This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/, as well as this copyright and license information must be included.
Dissociative states during psychotherapy sessions reduce the benefit of exposure-based therapy for posttraumatic stress disorder (PTSD). Thus, in evidence-based therapeutic programs such as dialectical behavior therapy for PTSD (DBT-PTSD), therapists apply specific antidissociative skills to reduce dissociative features during
In addition to therapist-guided sessions, exposure protocols often require that the patients listen to audio recordings of exposure sessions in self-management. The problem of how to prevent dissociative features during such self-administered exposure exercises has not been resolved yet.
Hence, we developed the computer program MORPHEUS that supports the application of self-administered exposure exercises. MORPHEUS continuously monitors the level of dissociative states and offers state-related antidissociative skills.
This study sought to examine the acceptance and feasibility of the MORPHEUS program.
Patients who underwent 12 weeks of residential DBT-PTSD treatment used MORPHEUS during exposure exercises in self-management. After the treatment, they filled out evaluation questionnaires.
In sum, 26 patients receiving a 12-week standard DBT-PTSD program participated in this study; 2 participants could not be analyzed because of missing data. All the patients used MORPHEUS as often as it was required according to the DBT-PTSD treatment (2 to 5 times a week). The overall acceptance and feasibility as rated by the patients was high: for example, patients found the skills useful to block dissociation (mean 4.24 on a scale from 0 to 5, SD 0.24) and stated that they would use the program again (mean 4.72 on a scale from 0 to 5, SD 0.11). Furthermore, patients indicated that they would recommend MORPHEUS to a friend (mean 4.44 on a scale from 0 to 5, SD 0.12). In 82% (32/39) of the cases, the use of antidissociative skills was related to a decrease in dissociation. In 18% (5/39), dissociation remained unchanged or increased.
The evaluative data suggest high acceptability and feasibility of MORPHEUS. Further studies should evaluate the effectiveness of the skills applied during the program.
World Health Organization International Clinical Trials Registry Platform: DRKS00006226; http://apps.who.int/trialsearch/Trial2.aspx?TrialID= DRKS00006226 (Archived by WebCite at http://www.webcitation.org/ 6hxuFbIUr)
One problem that might arise during such exposure exercises is the occurrence of dissociative states. In their literature review, Craske and colleagues [
Dissociation positively correlates with the level of acute emotional distress and this association is highest in patients with BPD [
There is recent evidence showing that dissociation is associated with attenuated improvement after treatment of BPD [
Thus, therapists are faced with the challenge to apply exposure therapy in patients with high dissociation proneness. A range of strategies to cope with dissociation in PTSD can be found in the literature. In their Prolonged Exposure (PE) manual, Foa et al [
To the best of our knowledge, no studies to date have tested the effectiveness of distraction to address state dissociation in patients with PTSD. However, the role of distraction tasks and the effect on working memory performance have been discussed as a potential treatment mechanism of Eye Movement Desensitization and Reprocessing (EMDR) therapy [
A second consequence of
As stated above, most exposure-based treatments include exposure exercises in self-management. Typically, during these exposure exercises patients are requested to listen to audio recordings of the exposure sessions [
So far, a few apps have been developed to support PTSD treatment. To our knowledge, only two of them have been published in clinical journals: PE Coach [
PTSD Coach can be used as either a stand-alone tool or an adjunct tool to face-to-face-therapy [
Although these apps appear to be promising, they do not allow monitoring dissociation while listening to the recording. Furthermore, PE Coach does not provide strategies to cope with state dissociation. Moreover, apart from recording SUDs, none of the apps provides tools for monitoring other trauma-associated emotions. Therefore, we developed a computer program (MORPHEUS) that is designed to support self-administered
MORPHEUS is a computer program that allows computer-assisted
Usability was a key requirement for MORPHEUS. The program was developed based on requirements expressed in interviews with patients and therapists at the PTSD unit of the Central Institute of Mental Health (CIMH), Mannheim (Germany). MORPHEUS was iteratively improved based on users’ feedback.
