Development of psychological interventions delivered via the Internet is a rapidly growing field with the potential to make vital services more accessible. However, there is a corresponding need for careful examination of factors that contribute to effectiveness of Internet-delivered interventions, especially given the observed high dropout rates relative to traditional in-person (IP) interventions. Research has found that the involvement of an online therapist in a Web-based intervention reduces treatment dropout. However, the role of such online therapists is seldom well articulated and varies considerably across programs making it difficult to discern processes that are important for online therapist involvement.In this paper, we introduce the concept of “therapeutic facilitation” to describe the role of the online therapist that was developed and further refined in the context of a Web-based, asynchronous psychosocial intervention for couples affected by breast cancer called Couplelinks. Couplelinks is structured into 6 dyadic learning modules designed to be completed on a weekly basis in consultation with a facilitator through regular, asynchronous, online text-based communication.Principles of therapeutic facilitation derived from a combination of theory underlying the intervention and pilot-testing of the first iteration of the program are described. Case examples to illustrate these principles as well as commonly encountered challenges to online facilitation are presented. Guidelines and principles for therapeutic facilitation hold relevance for professionally delivered online programs more broadly, beyond interventions for couples and cancer. There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions see ,2), eati, eati2])Despite its potentially critical role in program adherence and outcome, there has been minimal discussion and guidelines in the literature on how best to provide therapeutic support within the context of an online, primarily self-guided, psychosocial intervention. Online interventions are different from IP therapy in that much of the intervention is delivered by way of the Web program and an individual’s interaction with the program . The online clinician, when included, may have differing tasks depending on the program, but generally is there to provide support with the objective of ensuring compliance with the intervention. In contrast, the IP therapist provides the intervention itself. Therefore, the 2 types of intervention differ in their format and hence the role of the clinician. Still, as trained clinicians, online therapists/facilitators are likely to draw on their general psychotherapy skills, such as empathy and validation in the provision of support. Compared to IP therapists, online clinicians are not privy to the nonverbal communication and paralinguistic cues of their clients . Not surThis paper takes a step toward addressing this gap by defining the role of the online clinician, referred to in this paper as the online facilitator, and by presenting principles and guidelines for online therapeutic facilitation that were developed and refined in the context of a novel Web-based intervention for couples coping with breast cancer. The program, called Couplelinks, was previously developed and tested in a Phase I pilot trial  and is pInteraction with the online facilitator in this program is primarily via text-based asynchronous online communication. The online facilitator role was developed with the vision that it need not entirely mirror the IP therapist role given the obvious differences between a self-guided Web-based intervention program and IP therapy, but instead be defined differently bearing in mind the potential for unique advantages specific to the technological medium.In this paper, we review the modest literature on the various ways professionally offered support in online interventions has been defined and provided. This review is followed by a proposed definition of the online facilitator and guiding principles for online facilitation in the context of Couplelinks. Challenges for couple participation and engagement using the online modality are discussed and highlighted with use of case examples from the Couplelinks pilot study.Inclusion of a professionally trained support person in a Web-based intervention varies considerably across programs in terms of the role and the nature of his or her interaction with participants. Methods of online support that have been used and found to increase program adherence include online, telephone, or mailed reminders and brief written descriptions on how to use the program -27; onliFew studies have compared the same online intervention with and without therapist guidance and for the few that have been done, the results are equivocal with some finding superior outcomes for an online therapist-guided program over a non-therapist-guided version ,32 and oTodkill and Powell  assessedThe association between therapeutic alliance and outcomes in IP settings is well established ,39. WhenHow can we reconcile the findings that the therapeutic alliance is a major factor that explains outcomes of IP therapy but not Web-based interventions, yet both forms of intervention demonstrate comparable efficacy? One possible explanation for this seeming paradox is that the alliance with an online therapist is qualitatively different from that of the alliance formed with an IP therapist because it emerges from the synergistic effect of the website components and the online clinicians’ responses . Peck 4 addresseIn what ways does the online therapist provide this support and encourage such engagement? Despite recommendations that online interventions require the development of specific skills , little Mohr et al  propose Despite obvious limitations in the level of interaction that can be achieved with clients via a Web-based program, there are several advantages. For example, the clinician can review participant’s progress via the data entered online and provide feedback accordingly . FurtherProviding psychosocial support via the Internet for people dealing with serious chronic illness such as cancer is particularly compelling when considering the potential geographical, physical, or psychological barriers that may make IP therapy impossible. Serious illnesses such as cancer affect not just the person with the illness, but their family members and their intimate partner . Cancer A well-established finding is that younger, mainly premenopausal breast cancer survivors (age 50 or younger) and their partners are significantly more likely than older couples to experience relationship distress and poorer quality of life ,62, and Such barriers were taken into consideration in the development of Couplelinks—a novel, professionally facilitated, asynchronous online intervention designed to enhance relationship adjustment and dyadic coping, and reduce individual distress of young couples affected by breast cancer. The program is based on the premise that partners in intimate relationships vary in the degree to which they feel identified with the relationship, also referred to as “couple identity” or “we-ness.” When partners experience their relationship as part of their sense of self, they are more likely to think about issues and events from each other’s perspective and view stressors as shared. Consequently, such partners engage in greater perspective-taking, empathy, and interpersonal support and therefore experience greater relationship satisfaction ,69. GreaCouplelinks focuses on enhancing such we-ness through the use of experiential exercises designed to improve couples’ communication, perspective-taking ability, and mutual understanding and empathy in relation to breast cancer. The program is structured into 6 dyadic learning modules designed to be completed on a weekly basis in consultation with a Couplelinks facilitator through regular, asynchronous, online text-based communication at the end of every module. The Couplelinks facilitator, who is a mental health professional with experience in oncology, guides the couple throughout the program. Each weekly module assumes the following basic structure that the partners engage in on their own in the following order: (1) a theoretical component that explains a key relationship principle, (2) a dyadic, experiential exercise intended to assist the couple in grasping the principle, and (3) a feedback component that each partner is asked to complete on his or her own. The facilitator then reviews the modules and logs text-based feedback via the website. In addition to such online, asynchronous, text-based contact, the facilitator schedules phone check-ins with the couple after completion of Modules 2 and 4 to discuss any issues with the program and reinforce motivation and engagement with the program. The facilitator is also available as needed.The weekly modules are broken down into steps, some of which are completed separately by each partner and some that are completed jointly as a couple. Typically, a module starts with activities that partners complete separately, followed by a dyadic activity that incites discussion and new learning for the couple. Such learning is consolidated in the last stage of the module when partners separately answer a series of questions assessing what the partners learned and what benefits they gained from completing the module, if any. Once both partners complete a