resume traditional therapies in
person.
Results
Its difficult to predict what the results of the intervention will be. On one hand, there is
significant evidence that young people (ages 18-30) are comfortable with using email and the
Internet. This would seem to predict that the email-based treatment would be successful.
However, there are concerns specifically around the veteran population involving the lack of
success of online workshops. Overall, I believe that the results would be positive i.e. email
treatment would be effective but I dont believe that it would be any more effective than inperson traditional CBT techniques currently practiced by the VA.
Discussion
Potential Policy & Practice Implications
Success in this study would first call for additional research with a larger sample. As the
recruitment was not randomized, selection bias cant be ruled out. The results of this proposal
wouldnt be generalizable and it would be premature to advise policy or practice changes
regardless of the results.
Hypothetically, if additional research was carried out and found the intervention as good
or better than traditional treatment, the VA might consider integrating an email component into
their standard treatment regimen perhaps even giving veterans the option of what kind of
treatment they receive. The ability to choose what would best work for them could be construed

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as a new kind of self-empowerment, which might further impact the positive outcomes of their
chosen treatment.
Conclusions around existing familiarity with email and Internet-based systems might be
drawn, as well as additional data concerning physical distance to treatment. In 2014, Mackintosh
et al. determined that longer commutes to and from therapy resulted in better treatment
outcomes. Whether or not a proximity of zero (for the treatment group) had an impact would be
interesting to analyze.
Limitations
Advertisement only in VA means that all subjects were already seeking or receiving
treatment for either physical or mental health issues. Not representative and cannot be
generalized. Selection bias in that only those people who were interested in getting better applied
for the study. Fliers were only in English and so demographically the study is especially limited.
Due to concerns for client privacy, there is no way to verify adherence to email-based therapy
protocols and researchers must rely solely on clinician self-reporting.
Its also impossible to draw any conclusions based on gender as no women were recruited
for the study. Neither were long-term outcomes measured (later than six months after conclusion
of treatment); recurrence or relapse of PTSD symptoms as well as long-term mental health
outcomes unrelated to PTSD diagnosis remain to be studied.
Despite there being one standardized email therapy method, the possibility exists for
different clinicians to respond to emails differently (with shorter or longer turnaround times, for
example). Ideally, this data should be collected and procedures standardized & enforced
throughout the course of treatment.

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The reliability and validity of one of the instruments used in this study could not be
verified; it is a widely used diagnostic and evaluative tool used by health care professionals, but
almost always inside the Veterans Administration network. While this instrument is useful in
diagnosis and prescreening for PTSD in the veteran population using it in this study does
not increase the validity or reliability of the results.
Questions for Further Research
Questions for further research include the following:
1. Is asynchronous email-based CBT treatment more or less effective for digital non-natives
(that is, people outside the Millennial generation?
2. Is asynchronous email-based CBT treatment more or less effective for other sufferers of
PTSD (not combat veterans) in the same age bracket?
3. Is asynchronous email-based CBT treatment more or less effective than other forms of
online therapy (including workshops, group-based treatment, and tele- or videoconferencing)?

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References

Bush, N. E., Prins, A., Laraway, S., OBrien, K., Ruzek, J., & Ciulla, R. P. (2014). A pilot
evaluation of the AfterDeployment.org online posttraumatic stress workshop for military
service members and veterans. Psychological Trauma: Theory, Research, Practice, and
Policy, 6(2), 109-119. doi:http://dx.doi.org/10.1037/a0032179.
Department of Veterans Affairs. (n.d.). Review post traumatic stress disorder (PTSD) disability
benefits questionnaire. Retrieved from http://www.vba.va.gov/pubs/forms/
VBA-21-0960P-3-ARE.pdf.
Friedman, M. (n.d.). PTSD History and Overview. National Center for PTSD. Retrieved from
http://www.ptsd.va.gov/professional/PTSD-overview/ptsd-overview.asp.
Hammarberg, M. (1992). Penn inventory for posttraumatic stress disorder. doi:http://dx.doi.org/
10.1037/t07464-000.
Kilpatrick, Dean G., Heidi S. Resnick, Melissa E. Milanak, Mark W. Miller, Katherine M. Keyes,
Matthew J. Friedman. (2013). National estimates of exposure to traumatic events and
PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress,
October 2013, 26, pp. 537-547. Retrieved from http://www.ptsd.va.gov/professional/
articles/article-pdf/id87750.pdf.
Kojima R, Fujisawa D, Tajima M, Shibaoka M, Kakinuma M, Shima S, Tanaka K, Ono Y.
(2010). Efficacy of cognitive behavioral therapy training using brief e-mail sessions in
the workplace: a controlled clinical trial. Retrieved from http://www.ncbi.nlm.nih.gov/
pubmed/20720342.

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Litwack, S. D., Jackson, C. E., Chen, M., Sloan, D. M., Hatgis, C., Litz, B. T., & Marx, B. P.
(2014). Validation of the use of video teleconferencing technology in the assessment of
PTSD. Psychological Services, 11(3), 290-294. doi:http://dx.doi.org/10.1037/a0036865.
Mackintosh, M., Morland, L. A., Kloezeman, K., Greene, C. J., Rosen, C. S., Elhai, J. D., &
Frueh, B. C. (2014). Predictors of anger treatment outcomes. Journal of Clinical
Psychology, 70(10), 905-913. Retrieved from http://search.proquest.com/docview/
1560637760?accountid=9673.
News21. (2013). Returning Iraq and Afghan war vets find little government support,
investigation finds. Florida Center for Investigative Reporting. Retrieved from http://
fcir.org/2013/08/26/iraq-afghanistan-war-veterans-florida/.
Parish, M. B., Apperson, M., & Yellowlees, P. M. (2014). Frontline reports. Psychiatric Services,
65(5), 697. Retrieved from http://search.proquest.com/docview/1555962951?
accountid=9673.
Pew Research Center Internet Project Survey. (2014). Internet users in 2014. Retrieved from
http://www.pewinternet.org/data-trend/internet-use/latest-stats/.
Ruwaard J, Lange A, Schrieken B, Emmelkamp P. (2011). Efficacy and effectiveness of online
cognitive behavioral treatment: a decade of interapy research. Retrieved from http://
www.ncbi.nlm.nih.gov/pubmed/21685634.
Steenkamp, M. M., & Litz, B. T. (2014). One-size-fits-all approach to PTSD in the VA not
supported by the evidence. American Psychologist, 69(7), 706-707. Retrieved from http://
search.proquest.com/docview/1606043943?accountid=9673.

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Tran T., Rhee, S. & Shen, C. (2015). Multicultural social work research methods and data
analysis. Cognella Academic Publishing.
VA Office of Inspector General. (2005). Review of state variances in VA disability compensation
payments. Department of Veterans Affairs, Office of Inspector General. Retrieved from
http://www.va.gov/oig/52/reports/2005/VAOIG-05-00765-137.pdf.
Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Clinician-administered PTSD scale:
A review of the first ten years of research. Depression and Anxiety, 13(3), 132-156.
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Witherby, I. (2014). Research methods: instrument paper (PSS-I). Unpublished.

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Appendix: Additional Questions for Intake Questionnaire (Supplement to Review DBA)


1. Please rate your level of familiarity with using email.
0

None at all

A little bit

Somewhat

Familiar

Very familiar

2. Please rate your level of familiarity with using the Internet.


0

None at all

A little bit

Somewhat

Familiar

Very familiar

3. How long has it been since you returned from deployment?


___________ months
4. Have you ever sought mental health treatment via the
Internet or over email before?

______ Yes

_______ No

5. Do you have Internet access at home?

______ Yes

_______ No