Patients record their exposure sessions on a digital voice recorder where MORPHEUS is preinstalled. When the voice recorder is connected to a computer, the program imports and plays the recordings automatically (
Main screen: selection of audio recording and time interval for the iterative question for state dissociation.
Session recording with MORPHEUS.
While playing the recorded session, patients can monitor the level of state dissociation on a scale from 0 (not at all) to 100 (very much) in self-adjusted time intervals between 1 and 15 minutes. The question for state dissociation can be deactivated as well. During therapy, patients are trained to evaluate and monitor their individual levels of state dissociation on this scale. This intervention aims at increasing the patient’s awareness of dissociation and thus fostering their ability to address these symptoms.
A dissociation level of 70 is defined as an anchor point: at that point, cognitive functioning is severely impaired, and sensory awareness of the here and now is perceived as increasingly “unreal.” This concept corresponds to the idea of high aversive distress as defined by DBT [
If the patient endorses a dissociation rating of higher than 70, MORPHEUS randomly offers one of 15 available skills. These skills can be either used immediately or skipped. Patients can also predefine a subset of favorite skills from which the program chooses to offer one. On-demand use of skills is possible at any time during the exposure exercises and skills are available at any time after the exposure exercise as well. Patients can access and practice skills within the “skills box” of the program. Skills require a time frame of approximately 1 minute each or can be stopped earlier. Once it ends, MORPHEUS again asks for the level of dissociation. Skills in MORPHEUS are quick digital tasks. These tasks require full attention and serve as distractors that interfere with dissociation. MORPHEUS applies skills that address 4 sensory domains: spatial, cognitive, visual, and auditory (see
If a user is inactive for more than 10 seconds despite being asked for input (eg, during a skill or the monitoring question), white noise and an unpleasant tone (1-kHz sinus wave) are presented and the screen background alternates from white to black. This strong sensory signal serves as a distractor that helps the patient to interrupt a pronounced dissociative state and to reorient to the present.
Overview of the skills in MORPHEUS.
Skill name | Task | Sensory domains |
Treasure hunt | Find an audio signal with a noise detector. | Auditory |
Square pattern | Click if you see a square pattern or if you hear a sound. | Visual |
Color logic | Click on the announced color. | Visual |
Color mapping | Click on the square that matches the background color. | Visual |
Go round | Don't let the moving squares touch the cursor. | Spatial |
Maze | Remember the luminescent squares on a maze and then click on them with the cursor. | Visual |
One-way pong | Catch a moving ball. | Visual |
Rolling ball | Navigate a ball down the screen. | Visual |
Reaction | Move the cursor to the objects that appear as soon as possible. | Visual |
Finding new objects | Click on each new symbol. | Visual |
Mismatch | Find the symbol that differs from the rest. | Visual |
Brain Flic-Flac | Solve an arithmetic task. | Cognitive |
Multitasking | Solve an arithmetic task and choose a symbol that differs from the others. | Cognitive |
2 in 1 | Click on the symbol if it matches one of two symbols displayed above or if you hear a sound. | Cognitive |
Mother went shopping | Play the sounds that you've just heard. | Cognitive |
Distribution of the 15 MORPHEUS skills along the 4 sensory domains.
Finding new objects: in this skill patients need to click on the new object appearing on the screen.
Several items are rated on a scale from 0 to 100 before and after each exposure session: the intensity of trauma-related emotions (guilt, shame, fear, anger, and helplessness), distress, dissociation, and acceptance of the traumatic event as part of the personal history (see
Pre- and postsession assessments of dissociation (Dissociation Tension Scale-4) [
Statistics overview of trauma-related emotions and experiences. In this case, the patient chose to monitor fear (red). The time-dependent change of trauma-related emotions can be exported to a CSV file for research and feedback purposes.