module, an email notification is automatically generated and sent to their online facilitator who then logs in to a back-end administrative interface to review the couple’s entries to the dyadic learning module. The online facilitator provides tailored feedback on the couple’s responses to the module via the Dialogue Room, which is a 3-way virtual bulletin board embedded within the website. The partners receive an automatic email alert indicating that their online facilitator has provided them with feedback in the Dialogue Room and partners can only review the feedback by logging in to the secure Couplelinks website. The facilitator ends their feedback response with a description and explanation of the learning objectives of the upcoming module and a due date for its completion, typically a week from the date the feedback was sent. Although feedback is tailored to the couple and what they logged in their modules, a standard script of the description of the subsequent module is available to the facilitators in the facilitation manual  that canThe Dialogue Room acts as a forum where participants and the facilitator can communicate with each other. For instance, the couple can raise concerns and ask questions as well as let their facilitator know if they need more time or had something unexpected happen that will delay their progress. The facilitator can also use the Dialogue Room to check in with a couple if he/she has not heard from them and they are behind schedule. Facilitators log any interactions that occur with the couple outside the Dialogue Room in a section viewable in the administrative interface called “Contact Notes.” This section includes a summary of scheduled and unscheduled phone calls and emails. The module logs, Dialogue Room, and Contact Notes provide the basis with which to assess whether facilitators are adherent with the principles of facilitation as outlined in the treatment manual.The Couplelinks facilitator’s role is to provide encouragement, safety, and a sense of structure through regular online communication with the couple. We conceived of the role of the Couplelinks facilitator as that of an expert guide who functions to support and encourage the couple’s learning process and enhances adherence to the program. The Couplelinks facilitator is a trained mental health professional with expertise in psychooncology and couple interventions.Although not engaging in psychotherapy, the facilitator draws on his/her clinical skills and judgment when crafting customized feedback to the couple on completion of a dyadic learning module and as problems and unexpected situations occur, such as when the couple does not complete a dyadic learning module by the expected time or if one partner is less responsive than the other. We termed this style of facilitator-couple asynchronous online interaction as “therapeutic facilitation.” The term “facilitation” connotes providing assistance to move an action or process forward with greater ease. We see this term as accurately capturing the online facilitator’s role in the context of a primarily self-guided Web-based intervention, which includes assisting couples as they progress through the intervention by clarifying the objectives of each dyadic learning module, answering questions, providing psychoeducation, maintaining structure, encouraging commitment in order to maintain momentum, and validating and reinforcing the learning and insights derived by the couples from the exercises.The underlying theoretically informed objective of Couplelinks, as described previously, is to enhance couple’s we-ness so that the couple perceives and approaches the cancer as a shared problem. Thus, the overarching goal for the online facilitator when formulating responses to validate couples’ insights and reinforce gains—whether textual or by phone—is to enhance their sense of the illness being a shared experience and accentuate their shared strengths and experiences around this stressor.both partners remain equally engaged and motivated in the program, are able to easily understand how to navigate the program, and feel they are on the right track in terms of their progress. Complex processes such as these cannot be programmed into a computer but require a skilled person on the other end. Therefore, online facilitators play a necessary supporting role in structuring the exercises by drawing on their therapeutic skills to encourage the couple’s open discussion and commitment to the intervention and their shared progression through the program.The reasoning for employing therapeutic facilitation in the Couplelinks program was based not only on the need to maintain adherence, but on the premise that couples experience the most benefit when Given that the online facilitator is supporting the couple in proceeding through and benefiting from the exercises rather than providing couple therapy, the online facilitator does not engage in certain clinical techniques as an IP therapist would, such as directly challenging partners’ unconstructive behaviors or suggesting alternative interpretations of each other’s behaviors. Instead, emphasis is on skills such as highlighting what the couple shares, vis-à-vis the couple’s responses to the modules. For instance, the online facilitator encourages equal participation of both partners by consistently incorporating comments made by both couple members in their Dialogue Room feedback responses. Additionally, if partners provide differing opinions for dealing with a problem within their relationship and explicitly note their frustrations, like the IP therapist, the online facilitator might note the way in which partners approach problems differently by providing a response in their textual feedback, such as: “It sounds like, even though you may approach things differently, both of you are dedicated to figuring this out and resolving this issue that is causing both of you stress.” The online facilitator, however, does not engage in in-depth exploration of emotions, but frames feedback in such a way that highlights the couple’s strengths and insights gleaned from completing the exercises.To guide and standardize the delivery of online facilitation for the Couplelinks RCT, guiding principles and specific strategies were developed. The principles are not mutually exclusive; the facilitator often employs several of these strategies in a single response to a couple. All interactions described subsequently are asynchronous and occur via the Dialogue Room unless indicated otherwise . Research Ethics Boards of the institutions where the participants were being recruited approved of the Phase I and later Phase III trials. All participants enrolled in the trials were informed of the study objectives, risks, and consequences and consented to participate.During the introductory phone call, the online facilitator educates the couple on time commitments and the need to maintain a relatively weekly schedule in completing the exercises, encourages partners to come up with a tentative timeline for completing the dyadic learning modules, and to identify times during the week when they would complete the shared components of the dyadic learning modules. Although the program requires no more than 1 hour commitment per week, the added burdens associated with cancer can make even minimal obligations stressful and thus lessen the potential benefits of the program. The online facilitator encourages an open 3-way discussion that helps the couple examine all their current and upcoming obligations, and allows the facilitator to consider along with the couple how to work around any obstacles to their participation in the program, thus maximizing the likelihood that they will complete the program and obtain the greatest degree of benefit.Clearly communicating the online facilitator’s willingness to hear the partner’s feedback to the program, regardless of whether it is positive or negative, is key to establishing and maintaining open communication. The online facilitator cultivates an atmosphere of openness and curiosity about all aspects of the couple’s experience. This means that online facilitators acknowledge and directly address couples’ negative comments regarding the program. Importantly, this behavior also serves to model the concept of open dialog within the couple relationship. As well, although contact with the couple primarily occurs online via text, in order to maintain the couple’s momentum and commitment to the program, we have found it essential that the online facilitator also use brief telephone consultations with couples as necessary. For instance, when there have been significant lapses in online communication, the online facilitator may call the couple to inquire as to what happened.The online facilitator takes advantage of the convenience and accessibility of the online environment to create a safe, supportive therapeutic space in ways that are likely not possible in traditional psychotherapy, such as by responding promptly via the Dialogue Room to questions posted by couples. In contrast to IP therapists that are typically available on a weekly basis at a set time, online facilitators have the opportunity to be more accessible to couples throughout the week. Couplelinks online facilitators are expected to respond to couples’ messages within 24 hours in order to demonstrate their commitment to couples’ timely progress through the program as well as