Volume: 3 Issues: 17 [September, 2018] pp:57-67]

International Journal of Education, Psychology and Counseling

eISSN: 0128-164X
Journal website: www.ijepc.com

WEBSITE TESTING OF iTF-CBT (internet TRAUMA

FOCUSED – COGNITIVE BEHAVIOR THERAPY) AS AN
INNOVATION FOR THE PREVENTION OF TRAUMA AND
MENTAL DISORDER
Samsiah Mohd Jais1
Mohammad Nasir Bistamam2
Muhammad Bazlan Mustafa3

1,2,3
Counselling and Psychology Department, Faculty of Human Development, Sultan Idris Education University,
35900 Tanjung Malim Perak.

Accepted date: 30 January 2018 Published date: 13 September 2018

To cite this document: Jais, S. M., Bistamam, M. N., & Mustafa, M. B. (2018). Website
Testing Of iTF-CBT (Internet Trauma Focused – Cognitive Behavior Therapy) As an
Innovation for The Prevention of Trauma and Mental Disorder. International Journal of
Education, Psychology and Counseling, 3(17), 57-67.
__________________________________________________________________________________________

Abstract: This study has produced the internet Trauma Focused - Cognitive Behavior Therapy,
also known as iTF-CBT, as an innovation for the prevention and treatment of trauma and
mental health disorder. This study aims to present the development result of the TF-CBT
website and to test the percentages of agreement of the content, software interaction and
technical aspects of iTC-CBT. The iTF-CBT module consists of five modules, namely i. Psycho
Education; ii. TF-CBT; iii. Exposure Therapy; iv. Cognitive Therapy; and v. Anxiety
Management. All of these modules are supported by 12 activities. Besides, this study is divided
into two phases: i. Module development phase; and ii. iTF-CBT testing phase. The first phase
involved data collection by conducting interviews with the experts as well as literature review.
The second phase involved getting the percentages of agreement for the development of iTF-
CBT among 42 trainee counselors of the Sultan Idris Education University (UPSI). Results of
this study indicate that the mean of percentages of the agreement between content, software
interaction and technical aspects in the final test of iTC-CBT are high between 93 to 100
percent. These findings show that TF-CBT modules are applicable in the training to enhance
the efficiency of trauma and mental health counselling. As a result, this study has further
expanded the theory and practices of counselling in the context of mental health particularly in
Post-Traumatic Stress Disorder (PTSD) and trauma.

Keywords: TF-CBT Modules, iTF-CBT, Trauma, Crisis, Mental Disorder

__________________________________________________________________________________________

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Introduction
Trauma has been a main concern in the aspect of mental health and physical wellbeing of a
person (Beck & Sloan, 2012; Brown et al., 2011). Studies indicate that 82.8% of individuals in
the United States of America have experienced trauma throughout their lives and majority of
them have undergone at least one stress disorder after the trauma (PTSD) based on the criteria
and levels defined by the Diagnostic Statistical Manual - 5 (DSM-5; American Psychiatric
Association, 2013) (Beck & Sloan, 2012).

In Malaysia, mental disorder has become a common problem and the number of patient with
mental disorder receiving psychiatric treatment in the public hospitals has increased.
Malaysians are often startled by sudden tragedy, wars, economy or politic crisis, accidents, and
pandemic of sickness which could bring traumatizing impact to most of its victims. If these
victims do not received immediate treatment physically or psychologically, their conditions
will get worse, causing serious Post Traumatic Stress Disorder (PTSD) and might even lead to
suicide. Nevertheless, having a good mental health condition can reduce the risks of traumatic
stress or PTSD which could lead to more serious mental disorder (Samsiah et al., 2014).