The participants received 12 weeks of residential DBT-PTSD at the CIMH in Mannheim, Germany, where MORPHEUS is a part of the standard treatment protocol. After 3 weeks in treatment, the participants were informed about the study and given a short introduction to the program by a doctoral level student (NG). Technical support was provided if any problems arose with MORPHEUS or with the devices needed to run the program (laptop, audio-recording device). If informed consent was given, the patients were directly asked to fill out a questionnaire on demographic details. The evaluation questionnaire was filled out after the exposure phase. The study has been approved by the Ethics Committee of the Medical Faculty Mannheim, Heidelberg University, and conducted according to the Declaration of Helsinki. The trial was registered in the World Health Organization International Clinical Trials Registry Platform (DRKS00006226).
In this study, MORPHEUS was used as part of a DBT-PTSD residential treatment [
The intake criteria for this study were as follows: (1) PTSD according to the
As shown in
Co-occurring Axis I disorder and trauma categories (N=26).
Sample Characteristics | n |
Major depression | 20 |
Dysthymia | 1 |
Eating disorders | 5 |
Panic disorder | 3 |
Specific phobia | 3 |
OCDa | 2 |
GADb | 1 |
Substance abuse | 1 |
Somatization disorder | 1 |
Sexual abuse after age of 18 years | 9 |
Sexual abuse before age of 18 years | 23 |
Physical abuse after age of 18 years | 8 |
Physical abuse before age of 18 years | 13 |
Accident | 2 |
Imprisonment | 1 |
Suicide or violent death of family member | 2 |
aOCD: obsessive-compulsive disorder.
bGAD: generalized anxiety disorder.
Patient flowchart. DBT-PTSD: dialectical behavior therapy for posttraumatic stress disorder.
Before admission, patients were interviewed with the German version of the Structured Clinical Interview for
Diagnoses were double-checked by experienced clinicians at admission to the PTSD unit. The acceptance of MORPHEUS was assessed with a 17-item questionnaire (see
Frequency of MORPHEUS use per week on a 4-point Likert scale (N=25).
Frequency of digital skill use (N=25).
All data were analyzed on a descriptive level. Subjective ratings of dissociation on a scale from 0 to 100 were compared before and after skills use. As to the qualitative data, patients’ comments were analyzed using procedures adapted from content analysis according to Mayring [
All patients received
All patients used the program as often as it was required in the standard DBT-PTSD protocol, that is, at least 2 to 5 times a week (see
According to our session logs, a total of 10 patients used antidissociative skills. Because of technical difficulties, data were not available for 5 patients. On average, these patients started the skills 3.9 times. In 82% of the cases (32/39), the use of antidissociative skills was related to a decrease in dissociation. In 5%, (2/39) dissociation remained unchanged, and in 13%, (5/39) the scores of dissociation increased. In these outlier cases, the skills might have elicited great distress for the patients, maybe because they were not able to concentrate or because they felt enormous pressure to perform well in the skills. Mean change of pre- to post-skill dissociation was 17.82 with a standard deviation of 29.65.
Altogether, 96% (24/25) of the patients reported that they used other DBT skills, apart from the digital skills in MORPHEUS, during exposure (see
The results of the evaluation questionnaire revealed an overall high acceptance of the program as perceived by the patients (see
Acceptance of MORPHEUS: percentages of patients who indicated a rating between 0 and 5 on the Likert scale (N=26).