to model frequent engagement. The online facilitator communicates availability, presence, and commitment by responding quickly via text in the Dialogue Room as well as with phone calls, the latter being used if the couple is not responding via the Dialogue Room. Additionally, online facilitators are expected to log in to the administrative interface to review each couple’s progress through the substeps of the module and whether it appears they will complete by the agreed-upon deadline, otherwise providing gentle reminders to encourage them to complete by the due date they agreed to in collaboration with their facilitator.A common situation in which online facilitators’ online communication serves the dual role of demonstrating their commitment to couples while also modeling genuineness and empathic caring occurs when couples fall silent. Online facilitators are expected to consistently check in with couples when there are unexpected lags between starting and completing an exercise, but do so in ways that are meant to be supportive and encourage accountability to the program. Such a situation provides the facilitator with the opportunity to openly acknowledge and express concern regarding the couple’s silence, which often serves to strengthen the couple-facilitator relationship, reduce isolation, and foster program compliance. This also represents a critical moment when the facilitator can explore the barriers with a couple and problem-solve with the couple about ways to proceed.The online program allows the couple to participate in the privacy of their own home and set their own pace. Although the flexibility of an online program is an unquestionable strength, a lack of structure can also be a drawback in that partners may take the program for granted and easily delay completing the module. In this regard, the online facilitator’s task is to strike the right balance between acknowledging the need for flexibility and setting agreed-upon deadlines. Couplelinks online facilitators are asked to employ a “friendly but firm” stance with couples right from the beginning of the program. For example, when online facilitators are orienting new couples to Couplelinks, they emphasize upfront how couples need to set aside time on a weekly basis to work through each module and encourage the couple’s involvement in problem solving to carve out the time necessary to complete the exercises on a weekly basis. Including the couple in this discussion is meant to strengthen the couple’s commitment and accountability to complete the program. Online facilitators also provide suggestions and help to problem-solve when obstacles arise (as they often do while undergoing or recovering from treatment) and solicit couple involvement in setting revised deadlines when existing ones are missed.both members’ experiences as expressed in the feedback component for each module, which serves to reinforce the involvement and importance of both partners through the program.In general, equally engaging both members of a couple can be difficult. When one member has initiated the process, the other member may view him- or herself on the periphery of the experience. This is a considerable risk in the context of breast cancer where many male partners, although often eager and willing to help their partners, may view themselves as sitting on the sidelines. In this sense, the online facilitator’s objective during the introductory telephone call before they commence the program is to acknowledge each partner’s individual experience of the disease and personal motivation for participation, highlight the impact of the disease on the couple, and articulate the invaluable and active role that a partner may play in a woman’s recovery. On a weekly basis, a key aspect of the online facilitator’s comments to the couple is acknowledgment and integration of In situations where one member of the couple initiates an email outside the Dialogue Room to the online facilitator without including the other partner, the online facilitator will include the absent partner in the reply to maintain the “3-way conversation” format. This is meant to minimize the formation of alliances with the online facilitator that excludes the other partner. Whenever possible, however, the online facilitator will utilize the Dialogue Room to respond to partner inquiries rather than resort to email communication because of the Dialogue Room’s security features and because it automatically engenders the 3-way conversation format as it is always (and only) accessible to both members of the couple.The online facilitator reviews module content and feedback and more clearly articulates and emphasizes emerging insights and positive experiences for the couple. This may involve the online facilitator accentuating insights that partners share about themselves, each other, their relationship, or a given module. This may also involve providing psychoeducation about the module as it pertains to the couples’ reflections. Couples vary in terms of their strengths and areas of challenge. Therefore, some couples may indicate that they did not derive a shift in perspective as the module addressed an already established practice or strength in their relationship. In this case, the online facilitator demonstrates their attentiveness to what the couple is expressing by acknowledging and validating an existing relationship strength.A diagnosis of breast cancer signifies a crisis in the life of a couple. The online facilitator must attend to, manage, and, if need be, contain the emotional content that emerges throughout the course of the program. This is done by constructing Dialogue Room feedback that validates and normalizes the range of emotional responses of couples to different aspects of the program and responding to strong reactions voiced by both or either partner in a supportive way. Where the emotional content is indicative of acute distress, the online facilitator highlights his or her availability to the couple through the Dialogue Room or by phone.This section describes 4 common challenges in relation to online couple facilitation that came to light during the pilot study. The examples presented subsequently illustrate the ways in which the online facilitator used specific strategies related to the principles of facilitation described to increase the couples’ engagement and address common challenges. The examples of online facilitator responses to couples are taken from the Couplelinks Program Facilitation Manual .As described previously, one challenge to consistent participation and the desired outcome of a strong bond within a couple is ensuring equal engagement by both members of the couple in the program. Partners vary in terms of their levels of awareness of the impact of cancer on their relationship as well as their interest and motivation to take part in the program. For couples dealing with breast cancer, it was fairly typical for a male spouse to indicate that even though he agreed to participate in the program, his decision to participate was largely motivated by a desire to support his partner (rather than help himself too). Although differential involvement of partners may also pose a challenge for “offline” counseling, the IP therapist has the added benefit of being able to physically observe the couple dynamic and has greater opportunity to directly address any discrepancy in the moment, which may not be as apparent to the online facilitator who is working via asynchronous communication. Therefore, it was critical that the online facilitator connect with each member of the couple in “real time” over the phone, prior to program commencement, and use this time as an opportunity to highlight the way in which cancer creates havoc in both individuals’ lives and profoundly impacts them as a couple, not just as individuals. In discussions with the less keen individual, the online facilitator helps him/her to identify how helping to reduce the partner’s stress is personally meaningful and relevant to their daily life together.Throughout the program, online facilitators encouraged equal involvement between both couple members by incorporating aspects of both partners’ module feedback in crafting their own response to the couple. Such communication reflected engaging the couple individually and as a unit. For example, as illustrated in the following excerpt, the online facilitator highlights the individual and shared perspectives of a couple:It looks like you both got something out of the module and were able to really appreciate each other’s finer qualities, and the way in which you complement one another. I like [the female participant’s] comment about how the exercise was a “confidence builder,” and [the male participant’s] recognition of your “collective strengths.”At times, partners expressed having had a different experience of a particular module. In such cases, the online facilitator recognized the discrepancy, but also looked for and highlighted common ground in their responses. For instance, Module 4 is an exercise designed to assist the couple develop a sense that cancer is a common enemy by having the couple create a shared metaphor in relation to the illness using image, collage, or poetry (see ). In theYou two had quite a different reaction to this module exercise. [Male Participant], despite finding this module “kind of boring,” you were able to join in with [Female Participant] and