Based on literature review, TF-CBT shows good treatment effect, good security and also cost-
efficient (Strom, Pettersson, Andersson, 2000; Ost, 2008; Butler et al., 2006). In other words,
TF-CBT is a promising treatment based on its efficiency with a combination of good treatment
effect and security. However, the access to TF-CBT is limited. Only small amount of patients
have been able to receive such efficient psychology treatment due to limited trained therapist as
well as limited clinics provided in area with less population. As such, there is need to enlarge
the availability of treatment to more people in which therapy and access to CBT can be offered
more efficiently. As a result, the researchers have come together to create an innovation of
treatment which is way more efficient as it is accessible ‘online’, namely the iTF-CBT.

TF-CBT uses CBT concepts to help a person cope with trauma. CBT concepts guided this
study in focusing on how TF-CBT helps a person address and change his or her negative
thoughts, feelings, and behaviors. CBT relates to the idea of structured psychotherapy that
focuses on helping a person become aware of inaccurate or negative thinking so they are more
able to respond clearly and effectively. Thinking impacts feeling which also impacts behavior
and results in a multidirectional link. Since people respond differently to different situations, it
is important to understand how an individual experienced a situation in order to best help that
specific individual. Life’s events may lead a person to have inaccurate or negative thoughts
about future situations; often this shapes how people respond not only to situations and
experiences, but how people respond in social interactions and relate to others. Therefore, a
person’s relationships may be impacted or harmed by previous experiences. As a result, CBT
theorists believe that it is important to help a person address negative cognitions and restructure
them so that they are more accurate and less negatively impactful to the person’s future
(Hernandez, 2014).

With the emergence of internet, a new internet-based treatment method focusing on trauma
(iTF-CBT) is created, known as the internet CBT (iCBT). TF-CBT is an online service which
offers treatment and information on iTF-CBT, accessible to enhance knowledge on mental
healthcare and traumatic stress prevention. In Malaysia, the development of an online iTF-CBT
has not yet been carried out. As such, the researchers have initiated the development of iTF-
CBT and hopefully the result can offer benefits to the treatment and prevention of trauma and
mental health problem. Findings from the pilot study indicate that the TF-CBT module has

58
good validity value and high reliability value over level .60 which is .835; hence, this module is
regarded as a complete module (Samsiah et al., 2017).

Problem Statement
In Malaysia, based on the latest data of survey in 2015 by National Mental Health Morbidity
Survey (NHMS) (New Straits Times, September 26, 2016 in Samsiah et al., 2017), 4.2 million
out of 14.4 million of Malaysians age 16 and above have experienced problems related to
mental disorder. Besides, statistics by NHMS have also shown drastic increment on the cases
of mental disorder since 1996 (10.7%), 2006 (11.2%) and up till 2015 (29.2%). In terms of
psychiatric assistance, since 2013, statistics indicate around 400,227 mental patients have
received psychiatric treatment in public hospitals. These show an increment of 15.6 %
compared to 346,196 patients in 2012. Moreover, 3 million out of 26 million of Malaysians
including children are estimated with problems of emotional and mental disorder, with 6
suicide cases daily, 2,500 yearly, and 50,000 cases of attempt suicide yearly. The amount of
suicide cases in Malaysia is almost equivalent to those of the developed countries such as the
United States of America (Samsiah et al., 2015).

Cognitive Behavior Therapy or CBT is proven as a well-established and effective

psychological treatment method to treat PTSD and several other mental and health disorders
such as depression, anxiety disorder and obsessive compulsive (Andersson, 2009; Dobson,
2001). Among the random treatment group sampling, TF-CBT has been proven effective in
treating all of those disorders (Ost, 2008; Butler, 2006) and used as the main treatment because
of its combination of excellent treatment effect and good security (Strom, Pettersson,
Andersson, 2000; Ost, 2008; Butler et al., 2006). Besides, CBT focusing on trauma is also
viewed as a potential and promising treatment in terms of cost-efficient within the community.

iCBT can be used as an alternative strategy to assist clients with PTSD as well as other mental
disorders. Moreover, through the ‘online’ method, more clients or individual with needs of
mental health treatment who are shy to reach out and see the doctor because of stigma could be
benefited through self-guidance while receiving minor supervision by counsellors or therapist.
Besides, this method is also time-saving and enable the counsellors to identify clients with
trauma and mental disorder as early as possible so that help and treatment can be given at once
in a proper way before the problem turns into chronic.