Question | 0 | 1 | 2 | 3 | 4 | 5 | Mean (SEM) | Missing, |
|
During the use of the program I had 0: no control at all - 5: complete control | 0% (0/25) | 0% (0/25) | 0% (0/25) | 20% (5/25) | 40% (10/25) | 40% (10/25) | 4.20 (0.15) | 1 | |
The program meets my expectations 0: not at all - 5: very much | 0% (0/24) | 0% (0/24) | 0% (0/24) | 8% (2/24) | 50% (12/24) | 42% (10/24) | 4.33 (0.13) | 2 | |
I did get along with the program 0: not at all - 5: very well | 0% (0/26) | 0% (0/26) | 0% (0/26) | 12% (3/26) | 12% (3/26) | 77% (20/26) | 4.65 (0.14) | 0 | |
I found the program 0: not at all helpful - 5: very helpful | 0% (0/26) | 0% (0/26) | 4% (1/26) | 4% (1/26) | 19% (5/26) | 73% (19/26) | 4.62 (0.15) | 0 | |
I would recommend the program to a friend 0: not at all - 5: very much | 0% (0/25) | 0% (0/25) | 0% (0/25) | 4% (1/25) | 48% (12/25) | 48% (12/25) | 4.44 (0.12) | 1 | |
I would 0: not like to use the program - 5: like to use the program during therapy | 0% (0/25) | 0% (0/25) | 0% (0/25) | 4% (1/25) | 20% (5/25) | 76% (19/25) | 4.72 (0.11) | 1 | |
The support I got for using MORPHEUS was 0: not sufficient at all - 5: absolutely sufficient | 0% (0/26) | 0% (0/26) | 0% (0/26) | 4% (1/26) | 12% (3/26) | 85% (22/26) | 4.81 (0.10) | 0 | |
The skills were 0: very unuseful - 5: very useful in order to avoid dissociation | 0% (0/21) | 5% (1/21) | 0% (0/21) | 19% (4/21) | 19% (4/21) | 57% (12/21) | 4.24 (0.24) | 5 | |
I was 0: very unsatisfied - 5: very satisfied with the digital skills in MORPHEUS | 0% (0/19) | 5% (1/19) | 0% (0/19) | 21% (4/19) | 47% (9/19) | 26% (5/19) | 3.89 (0.23) | 7 | |
The digital skills in MORPHEUS 0: didn't work as I would like to - 5: worked exactly the way I liked to | 0% (0/19) | 5% (1/19) | 11% (2/19) | 11% (2/19) | 53% (10/19) | 21% (4/19) | 3.74 (0.25) | 7 | |
During my exercises with MORPHEUS I used my own skills beyond the skills in the program 0: never - 5: very often | 4% (1/25) | 0% (0/25) | 8% (2/25) | 16% (4/25) | 28% (7/25) | 44% (11/25) | 3.96 (0.26) | 1 |
aSEM: standard error of the mean.
Reasons for not using MORPHEUS (N=9).
Altogether, 23 patients reported what they found helpful within the program in an open question format: the answers were related to the skills (eg, “no dissociation possible, skills directly available”), easy handling (eg, “suitable for people who haven’t worked with computers before”), dissociation monitoring question, the possibility to pause recordings, and the graphs about the longitudinal course of trauma-related experiences and emotions (eg, “You were able to see any time what you have reached in your therapy”). One patient referred to the intervention as such (“hearing how my voice got stronger and how I acted opposite”).
In all, 12 patients suggested ways to improve the program, again relating to the skills (“the program should offer skills to differentiate between present and past, for example: “Where am?” “How old am I?”), the pre- and postsession assessments (“the screen with the question disappeared too quickly after logging in the answer”), and the upload of the recording (“ability to upload two recordings with only one pre- and post-exercise assessment”).
Only 3 patients answered the question whether they had wished additional information. One patient indicated confusion about the pre- and post-session ratings of trauma-related emotions (“How do I rate the questions if two trauma networks overlap? If there are no feelings, what should the rating be?”). Another participant mentioned problems regarding asking for help while using the program (“I didn’t have the heart to ask for additional support”). A third patient expressed the wish for more support during the first use (“When you do your first exposure exercise with the program, someone should be with you, because I couldn’t cope with MORPHEUS the first two times”).
Our preliminary data show high acceptance and satisfaction with the computer program MORPHEUS as a self-administered adjunct to therapist-guided exposure therapy. Patients used the program as often as it is recommended in DBT-PTSD. Overall, patients found the skills helpful to block dissociation, and they stated that they would use the program again in therapy and would recommend it to a friend. In an open question format, patients mentioned all the elements within the program as being helpful. However, patients often used their own skills rather than the digital skills. Suggestions for improvement related to the skills, upload of session recordings, and assessment questions. Use of antidissociative skills by the participants was usually related to a decrease in dissociation (82%). Because of the lack of a control group and the small sample size, this result should be considered as preliminary and requires replication from a study designed to establish efficacy of MORPHEUS.