her enjoyment with this creative exercise, and come up with a shared concept together.Women with breast cancer and their partners, particularly younger couples, are understandably more distressed ,66. A coIt sounds like it was beneficial to a certain degree for the two of you to think about the positive qualities that you see in each other, as well as the strengths of your relationship, which can be especially difficult to do during stressful times. On the other side, sometimes sitting down to examine even positive aspects of the relationship can draw attention to the more difficult parts. It sounds like this happened to some degree for both of you.By providing psychoeducation about the module and the program in general, the online facilitator tried to motivate the couple to persist and assure them that the program could provide them with an opportunity to work on their communication skills. The online facilitator also tried to unite the couple by drawing their awareness to the degree that they share in the concerns about their relationship:Looking at your relationship a little more closely, and the way you interact, is a big part of this program—and you’ll see the exercises are designed to get both of you to do this. We believe that the first step to improving the relationship is being able to take a good look at it—what is working and what can be improved. The first few exercises focus more on building that relationship awareness so that you can communicate and problem-solve better in the long run. Nevertheless, I am glad to see that you were able to identify some meaningful attributes in each other and the relationship. It seems that both of you are aware that communication is an area in your relationship that needs attention. While enhancing communication is an implicit part of each module, there is one module in particular that explicitly focuses on this and provides specific guidance.In addition to the preceding feedback, the online facilitator reiterated her availability to the couple, both online and by telephone. Although they did not seek out greater involvement, it is important for participants to know that this is an option. In addition, the online facilitator highlighted how she viewed the couple’s willingness to engage in this process, and look at their own behavior, as positive:Although it seems like this was a difficult exercise on a certain level, it is excellent that you, [Male Participant], were able to identify what you could be working on as a couple, and also in terms of modifying your own behavior.The convenience of an online program can also be a drawback as the lack of IP contact may engender less accountability. Some couples tend to delay completion of the weekly modules and fall out of touch. In order to keep such “straggler” couples engaged and avoid disconnecting from the program, the online facilitator reinforces structure and commitment to the program by communicating his or her own commitment, presence, and availability on a regular basis. The online facilitator’s responses are meant to encourage a couple’s progress while not seeming overly demanding. For instance, when a couple did not complete their module as scheduled, the online facilitator sent the following response:Hi [Female Participant] and [Male Participant]—I haven’t heard from you in a while so just wanted to check in and see how you are doing. Please touch base whenever you have a moment, even if it is just to let me know that you have been busy. I look forward to hearing back from you.The goal of such a communication is to express the way in which any response is preferable to no response and to open the door to communication.The online facilitator will also send “gentle reminders” and assume that in the case of silence the couple may be having difficulty carving out some time in their schedule to do the exercise. At times, however, the couple may require more than a gentle reminder and when a couple has not responded to online communication, telephone contact initiated by the online facilitator is necessary. Similar to IP counseling, in connecting with the couple, the online facilitator communicates from a nonjudgmental, curious, and supportive stance. This means, for example, that she is open to hearing and accepting with respect to the couple’s reasons for delays, even if it is critical of some element of the program, and tries to best support the couple in order to help them overcome any obstacles that they are facing. As well, the online facilitator can review a couple’s progress within a module and send them a message validating the steps that they have completed and highlighting what remains to be done as a way of signaling her engagement with them.Breast cancer tends to be more aggressive, more likely to recur, and more fatal in younger women -76; hencSorry for the delay but we have had a bit of a fright. [My wife] found a lump on her neck which is a swollen lymph node and had an ultrasound, at which point the doctors decided that a biopsy is best. It looks suspicious. We are very worried as you can imagine and this is a priority right now...touch base with us in a week or two and we’ll let you know how things are going. I don’t think we will be doing the exercises until we know what the story is. I hope you understand.The online facilitator addressed this email immediately with a response that reflected support and concern for the couple:Thanks for letting me know. I am very sorry to hear that. I will be thinking of the two of you and sending warm thoughts.Given the magnitude of the concern, rather than following up with the couple through the Dialogue Room, the online facilitator called the couple a few weeks later to check in. Thankfully, the results of the female participant’s tests were clear. The couple expressed how stressed they had been and seemed grateful for the opportunity to discuss the stress they had undergone in the past few weeks. They also indicated that they were ready to resume with the program and the online facilitator sent them a message through the Dialogue Room letting them know that she set them up for the next module. This message allowed the online facilitator the opportunity to emphasize their we-ness in the very real and recent dealings with the fear of recurrence:Whew! I am so relieved and happy to hear for the two of you that everything is okay, and the results were clear. I am sure that the two of you are very relieved. Doctor’s orders—please go out and celebrate! Feel free to start the next module at any time. I hope that this will be a good creative outlet for the two of you, and it will be interesting to see the way in which the two of you represent your shared experience especially given what you’ve just been through. Kindest regards and thinking of you both!Another point to note here is the online facilitator’s appropriate use of humor within the framework of employing her skills as a clinician to support and empathize with the couple, while also keeping them on task with respect to their progression through the program. Also, she suggests that the next module may be a way for the couple to process their recent difficult experience in relation to cancer thereby demonstrating how preestablished exercises may be positioned to incorporate fluidly the couples’ fluctuating experiences and corresponding needs. Although health concerns may arise similarly in IP approaches, it is important to note that in an online intervention where there is no set appointment time and the online facilitator is remote, couples may find it easier to delay their involvement while facing a health crisis, making it important for the online facilitator to communicate her patience, empathy, and availability to the couple.To date, there has been very little discussion in the online intervention literature on the role of the online clinician, particularly using asynchronous interaction. An online facilitator in the context of online couple interventions is particularly important to manage engagement of both partners and maximize the couple’s learning. We propose that online therapeutic facilitation—a supporting role of the online clinician that (in the case of Couplelinks) focuses on encouraging the couple’s bond as well as adherence to the intervention—is a useful clinical construct to guide more effective online therapist involvement with couples. Therapeutic online facilitation of couples is distinct from IP couple interventions, the latter being more intense and often entails more liberal use of interpretation and inference. However, online facilitators have several other tools at their disposal that can enhance outcomes, such as being able to review progress made by the couple as well as being available for immediate feedback and support at any time throughout the week. The clinical perspective on online facilitation presented here was derived over the course of developing and applying an online intervention for couples affected by breast cancer. Research on whether adherence to such principles contributes to outcomes has yet to be evaluated. Nonetheless, the principles presented here may offer guideposts for clinicians in the process of developing an online support program entailing asynchronous interaction between client and facilitator, stimulate discussion with respect to the theoretically necessary components of online facilitation, and identify research questions for future studies.