Nevertheless, access to TF-CBT is still limited especially to those in need. Only small amount
of patients are able to receive such efficient psychology treatment due to limited trained
therapist available as well as limited outpatient clinics provided in area with less population
(Shapiro, et al., 2003). As such, there is need to enlarge the availability of treatment in which
the time of therapy can be used efficiently with wider access to TF-CBT. As a result, this study
aims to develop an internet-based TF-CBT training module in order to increase the
accessibility level of the trauma and mental health counselling services and to improve the
mental wellbeing of clients. In accordance with the globalization era, therefore, a new internet-
based treatment method is developed, namely the TF-CBT.

Research Aims
This study aims to develop a TF-CBT website, known as the iTF-CBT; and to test the interface
design, content, software interaction and technical aspects of iTF-CBT as early prevention
strategies of mental health disorder. The module of iTF-CBT is developed through literature
review in which it is adapted and made based on the TF-CBT model by Cohen, Mannarino &

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Deblinger (2012). Mean while, the training module of iTF-CBT is made based on the module
development procedures by Rusell (1974) and Sidek and Jamaludin (2005). This training
module is made to enhance the competency level and sensitivity of counsellors towards
counselling cases involving trauma and crisis as well as mental health.

Research Methodology
Research Design
The design of this study is the preliminary study in the forms of literature review and survey in
order to gather information on the CBT theories, CBT theories focusing on trauma, and to
develop the iTF-CBT module. Besides, literature review and survey are carried out to identify
the components of TF-CBT training module, to review the best literature, theories and model as
well as the requirements of the module. Furthermore, survey is carried out to gather the
percentages of agreement based on the research sample among the trainee counsellors of UPSI.

Research Location
42 undergraduates of the Bachelor Degree of Guidance and Counselling Education are
involved as respondents in this study to test the iTF-CBT website. Research location is the
lecture room of Psychology and Counselling Department of the Sultan Idris Education
University in Tanjung Malim.

Research Sample
42 undergraduates of the Bachelor Degree of Guidance and Counselling Education from UPSI
are involved in testing the usability of iTF-CBT. Purposive sampling is used to select the
sample of this research in order to fulfil the objectives of this study and answer the queries
from a study (Kerlinger & Lee, 2000). Selection of undergraduates from the Guidance and
Counselling stream are mainly based on their specialization, having been exposed theoretically,
practically and clinically in conducting the guidance and counselling session individually.

Research Tool
Data of the usability of the website is gathered by conducting early and final tests using the
iTF-CBT Module Development Questionnaire Survey. These questionnaires consist of two
parts: Part A and Part B. Part A contains information on the background of the respondents;
whilst Part B contains a list of questions related to the iTF-CBT Module Development. There
are two types of questionnaires used in the early and final tests, namely the questionnaire on
Interface Design, Content and Overall; and the questionnaire on Interface Design, Content,
Software Interaction and Technical.

Research Findings
In this study, the TF-CBT module is adapted and made based on the model by Deblinger,
Cohen & Mannarino (2006). The overall components of TF-CBT module consists of five
modules with 12 activities. Module 1: Psycho education aims to increase involvement in order
to develop therapeutic relationship, offer information related to trauma, normalize trauma
symptoms, and to demonstrate relaxation exercises to overcome daily stress. Module 2: TF-
CBT explains to the basic concepts of cognitive behavior theory focusing on trauma involving
thoughts, attitude and perception of individuals about themselves and others; and how these
would influence their interpretation of a traumatic event that happen; and this interpretation is
important as it could influence the resurgence of emotion and behavior. The next modules are
Module 3: Exposure Therapy; Module 4: Cognitive Therapy; and Module 5: Anxiety
Management, mainly discussing on trauma intervention techniques based on behavior theory

