Although we are working within unprecedented circumstances, seasoned behavioral health providers have delivered services during other national and global crises, including 9/11, weather-related disasters, and economic crises. Lessons learned in those scenarios can help us anticipate some challenges unique to our patients with PTSD and inform our interventions.
Below you’ll find a collection of considerations and recommendations sourced from CDP’s Subject Matter Experts as well as from resources provided by the National Center for PTSD.
It’s perhaps most important to remember that each patient will have their own unique response to the COVID-19 outbreak. While there are common reactions, do not be surprised if each of your patients with PTSD responds slightly differently. As always, it is crucial to individually assess each patient’s safety, current symptoms, support system, and coping mechanisms.
A common concern is exacerbation of symptoms. This outbreak and the quickly evolving responses to it can fuel anxiety, worries about safety and control, hypervigilance, sleep disturbances, and just about every other symptom of PTSD. Some interventions that may be helpful for general symptom exacerbation include:
- Psychoeducation and normalization. Fear and distress associated with this outbreak are not unique to your patients with PTSD. SAMHSA summarizes normal reactions to global outbreaks and quarantines and describes ways to cope with associated distress. Their fact sheet may be a good resource to review with your patients. The National Center for PTSD has a similar resource specific to the COVID-19 outbreak: https://www.ptsd.va.gov/covid/COVID_managing_stress.asp
- Incorporate relaxation strategies. If you’ve not introduced these strategies to your patient before, this is a good time to explore options such as diaphragmatic breathing, mindfulness meditation, progressive muscle relaxation, and guided imagery. If your patient is already familiar with relaxation strategies, remind them to utilize those skills. This is not a one-size-fits-all approach. You can teach several interventions to your patients and encourage regular practice. Mobile apps (such as Breathe2Relax and websites (such as Headspace) can be particularly helpful tools to complement treatment.
- Utilize cognitive strategies. A hallmark of PTSD is a tendency to overestimate danger and underestimate abilities and resources. Use your cognitive therapy skills to help patients develop a more realistic and balanced assessment of their vulnerability, identify existing resources and realistic safety measures that can be implemented, and develop a plan for responding to realistic feared situations.
- Limit exposure to news and social media. Fear and a sense of helplessness can be fueled by 24-hour news cycles and panicked (and often inaccurate) social media posts. You might help your patient develop a specific plan for how to stay informed on the latest news without succumbing to hysteria. This might include limiting the duration of exposure and identifying credible news sources.
Avoidance symptoms may increase and, in fact, may be supported by public health guidelines. For example, pleas to practice social distancing reinforce avoidance of public spaces. If you have been working on confronting avoidance as part of treatment, it will be important to explore ways in which your patient may be avoiding anxiety-provoking situations in a way that extends beyond social distancing and quarantine guidelines. For example, while visiting crowded malls is not possible or advisable, taking a walk in the local park may be safe and a reasonable way to stem avoidance. If you are conducting exposure-based treatment such as Prolonged Exposure, some exposure tasks may need to be suspended, but others (listening to a specific song, exposure to a specific smell, looking at photographs) can continue.
Relationship stressors may increase as families are spending more time together in close quarters and simultaneously experiencing their own anxieties and distress. It may be helpful to work with your patient on healthy communication strategies, setting healthy boundaries, and conflict resolution. It may also be helpful for families to develop a plan to preserve privacy and “alone time” during this period. If there is any history of violence or abuse in the household, continue to assess safety needs and review safety plans as necessary.
Support systems may be more difficult to access during this period of social distancing. Fortunately, there are many ways to stay connected virtually. Emails, phone calls, and texting are convenient ways to stay in touch. Video-enabled options may be new to some patients but having a visual connection with loved ones can help mitigate loneliness and isolation. Most smartphones offer free video call software, and free online and mobile platforms are available, too. And while gyms, places of worship, and community centers are on lock-down, many are offering online classes and services. Identify several ways that your patient can keep in touch with members of their support network.
Don’t be surprised if some patients’ resiliency comes to the forefront. Some Service members and Veterans have expressed that they’ve “dealt with worse before” and feel uniquely prepared to weather this outbreak.
For patients with associated depressive symptoms, behavioral activation remains an effective strategy. Help your patient plan activities that can be done during periods of social distancing (playing a musical instrument, completing an online workout, etc.) and use goal setting and progress measurement as you typically would.
Given all of these considerations, it is possible that your patient’s needs have changed and, therefore so must your treatment. Even the most motivated and high functioning patient may be experiencing more urgent basic concerns the next time you see them, such as arranging emergency childcare, new or worsening economic stressors, or worry about obtaining basic necessities. It may be helpful to reassess current needs at each session for the duration of this outbreak. Use shared decision making to prioritize needs and adjust treatment accordingly, recognizing that needs and resources may shift several times. If you have been delivering a protocol-based treatment, you may have questions about continuing. Check out our blog on this topic here.
Many treatment sessions have necessarily, but suddenly, changed from face-to-face delivery to virtual delivery. If this is a new format for you and your patient, expect a period of transition as you adapt to things like technology obstacles and privacy concerns. Check out our tips for transitioning to telebehavioral health here.
Given the rapidly changing circumstances of this outbreak and the unclear duration, you will be relying on your clinical judgment to make the best decisions in your practice. Without a codified set of regulations specific to this outbreak, you will further rely on the ethical guidelines of your profession and your own ethical decision making model. Now is a good time to review the material you learned in your mandatory ethical continuing education courses and put it into practice as your work evolves.
Don’t forget to consult. You should never treat trauma alone and especially not in these evolving circumstances. Stay in touch with your trusted colleagues and discuss what has (and has not) worked for you during this outbreak. As always, CDP’s consultation services are available to the public and can be accessed by clicking here.
Finally, don’t forget your own self-care. Whether it’s staying virtually connected, completing an online workout, or practicing relaxation skills, it’s time to practice what you preach. While you may feel pulled in many (some new) directions, remember that you must take care of yourself before you take care of others. As the saying goes, “an empty lantern provides no light.”