The purpose of this survey study is to investigate behaviors in conflict with the ethical standards of the Medical Physics Residency (MedPhys) Match (MPM) process as stated in the MPM rules (a) and with the nondiscrimination regulations of the Equal Employment Opportunity Commission (EEOC) (b), in addition to other behaviors that may in other ways erode the fairness of the system.A survey was sent to all applicants and program directors registered for the 2015 and 2016 MPM. Survey questions asked about application, interview, and postinterview experiences, match results, and overall satisfaction with the process.Thirteen percent of 2015 respondents and 20% of 2016 respondents were asked by at least one program how highly they planned to rank them or which program they would rank first. Thirty‐seven percent of 2015 and 40% of 2016 program directors indicated that candidates communicated to the program their rank intent, with 22.0% in 2015 and 12.5% in 2016 being told that their program would be ranked first. Twenty‐three percent of 2015 respondents indicated being asked by at least one program during the interview about children or plans to have children; including 19% of males and 33% of females. In 2016, these values were 28% overall, 22% male, and 36% female. Fifty‐seven percent of 2015 respondents who were asked this question indicated being uncomfortable or very uncomfortable answering, including 27.3% of males and 88.9% of females. In 2016, 42.9% of all respondents indicated being uncomfortable or very uncomfortable answering, including 10.0% of males and 80.0% of females.In the first two years of the MPM, there were widespread instances of ethical violations and discriminatory questioning during the interview process. Educating both interviewers and candidates on the MPM rules and general EEOC guidelines should decrease these instances and increase the fairness of the residency selection process. https://doi.org/10.1002/acm2.12169This article is related content to the editorial:  A limited number of CAMPEP‐accredited residency training programs are creating similar levels of competition as experienced in medical residencies.A survey of participants in the 2015 and 2016 MPM has been conducted to investigate the occurrence rate of possible behaviors that are in violation of the ethical standards of the MPM, against EEOC guidelines, and general attempts to pressure other parties or to game the system. By conducting this survey in the inaugural and second years of the MPM, a baseline for the culture and conduct of Match participants in Medical Physics is established. By raising this awareness from the beginning, it is hoped that a more positive culture can be established and maintained by the Medical Physics community.2After review by the University of Washington Human Subjects Division that determined the study to be exempt by the Institutional Review Board, a voluntary and anonymous survey was sent to all applicants and program directors registered for the inaugural 2015 MedPhys Match. Initial invitations were sent via email October 9, 2015. One additional reminder was sent 1 week later. The survey was open until October 31, 2015. Each invited participant was sent a unique web link to their respective survey. The survey was conducted by the University of Washington with the consent of the AAPM Medical Physics Residency Training and Promotion Subcommittee. The use of the participants' contact emails for this study was approved by the AAPM Subcommittee on the Oversight of the MedPhys Match. Furthermore, the survey was supported by the AAPM Students and Trainees Subcommittee.A second year follow‐on survey was sent to all applicants and program directors registered for the 2016 MedPhys Match on June 15, 2016, and open until June 30, 2016. This second survey duplicated the initial survey along with additional questions for program directors comparing the 2 yr of experience and for re‐applicants who did not match in the 2015 MPM and were participating again in the 2016 cycle.2.AAll registered participants (applicants and program directors) were contacted via email. The initial applicants' survey consisted of a total of 57 questions including general demographic information, residency applications, interview experiences, postinterview interactions, MPM experiences and results, and questions regarding their opinion of honesty within the MPM system and their overall experience. At various points throughout the survey, textboxes were provided to encourage additional comments on the MPM experience and suggestions for changes or improvement in the process. The second‐year applicants' survey included a total of 63 questions, adding questions about the previous year's MPM experience for re‐applicants.The program directors' survey included 35 questions that addressed the numbers of applicants and interviews including changes from previous years, factors that determined or contributed to the program's selection of candidates to interview and rank, the number and mode of interviews , reflections on the interview experience including postinterview communications in general and more specifically related to potential MPM rules violations, opinions on the program's overall MPM experience and current status of the residency/trainee situation. The second year program directors' survey included 36 questions, adding a question regarding the previous year's participation.Responses to the questions regarding opinions were collected using a 5‐point Likert scale. Study data were collected and managed using REDCap (Research Electronic Data Capture) hosted at the study institution and supported by an institutional grant.2.BSummary statistics were used to describe the response rates, demographics, interview experiences, ranking and matching experiences, as well as opinions regarding the MPM process. All analyses were conducted using functions available in Excel 2010 .3Applicant surveys were returned by 111 of 402 emailed invitations in the initial survey year, yielding a response rate of 28%, consistent with typical AAPM response rates. One hundred nine surveys were completed and included in this analysis. In the second year survey, 101 of 331 applicants returned the survey, yielding a response rate of 30%. All surveys are included in the analysis.The demographic distribution of the survey respondents is shown in Table In the second year, 83% of the respondents submitted a rank list, including 81% of the male respondents and 88% of the female respondents. Seventy percent of the respondents matched with a residency position in 2016, including 63% of the male respondents and 87% of the female respondents. This compares to 51% of all applicants participating in the MPM.In the second year survey, 41.6% of respondents indicated a final degree of MS, 53.5% indicated PhD, and 2% did not respond. This question was not included in the first year survey.Program directors' surveys were returned by 42 out of 79 emailed invitations in the inaugural year, with a response rate of 53%. In the second year survey, 47 surveys were completed in response to 77 emailed invitations, with a response rate of 61%. In the inaugural year survey, none of the responding programs indicated that they interviewed only MS candidates. Forty‐three percent interviewed PhD candidates only, and 57% interviewed both MS and PhD candidates. In the second year survey, one responding program indicated that they interviewed only MS candidates. Forty‐two percent interviewed PhD candidates only, and 56% interviewed both MS and PhD candidates. In the inaugural year survey, program respondents indicated that they largely experienced an increase in applications over the previous year. This situation was reversed in the following year, where most programs reported a decrease in the number of applications  during their interview. Twenty‐nine percent in the first year and 27% in the second year surveys indicated that they were told by at least one program that they were “ranked to match” or told their rank number prior to the match deadline. If they had knowledge of their rank position, 78% in the first year and 67% in the second year surveys indicated that the information did Furthermore, one applicant respondent to the 2015 survey stated, “My only opposition to the process was regarding schools that sent out emails or called multiple people, essentially inferring they were a top pick, only to find out that they had told several other applicants the same thing. This situation happened to several friends going through the process and one friend and I even received nearly identical emails from an institution that was only offering one position.” This respondent continued to complain that this behavior by programs was unfair and misleading to candidates, to the point that applicants altered their rank lists based on the information. This sentiment was echoed in other applicant comments.did affect how they ranked programs.Ten percent of all respondents in both years of the survey indicated that they were told by at least one program that they would not match to their program. Seventy‐eight percent of the positive respondents in the inaugural year and 75% in the second year surveys said this knowledge Sixteen percent of survey respondents in 2015 and then 15% in 2016 indicated that they were offered a residency position outside the MedPhys Match Program.3.BFifty percent of all survey respondents in the inaugural year survey indicated that they were contacted via a phone call, email, or letter by a program director, faculty or staff member, or a resident after their interview, which was not in direct response to a contact or question initiated by the candidate. In