60
focusing on the aspects of cognitive in managing anxiety. The activities in these modules aim
to enhance skills such as managing anxiety, managing thoughts distortion as a result of trauma,
restructuring the cognitive in order to transform the negative thoughts, managing anger,
interpersonal communication, and getting ready for stress reaction (stress inoculation) and
managing trauma symptoms in the future. In other words, the draft of this TF-CBT module
consists of main module, activities, content and techniques as shown in Table 1 below:

Table 1: Module, Activities and Techniques of TF-CBT Module

Module Activities/Content Techniques

Module 1: Activity 1: Trauma and - Explanation/talk

Psychoeducation PTSD - Tacit consent form
- Discussion
Activity 2: Traumatic Event - In group training

Activity 3: Relaxation Exercises

Module 2: Activity 4: CBT and - Explanation/talk

Trauma Focused- A-B-C Concepts - Discussion
Cognitive Behavior - In group training
Therapy (TF-CBT) Activity 5: TF-CBT - Presentation

Module 3: Exposure Activity 6: Imagination Exposure & In- - Explanation/talk

Therapy vivo - Discussion
- In group training
Activity 7: Prolonged Exposure - Presentation

Modul 4: (Cognitive Activity 8: Negative Thoughts/maladaptive - Explanation/talk

Therapy) - Discussion
Activity 9: Cognitive - In group training
Restructuring & Cognitive - Presentation
Diffusion - Role-play

Modul 5: (Anxiety Activity 10: Stress Inoculation Therapy - Explanation/talk

Management) Activity 11: Narrative Exposure Therapy - Discussion
Activity 12: Relaxation - In group training
- Presentation

The testing of iTF-CBT module involved two series: the early test and the final test. In the
early test, the questionnaires are distributed to 42 undergraduates of Bachelor Degree of
Guidance and Counselling from UPSI before the pre-test. The questionnaires consist of two
parts: Part A and Part B. Part A contains information on the background of the respondents;
whilst Part B contains a list of questions related to the iTF-CBT Module Development. In the
early test, the respondents are not allowed to use the computer personally. Only one computer
and a projector are used to show the development result of iTF-CBT module to the respondents
in front of a lecture room. Results from this test are for Part B as shown in Table 2 below.

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 Table 2: Questionnaire of Interface Design, Content and Overall

Aspects Items Percentages (100)

of Agreement
Interface Design Usage of suitable text 68
Usage of suitable graphics 90
Usage of suitable animation 86
Rapid software reaction (grain size) 90

Content Inadequate information 30

Complicated information 44
Accurate information 80
Practical information 92
Organised information 89
Clear and understandable information 76
No spelling error 88

Overall Attractive software 87

User-friendly software 95
Contents of software are suitable 86
Contents of software are helpful to counsellors 93
Contents of software are helpful to students 90
Contents of software are helpful to clients 96

The development process of iTF-CBT module involved improvement based on feedbacks and
suggestion received from the early test as shown in Table 2. Referring to the Interface Design,
results show that 68% of the respondents felt that the text usage needs changes or bigger font
size. However, most of the respondents agreed with the usage of graphics with 90% of
agreement; and also with the usage of animation with 86% of agreement as well as the rapid
software reaction (grain size) with 90% of agreement. As for the Content, 44% of the
respondents felt that the information needs to be simplified; while only 30% commented that
the information is inadequate. Apart from that, between 76 – 92% of the respondents agreed
that the contents of the software are easy to understand, organised, practical in daily life and
contain no obvious spelling error. The Overall indicates that the software is attractive, user-
friendly, and its contents are helpful to counsellors, students and clients with the percentages of
agreement between 87 – 96%.