To our knowledge, this is the first study testing the longitudinal use of technology to reduce dissociative states and track trauma-related emotions during exposure exercises in PTSD therapy. Other programs such as PE Coach and PTSD Coach emphasize other aspects of PTSD therapy such as breathing retraining, in vivo exercises, and psychoeducation. Acceptance rates of MORPHEUS were comparable to the ratings from the feasibility study of PTSD Coach, using veterans as participants [
On the basis of the finding that patients more often used the skills already learned in DBT skills groups as compared with the MORPHEUS program, it can be assumed that patients rely heavily on already established antidissociative skills that are available without electronic devices. However, we did not test whether monitoring of dissociation in MORPHEUS might have increased patient’s awareness of state dissociation. Increased awareness of dissociation might have prompted the use of skills outside of MORPHEUS. Future versions of this program should prompt skills use outside of MORPHEUS in addition to the digital skills, comparable to the grounding techniques suggested in PTSD Coach.
At this point in our research project, we cannot provide data about the efficacy of the digital skills in MORPHEUS to block dissociation. To the best of our knowledge, studies that empirically test the efficacy of distraction skills or grounding techniques to block dissociation during trauma exposure do not exist. Thus, future studies will test whether the skills in MORPHEUS are effective in blocking dissociation during exposure as compared with a control condition without skills.
The program was explained to the patients by one of the authors (NG) during a 30-minute information session. This procedure might have resulted in a bias within the evaluation questionnaires toward more positive ratings. All patients learned about digital antidissociative skills within this session and also had the chance to test some of the skills. This might explain why patients gave overall positive ratings for the skills while at the same time indicating infrequent use of the MORPHEUS skills during the actual exposure exercises. During the trial period, one patient spontaneously reported that she used the MORPHEUS skills after the exposure exercises in order to reduce dissociative states. Thus, she might have rated the skills as highly useful to block dissociation yet at the same time she did not use them during the exposure. However, only skills use during the exposure exercise was monitored for the purpose of this study.
Some technical problems arose because of the need to use different electronic devices to run the MORPHEUS program (computer, digital voice recorder). Therefore, a mobile app version of MORPHEUS was developed and a prototype with the MORPHEUS skills is freely available for Android devices [
A major limitation of this study is that all except one participant were female. The PTSD unit of the CIMH is specializing in the treatment of consequences of early interpersonal violence. However, the majority of patients seeking this treatment are female (around 11 out of 13). Studies on the prevalence of childhood sexual abuse point to the direction of a higher prevalence of severe forms of victimization in girls than in boys (eg, higher rate of penetration; see [
With MORPHEUS, patients can record and listen to the therapy session and check the feedback of pre- and postexercise assessments. Our data suggest high acceptability and feasibility of the program. Further studies will evaluate the effectiveness of using MORPHEUS through mobile apps.
Presentation and video material showing the main functions of the MORPHEUS program.
borderline personality disorder
Central Institute of Mental Health
dialectical behavior therapy
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
Dissociation Tension Scale-4
eye movement desensitization and reprocessing
generalized anxiety disorder
obsessive-compulsive disorder
Prolonged Exposure
posttraumatic stress disorder
standard error of the mean
Skills Training in Affective and Interpersonal Regulation
subjective units of distress
We would like to thank all participants in this study. We would also like to thank Andrea Schropp and Daniel Graf for testing and optimizing the pilot version of MORPHEUS and Annika Deufel for her help with the literature section of this paper. Finally, we would like to thank the team of the CIMH PTSD unit for their help in recruiting participants and with data collection: Silke Huffziger, Janina Tervoort, Christine Jung, Corinna Groß, Nadine Defiebre, Julia Herzog, Franziska Rother, Barbara Beckmann-Schumacher, and Teresa Knorz.
The authors TD and MS have developed both the MORPHEUS app and the MORPHEUS software. They are planning to sell the full version of the MORPHEUS app in the future. MS and TD were not involved in collecting or analyzing the evaluation data of this study.