the second year survey, the positive response rate was 53%. Of all survey respondents, 21% in 2015 and 25% in 2016 said they felt very or moderately pressured by the program to offer assurances see Fig. .not say that they would rank a program highly in their thank you note.Some candidates initiated communication with the program after their interviews. Figure 3.CApplicants were asked about their beliefs in the honesty and motivation of participants in the MPM process. In response to “Applicants often make dishonest or misleading assurances or statements to programs about their level of interest,” 37.9% of candidates in the 2015 survey strongly agreed or agreed, while the majority 62.1%) were neutral to strongly disagreed  responded positively to this question  to at least one candidate after their interview that was not in direct response to contact initiated by the candidate. This value is the same in the second year survey. Thirty‐six percent in 2015 indicated that they contacted all candidates after the interview, while 15% indicated that they only contacted those candidates that the program was interested in ranking. In 2016, these values were 31% and 25% respectively. Figure did influence the program's ranking of candidates. Again of these 37% in 2015, 60% said interviewees indicated that they would rank that program first and 20% were asked by the interviewee how the program would rank them; the values changed to 32% and 0% in the second year survey. Forty‐seven percent of the program directors in both surveys indicated that they felt applicants were  dishonest about their intent to rank the program when the ranking statements were made. Additionally, 13% (two in 2015) and 11% (two in 2016) of the programs failed to match with a candidate that had made a commitment to rank that program number one.Sixty‐eight percent of the program directors in the 2015 survey said that candidates initiated communication with the program after the interviews. This value increased to 81% in the second year survey. Thirty‐seven percent and 40% of program directors said candidates communicated their rank intent to the program, in inaugural and second year surveys, respectively. Of these 37% in 2015, none of the programs agreed with the statement that knowledge of the candidate's intent to rank influenced their own ranking of candidates. In 2016, two program directors responded that the intent to rank information Program directors were asked about the importance or role of postinterview communication by an applicant's mentor or other advocate. In the inaugural year survey, 20% of program directors responded that at least one contact was made on behalf of an applicant. This value decreased to 13% in 2106. Figure 3.FNinety‐eight percent (2015) and 92% (2016) of program directors were satisfied or very satisfied with the MPM experience, with 66% and 62.5% very satisfied. In response to a separate question, 25% in 2015 and 23% in 2016 did indicate that the process could be improved, while the majority felt the process is reasonable and needs no changes.Responses to free text boxes throughout the survey  is responsible for enforcing federal laws that make it illegal to discriminate against a job applicant or an employee because of a person's race, color, religion, gender (including pregnancy), national origin, age, disability, or genetic information. The laws apply to all types of work situations, including hiring and training. The EEOC provides general guidelines for interviewing behavior and a list of inappropriate and/or invasive personal questions that should be avoided.In this survey, questions about marital status, children or plans to have children, and religion were included. No one should be asked these questions during an interview for residency positions, including all formal and social interactions. It has been previously well‐established, and is clearly supported by Figs. every program at which she interviewed asked whether she had children or planned to have children during the two‐year residency. These questions left her unsure of how to answer without being dishonest or offending when in fact she knew the line of questioning violated her rights as an interviewee. “My options to answer those questions is [sic] to either say “no” (which may or may not be truthful) or to prefer not to answer which would be taken as a definite yes.”Furthermore, one applicant respondent to the 2015 survey commented that 4.BThe most relevant MedPhys Match rules are contained in The Medical Physics Matching Program Terms of Residency Agreement.voluntarily inform an applicant as to whether or not it intends to rank the applicantA program may voluntarily inform a program as to whether or not the applicant intends to rank the programAn applicant may solicit the intentions for ranking from another partyNeither party (program or applicant) may positioning of any applicant or program on a Rank Order List.Neither party may disclose to the other party or solicit from the other party any information regarding the It is understood that during recruitment discussions a program may freely discuss any matter with an applicant, and each may express a high level of interest in the other. Communication guidelines are as follows:Any expression of interest that may be made during the free discussion between a program and an applicant is subject to change based on further considerations by either party.The intent is for both applicants and programs to rank their selections in order of their true preference, without regard to how they believe they will be ranked by the other party. That is, to eliminate any “gaming of the system” by pressuring the other party in an effort to ensure a match by making false assurances of rank intent.Several questions in the candidate and program director's surveys addressed questions explicitly prohibited by the MPM rules (soliciting ranking information and pledging rank order one) and additional questions that–while not explicitly prohibited by the MPM rules–tend to pressure the candidate or program and therefore are inconsistent with the spirit of the rules.where else they were interviewing. Figure Sixty‐nine percent of applicant respondents in 2015 and 79% in 2016 reported being asked by at least one institution Thirteen percent of all respondents in the inaugural year survey and 16% in the second year survey indicated that they were “offered incentives”  during their interview. Incentives are often meant to pressure the candidate to rank the program highly.Twenty‐nine percent of all applicant respondents in 2015 and 27% in 2016 reported that they were told by at least one program that they were “ranked to match” or told their rank number prior to the MPM deadline. Thirty‐seven percent and 40% of program directors said candidates communicated their rank intent to the program, in inaugural and second year surveys, respectively. Of these 37%, 60% said interviewees indicated that they would rank that program first and 20% were asked by the interviewee how the program would rank them; the values changed to 32% and 0% in the second year survey. These disclosures of exact rank value are direct violations of match rules, as are questions to the other party of rank intent. Additionally, 13% (2015) and 11% (2016) of the programs failed to match with a candidate that had made a commitment to rank that program number one, which would be impossible to achieve if the candidate did not withdraw from the MPM and indeed had ranked that program number one. Of these 37% in the inaugural year, none of the programs agreed with the statement that knowledge of the candidate's intent to rank influenced their own ranking of candidates, perhaps wisely not taking declared rank intent seriously. In the second year survey, two program directors responded that the intent‐to‐rank information did influence the program's ranking of candidates.As shown in Fig. While 16% 2015) and 15% (2016) of candidates responded that they were offered a residency position outside of the MPM, we cannot ascertain the nature of these offers. Clearly, it is unethical to use the MPM application and interview process to hire a candidate out of the MPM process (“pair up” with the program and both drop out of the match). We hope that none of the offers identified in this survey represent such an effort to “pair up” and that these were simply positions  available outside the MPM system that operated on overlapping timelines. Nevertheless, even such fair offers can have undesirable consequences on the MPM process. Indeed, several program directors commented that candidates that they interviewed and ranked withdrew from the MPM before match deadline. Ideally, programs should not have to factor in such attrition when determining the number of applicants to interview and rank. Programs that are hiring during the match recruitment/interview period but not participating in the MPM should therefore be mindful of the effort and expense that programs in the MPM spend on candidates and make every effort to avoid making offers to match participants who have accepted an interview within the MPM until after the match results are released. Such programs are, of course, also encouraged to join the MPM to avoid such difficult situations. Match participants who accept a position outside of the MPM or otherwise withdraw prior to the rank order list deadline are strongly encouraged to immediately contact and inform the residency programs where they have interviewed. The NRMP currently has a rule limiting applicants and programs from discussing, interviewing, or accepting/offering a position outside of their Match between the rank order list deadline and the