The second test is carried out to the same respondents as in the early test. Results from the final
test enable the researchers to identify the level of satisfaction on software interaction and
technical aspects. The questionnaires are further amended with the addition of technical aspects
and software interaction. Results of the test are shown in Table 3.
Table 3: Findings on Interface Design, Content, Software Interaction and Technical in Final Test

Aspects Items Percentages (100)

of Agreement
Interface Design Attractive screen design 95
Clear text 90
Attractive graphics 83
Attractive colors 85
Effective usage of audio 70
Effective usage of animation 86
Animation aid learning 78
Suitable interaction 80

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 Appropriate feedback/response time 76
Combination of text, graphics, audio, video, animation and colors
enhance learning 93
Clear software instructions 86
Easy-to-understand software instructions 80
Manual available anytime 96
Easy-to-understand choices of icons 86
Consistent usage of icons 85
Presentation without facilitator 90
Organised reference list for easy-to-reach additional information 95

Content Shallow/limited knowledge 43

Information too easy to users 95
Accurate information 97
Practical information in daily tasks 100
Information related to users’ current knowledge 95
Organised information 93
Easy-to-understand language 95
No typo error 92

Software User can move forward and backward whenever necessary 95

Interaction User can log out from the program anytime 97
User can stop and restart from the same location 87
Well-organised presentation 93
Presentation suitable to users’ learning style 95
Attractive presentation 95
Software stimulate users 97
Software enhance learning 100
User-friendly software 100

Technical No technical problem 100

Software compatible with computer 90
Software without error 95
Software without crash 95
Software will not hang when used wrongly 91

Table 3 shows between 70 to 96% of the respondents agreed that the interface design of iTF-
CBT website in the Trauma and Mental Health Counselling is attractive with clear text,
attractive colors and graphics, with manual that is accessible anytime and helps users get
additional information. On the other hand, the usage of audio needs some improvement or
updates in order to achieve higher efficiency because only 70% of the respondents agreed with
this design. Besides, animation to aid learning and the appropriate feedback/response time also
need improvement with only 70% and 76% of agreement respectively from the research
samples. Apart from that, around 93 to 100% of the research samples agreed with the content
of information. However, the content still needs to be upgraded because 43% of the research
samples agreed that the content is still shallow; while 8% of the research samples agreed that
there are spelling error. Furthermore, between 87 to 100% of the research samples agreed that
software interaction and navigation are suitable to the needs of the users. In terms of technical,
between 90 to 100% of the research samples agreed and are satisfied with the software.

Discussion
The development and testing of iTF-CBT website is based on current needs with themes related
specifically to the prevention and treatment of trauma and mental disorder. Besides, the

63
development and needs of the iTF-CBT are in accordance with the CACREP standards which
have approved the needs to include issues related to trauma for crisis intervention. According
to Webber and Mascari (2009), “The 2009 CACREP standards provide competencies for crisis,
disaster, and trauma response that are infused in both core counselling and program specific
curricula” (pg. 125). These standards can enhance competency of counsellors when managing
trauma and calamity cases; while bringing innovation to the basic training needs of counsellor.

This module is not developed to solely fulfil the needs of trauma counselling competency
standards, but also to meet the current needs nowadays with various types of traumatic events
and emergency. The iTF-CBT module consists of five main modules with 12 activities, namely
Module 1: Psycho education which aims to increase involvement in order to develop
therapeutic relationship, offer information related to trauma, normalize trauma symptoms, and
to demonstrate relaxation exercises to overcome daily stress; Module 2: TF-CBT explains to
the participants about the basic concepts of cognitive behavior theory focusing on trauma
involving thoughts, attitude and perception of individuals about themselves and others; and
how these would influence their interpretation of a traumatic event that happen; and this
interpretation is important as it could influence the resurgence of emotion and behavior. The
next modules are Module 3: Exposure Therapy; Module 4: Cognitive Therapy; and Module 5:
Anxiety Management, mainly discussing on trauma intervention techniques based on behavior
theory focusing on the aspects of cognitive in managing anxiety. These activities within the
TF-CBT module aim to enhance skills such as managing anxiety, managing thoughts distortion
as a result of trauma, cognitive restructuring in order to transform the negative thoughts,
managing anger, interpersonal communication, and getting ready for stress reaction (stress
inoculation) and managing trauma symptoms in the future. Most of these activities within the
TF-CBT module are new and have not been expose to most participants.

The iTF-CBT website is not only developed for the purpose of prevention and treatment, but
also to educate users about the knowledge on mental healthcare and methods to avoid traumatic
stress. Besides, this website can also serves as a good reference source about issues on trauma /
PTSD or mental disorder to the community whether professional or non-professional groups.
As such, by having this module, counsellors can enhance their level of competency and
awareness on the treatment and prevention of trauma and mental disorder; as in accordance
with most of the trauma counselling models by several researchers which have given some
guidelines to the counsellors (Powers, 2006; Eagle, 1998; Hobfoll, 2009; Egan, 1998; Prout
and Schwarz, 1994; Lewis, 1999; Du Tolt, 2002; Goleman, 1995; Greenberg, 2002).

Research Implications
Counselling nowadays has begun to recognise the importance of positive mental health and the
consequences of ignoring it. American Psychological Association (APA) and American
Counselling Association (ACA) have declared that mental health is an important element
because it is related to the wellbeing of human life. Besides, plenty of studies show that
positive mental health would help individuals to remain sensible even in an emergency.

Findings of this study indicate that TF-CBT module has high validity and reliability values. In
other words, it has achieved its development objectives and suitable to its target users. Besides,
this module can serves as an intervention to enhance the competency level of trauma and
mental health counselling practices particularly in the treatment and prevention of trauma and
mental disorder. The TF-CBT module can also be used by school counsellors to identify

64
students with traumatic stress which could have lead to more serious problem (such as suicide,
taking any substance or run away from home) if early assistance is not provided.

This study introduced the ‘online’ training approach using the online trauma and mental health
module to enhance competency level of counselling practices. Moreover, the approaches used
in the development of this module can also serve as guidelines to other researchers to develop
future module in order to verify validity or reliability of the module. These methods were used
by previous researchers to developed training modules related to trauma and counselling to
train counsellors, social workers and those involved in the profession of helping others with the
aim to enhance their skills in helping the trauma victims efficiently (Van Houten & Tom, 2006;
McEvoy & Ziegler, 2006; Jordons, 2002; International Planned Parenthood Federation, 2002).

Besides, findings of this study could also enhance knowledge on counselling based on trauma
and mental health as well as other related aspects such as crisis and traumatic stress. In
Malaysia, study on development of iTF-CBT module has not yet been carried out
systematically and comprehensively; therefore, this study has further enhanced the available
theory of trauma and mental health counselling. Furthermore, this study has also enriched the
available practices in the guidance and counselling theory; directly enhances competency and
professionalism. Counsellors can enhance their competency while using it in counselling.

Conclusion
Trauma-focused Cognitive Behavioral Therapy or TF-CBT has been proven as an efficient
psychological treatment method in treating PTSD and other mental disorders. As such, a more
efficient ‘online’ treatment innovation, known as TF-CBT or internet-based CBT (iCBT)
focusing on trauma (iTF-CBT) is developed with five modules and 12 activities based on TF-
CBT. The iTF-CBT module has undergone testing and is proven with high validity and
reliability values, as well as with high percentages of agreement in the final test in terms of the
content, software interaction and technical aspects of the module. This brings positive influence
to the development of counselling theory while enhances skills in counselling practices. As
such, further research in trauma and mental health counselling could be expanded as a
knowledge field of study that helps counsellors and those involved in the profession of helping
others for the wellbeing of mankind.

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