Monday of Match week. and 15% 4.CPostinterview communications can be merely polite thank you letters from the program to the candidate and/or from the candidate to the program. The communications can also be another opportunity to further influence or pressure the other party by including comments related to rank intentions.Wu et al. discuss in their 2015 publication that the perceived problem with postinterview thank you notes and other communication such as advocacy calls is that it has been used as a means by which to subtly or overtly convey rank intentions in order to “prearrange” the match ahead of the deadline.Figures 4.DDermatology is an example of a competitive medical field that participates in a national residency matching program with similar rules for ethical conduct. In a 2009 survey study that included Stanford dermatology applicants, current US dermatology residents, and US dermatology program directors, residents felt pressured to reveal rank intent to the programs.Similarly, 21–25% of MPM applicants felt pressured to offer assurances regarding ranking. Twenty‐nine percent (2015) and 27% (2016) reported being told by at least one program that they were “ranked to match” or their rank number prior to the MPM deadline. Furthermore, 13% (2015) and 20% (2016) reported being asked by at least one program how they intended to rank that or other programs.A follow‐up survey in dermatology was launched the subsequent year, to investigate whether raising awareness of the violations and issues in the initial publication had led to improved behavior.Jena et al. surveyed senior medical students who had applied to first‐ and second‐year residency positions in the NRMP in a variety of subspecialties.In the MedPhys Match surveys, fewer program directors  indicated postinterview communication with candidates compared to the senior medical student survey quoted above. More frequently, communication was initiated by candidates by sending thank you notes to institutions at which they interviewed. According to the survey results, 73% (2015) and 74% (2016) of the candidates responding to the survey sent thank you letters to institutions. Of the program directors who indicated that they received postinterview communication, 37% (2015) and 40% (2016) said candidates communicated their rank intent to the program.In a 2015 publication by Holliday et al. on the integrity of the Match for Radiation Oncology residency applicants to a single institution, 92.7% reported being asked by a program where else they were interviewing.In a 2016 survey returned by 118 residency applicants to a single radiation oncology department, 84% reported being asked at least once about where else they were interviewing, 51% were asked about marital status, and 22% were asked about plans to have children.A survey of 137 obstetrics and gynecology program directors reported that 29% would consider ranking an applicant more favorably if the applicant expressed interest beyond a routine thank you note or if a faculty mentor personally known to the program director endorsed them as outstanding.A survey of urology program directors and resident applicants was completed in 2000 including participation by 230 applicants and 94 program directors.4.EThis study is limited by the overall response rate, and the potential differences in results with a higher response rate cannot be estimated. The survey is confidential, which encourages honest responses. However, there is the added inherent problem in asking for honest answers regarding dishonest behavior that can lead to a potential underestimate of unethical behavior.This survey study may be biased in that it is a voluntary survey thereby completed only by those sufficiently motivated to follow the supplied link and complete the survey (self‐selection bias). It cannot be known if the responses are representative of all participants in the MPM. In 2015, 48% of applicant survey respondents matched with a residency, and 52% reported not matching  after MPM decisions were finalized. Anecdotally it is known that these positions were filled outside the MPM using lists of unmatched candidates and professional networks with graduate programs.Other medical specialties tout that their residency positions were filled by their top ranked choices as a measure of their program's value or desirability.Applicants are under pressure to secure a match given limited residency positions relative to the number of applicants. Programs are at an advantage since they control access to training positions and are generally in a position of power and authority.program behavior that needs to lead the way by modeling the desired ethical behavior. Suggestions for this model come from the same literature that has reported the ethical violations in other medical residency match programs.Rank according to quality of the candidate and not on how highly it is believed that they will rank the programs.Do not directly or indirectly divulge ranking intent; and do not solicit this information from candidates.Eliminate postinterview communications to further minimize the risk of divulging or soliciting rank intent information. Questions about the program can be addressed to a neutral and knowledgeable program administrator.Determine rankings immediately following interviews.Regardless of the potential motivations for unethical or dishonest behaviors within the MedPhys Match, ultimately it is Postinterview communication via a thank you letter or by an applicant's mentor has overall little effect on the program's ranking of the candidate. Therefore adopting a system of determining rankings immediately following interviews, such as recommended by Wu,Program directors can inform interviewees as a group, “Please feel free to contact us about any questions that you have about our program. We will not ask you how you intend to rank us. We will not share with you where you are positioned in our ranking.” If it is true that the program will determine its rankings immediately following interviews, then it is pertinent and helpful to tell this to all interviewees.An example template that programs could choose to adapt and adopt in an effort to educate all interview participants on EEOC guidelines and Match rules is included in Fig. It is important to note that the AAPM Subcommittee on Oversight of MedPhys Match (SCOMM) is ultimately responsible for investigating any potential Match violations. Potential penalties include a ban from participating in the MPM for a given time period and reporting the violations to other relevant associations such as the Society of Directors of Academic Medical Physics Programs (SDAMPP) or AAPM committees. Comments from program directors in the survey indicated that there is some confusion about what can and cannot be said to applicants and instructions from the MPM were incomplete in this regard, including lack of information on policing of the MPM rules.The authors declare no conflicts of interest.File S1: All Survey Questions.Click here for additional data file.


ABL1 kinase domain mutations is prevalent. In chronic-phase patients, these mutations become evident early in the disease course. A case is described of a chronic-phase CML patient who achieved a sustained, deep molecular response but who developed an Y253H ABL1 kinase domain mutation nearly nine years after commencing imatinib. Switching therapy to bosutinib resulted in a rapid reachievement of a major molecular response. Long-term TKI treatment impacts on quality of life and late losses of responses are usually due to lack of adherence. This case highlights the requirement for ABL1 kinase domain mutation analysis in those CML patients on long-term imatinib who lost their molecular response, regardless of whether nonadherence is suspected.The introduction of the tyrosine kinase inhibitor (TKI) imatinib has revolutionised the outlook of chronic myeloid leukemia (CML); however, a significant proportion of patients develop resistance through several mechanisms, of which acquisition of  BCR-ABL1-positive clones harboring mutations within the ABL1 kinase domain (KD) with identification of these mutations as important in selecting a subsequent TKI [ABL1 KD mutations predominantly manifest within eighteen months of commencing imatinib and usually in those patients whose best response has only been hematological or cytogenetic [ABL1 KD mutations in late as opposed to early chronic-phase patients [ABL1 KD mutation was detected nearly nine years after starting imatinib and who had previously achieved a sustained and deep molecular response.Introduction of the tyrosine kinase inhibitor (TKI) imatinib has revolutionised the treatment of patients with chronic myeloid leukemia (CML) with long-term administration showing persistent efficacy and lack of unacceptable cumulative or late toxic effects . Resistauent TKI . Studiesogenetic , 5. Evidpatients , 7. A CM9/L, hemoglobin of 7.7 g/dL, and platelets of 746 × 109/L. Bone marrow morphology revealed granulocytic hyperplasia with increased megakaryocytes and <1% myeloblasts. Cytogenetics detected the t translocation with molecular analysis demonstrating high levels of e13a2 BCR-ABL1 transcripts, consistent with a diagnosis of chronic-phase CML with a low-risk Sokal score. She commenced imatinib 400 mg oral daily with transient toxicities of nausea and increased susceptibility to infections but overall tolerated imatinib well, achieving a major molecular response (MMR) of BCR-ABL1/ABL1 0.09% on the International Scale (IS) at 20 months (BCR-ABL1 transcripts became undetectable (<0.001% IS) at 40 months with optimal adherence and a good quality of life. After BCR-ABL1 transcripts became undetectable, monitoring intervals were extended to six months. Rising transcript levels resulted in loss of MMR at 105 months, peaking at a BCR-ABL1/ABL1 IS of 3.43%, almost nine years after starting imatinib . The BCR-ABL1 transcript level continues to decline (A 49-year-old female presented with nausea, vomiting, and weight loss. Full blood count revealed a white blood cell count of 238.0 × 100 months . BCR-ABLimatinib . After a decline  with conABL1 kinase domain mutation analysis provided the rationale for switching TKI to bosutinib which induced a rapid molecular response. This case suggests that loss of MMR should always trigger ABL1 KD mutation analysis even after many years of follow-up, regardless of whether nonadherence is suspected.The long-term mild and chronic side effects of TKI therapy may impact on quality of life of CML patients and could be a trigger for lack of adherence . Despite


Ms 6.5 (Mw6.1) Ludian earthquake occurred in the eastern Sichuan–Yunnan border region of western China. This earthquake caused much more severe engineering damage than the usual earthquakes with the same magnitude in China. The National Strong Motion Network obtained large set of ground motion recordings during the earthquake. To investigate the engineering interested characteristics of ground motion from Ludian earthquake and compare it with the Mw 7.9 Wenchuan and the Mw 6.6 Lushan earthquakes in western China, studies on the ground motion field, attenuation relationship, distance dependence of significant duration, and site amplification were carried out. Some conclusion is drawn. Specifically, the ground motion field reveals a directional feature, and the distribution characteristics of the two horizontal components are similar. The attenuation relationship for Ludian earthquake is basically consistent with the ground motion prediction equation (GMPE) for western China, except the slight smaller than the GMPE predicted at short periods. The distance dependences of ground motion duration are different in Sichuan and Yunnan regions due to the local physical dispersion and Q value. The site amplification factors are dominated by linear site response for lower reference ground motion, but the nonlinearity becomes notable for higher reference ground motion. This feature is basically consistent with the empirical model for western China. All the results indicate that the spatial distribution of ground motion, the attenuation characteristics, and the site amplification effect should be considered in characterization of near-field ground motion.The 2014  Ms 6.5 (Mw 6.1) Ludian earthquake occurred at 16:30 on August 3, 2014 (UTC+08:00) in Yunnan province, China. The epicenter was located at latitude 27.189 °N, longitude 103.409 °E, with a focal depth of 12 km according to the US Geological Survey (USGS). As a result of high vulnerability of most of the structures in this region, the earthquake caused huge engineering damage. More than 600 fatalities and,3000 injuries had been reported as of a week after the earthquake. The seismic intensity from field survey in the magistoseismic area reached IX, and the affected area with the seismic intensity over VI is about 10,350 km2.The M > 6.0) occurred in western China, such as the Wenchuan Ms 8.0 (Mw7.9) earthquake in 2008, the Lushan Ms 7.0 (Mw 6.6) earthquake in 2013, the Minxian–Zhangxian Ms 6.6 (Mw 6.0) earthquake in 2013, and this Mw 6.1 Ludian earthquake in 2014. Recordings from destructive earthquakes were significantly useful for study of strong ground motion characteristics and developing new ground motion prediction equation (GMPE) for this high seismic risk region.In recent years, there have been several destructive earthquakes  project developed a set of updated attenuation relationships, which greatly promoted the worldwide study of new ground motion attenuation relationships  structures, wood structures, and adobe structures. Figure The 2014 Except the destroys and collapses of many rural constructions with no consideration of seismic design, some new built RC structures and masonry structures were also destroyed in the seismic intensity IX areas. As a typical example, Fig. http://www.csmnc.net/) were released. The strong motion stations and epicenters of Ludian, Lushan, and Wenchuan earthquakes are shown in Fig. During the main shock, a total of 74 strong motion seismometers owning to the China Digital Strong Motion Observation Network  both horizontal components are with usable periods from 0.1 s to 5 s. So the final dataset for attenuation relationship studies consists of recordings from 26 stations, listed in Table After baseline correction and band-pass filtering to the raw data, strong motion recordings in Ludian earthquake were selected for this study by using the following criteria: (1) recordings are representative of free-field; (2) the rupture distance is not greater than 200 km; 3) both horizontal components are available and the PGA is greater than 5 cm/s both horRrup) were used as rupture distance metric. To obtain the rupture distance for each station, instead of using the finite fault model, an estimation method by Chiou and Youngs  and fault-parallel (FP) components according to the fault geometry.Sa) for different periods were analyzed, aiming at better understanding of the distribution characteristics of ground motions. Figure T = 0.3 s). Where part (a), (b), and (c) represents the FN, FP, and UP  component, respectively. The spectral period of 0.3 s was selected because the local engineering structures were mostly low rise masonry buildings, and their natural periods are about 0.3 s. The contour maps indicated a directional distribution of spectral acceleration along the fault strike direction due to the strike slip mechanism; this feature is consistent with the intensity contour map in Fig. Taking advantage of the acceleration recordings in the 2014 Ludian earthquake, the contour maps of PGA and spectral acceleration , and response spectra with 5 % damping from 0.1 s–5.0 s. Equation  are compared in Fig. T = 1.0 s was significantly larger than the others. It can also be found from Fig. b for periods from 0.5 s–2.0 s are markedly greater than those for the other periods.Distance attenuations of PGA and response spectra for some typical periods  was developed based on the Wenchuan g et al. . Equatiog et al.  shows thg et al. .Table 5MMs 6.5 Ludian earthquake, as well as to observe the GMPE  and long period (T = 3.0 s) are compared with the fitted curves using Eq.   show similar slope (about 0.135) with distance, which is observably steeper than that for Ludian earthquake (the slope is 0.097) in Yunnan region.As shown in Fig. Ds5–75 is mainly determined by S-wave, so the effect of geometrical dispersion can be neglected. Thus, we can attribute the distance dependence of Ds5–75 to the physical dispersion due to non-elasticity. According to Azimi’s attenuation law , the dec is phase velocity, Q is quality factor of the earth crust.Where, Ds5–75 from two Sichuan region earthquakes and the 2014 Ms 6.5 Ludian earthquake in Yunnan region, we can draw a conclusion that Yunnan region has lower physical dispersion and higher Q value than that in Sichuan region.Incorporating with the companion result of the distance dependence of The local site condition is one of the factors affecting the ground motion. In order to study the effect of soil site on ground motion, we can compare ground motions from soil sites with those from rock sites with the same distance attenuation and source radiation conditions. Unfortunately, it is hard to find a pair of soil site and rock site meeting the aforementioned strict conditions during Ludian earthquake. To address this situation, a method of corrected reference site is used. The attenuation of amplitude with distance is utilized to correct the amplitude of ground motion at rock site so as to remove the effect of geometric attenuation and anelastic attenuation of ground motion. The key point for reference site method is to address the difference of source and path effect on soil site and reference rock site  Ludian earthquake occurred in the eastern Sichuan–Yunnan border region of western China. This earthquake caused serious engineering damage, large economic loss, and high death rate. During the earthquake, the National Strong Motion Network obtained series of acceleration recordings, which provided valuable data to be used in the attenuation relationship studies and characterization of ground motions in western China. Incorporating with the result on the Mw 7.9 Wenchuan earthquake and the Mw 6.6 Lushan earthquake, the peak ground acceleration, spectral acceleration, and significant duration parameters were adopted to study the ground motion distribution, attenuation, and site amplification.The 2014 Ms 6.5 Ludian earthquake; and there appears similar distribution characteristics of the two horizontal components, and the amplitude of vertical component is smaller than the horizontal ones. (2) The ground motion attenuation relationship for Ludian earthquake is basically consistent with the GMPE for western China  The distance dependences of duration are similar in Lushan earthquake and Wenchuan earthquake in Sichuan region, but it is different from that of Ludian earthquake in Yunnan region, which may attribute to the lower physical dispersion and higher Q value in Yunnan region. (4) The site amplifications for the three earthquakes are basically consistent with the model for western China  The ground motion field reveals a directional distribution characteristics along the fault strike, but the asymmetry features of ground motion distribution for hanging wall/foot wall effect is not clear in the 2014