Enhancing Social Support May Improve Cognitive Processing Therapy Outcomes in Telemedicine for PTSD
Sarah B. Campbell, PhD
July 13, 2020
As we work to sustain and tailor our mental health services during the era of COVID-19 and think ahead to future clinical needs, clinicians are increasingly transitioning their care to telehealth modalities. This format has the benefit of reaching the greatest number of people while still practicing physical distancing and following public health guidelines. The good news for health care providers (hereafter referred to as ‘providers’) is that telehealth-based delivery of gold-standard posttraumatic stress disorder (PTSD) treatments such as Cognitive Processing Therapy (CPT; Resick et al., 2017) has been shown to be no less effective than in-person delivery of care (Morland et al., 2014, 2015). As many readers are likely aware, CPT involves teaching participants skills for challenging unhelpful beliefs they may hold about themselves, the world, and other people resulting from, or exacerbated by, the experience of trauma. Although CPT delivered remotely appears to be noninferior to in-person care, providers may be curious about which characteristics of individuals seeking to participate in CPT via telehealth might improve their outcomes. In particular, potentially malleable characteristics are of special interest if their enhancement might direct providers to specific treatment plans or targets.
One such modifiable characteristic is the amount of social support an individual perceives they have. Social support, often defined as feeling listened to or understood by another person (e.g., emotional support) or receiving practical help with tasks (e.g., tangible support), is commonly studied in the context of PTSD (Wagner et al., 2016). Indeed, higher amounts of perceived social support have been shown to improve treatment outcomes (e.g., Price et al., 2013, 2018). It is easy to imagine how having an emotionally supportive relationship might prepare an individual to more effectively challenge unhelpful beliefs about the safety or trustworthiness of others. Similarly, having a relationship with someone who could take on household responsibilities to make time for CPT homework completion or drive a person to a medical appointment might boost treatment outcomes by enabling greater engagement with the treatment.
Although some research has shown that social support established before beginning treatment can encourage greater reductions in PTSD symptoms (Price et al., 2018), it’s not clear whether these findings can generalize across populations. In particular, individuals living in rural areas might have important differences in their levels of perceived social support that could change the degree to which social support benefits treatment. Specifically, rural individuals frequently prize self-reliance and privacy, particularly as those characteristics relate to mental health (Fischer et al., 2016). This preference for self-reliance and privacy might thus weaken the positive effect of emotional support for rural individuals. In fact, research conducted with veterans living in rural areas of the United States shows that social support might help with treatment initiation (McGinn et al., 2017) but not sustained use (Fischer et al., 2016), and it appears research has yet to be conducted about the treatment-boosting effects of social support among rural individuals. Therefore, we set out to evaluate the degree to which pre-existing perceived social support could enhance the effects of CPT for rural American military veterans participating in a pragmatic randomized effectiveness trial of telehealth-based collaborative care for PTSD (Fortney et al., 2015).
We used data from 225 veterans from 11 geographically diverse rural community-based outpatient clinics associated with three Veterans Affairs Medical Centers (Shreveport, Louisiana, Little Rock, Arkansas, and Loma Linda, California). Using bootstrapped ordinary least squares regression, we evaluated the degree to which the link between number of sessions of CPT attended and treatment outcomes depended on the level of pre-treatment social support (overall support, emotional support, and tangible support). We also determined the level of social support needed to experience clinically meaningful reductions in PTSD among the 41 individuals in our sample who completed a sufficient dose of CPT (defined as eight sessions; Holder et al., 2020). Analyses showed that although veterans reported similar levels of overall social support to other samples with PTSD (e.g., Brancu et al., 2014), they reported lower levels of emotional support compared to their reported tangible support (M = 56.40 versus M = 70.61). Regression analyses revealed that overall social support moderated the link between CPT duration and PTSD symptom change. Specifically, among those with roughly average and higher levels of social support, increased session attendance in CPT was associated with reductions in PTSD symptoms. This same pattern was observed when exploring emotional support, but it was not observed for tangible support. We also found that among the 41 individuals who attended eight or more sessions of CPT, only those who reported that their perceived social support was at or above one standard deviation above the mean level of social support showed any meaningful clinical improvement in PTSD.
Together, our findings suggest that providers would be wise to explicitly spend time assessing patients’ levels of perceived social support in an intake or treatment planning session. For those who report low levels of support, it may be prudent to engage in brief treatments to reduce isolation, generate new supports, or increase engagement with existing emotional supports prior to beginning trauma-focused treatment. Fortunately, videoconferencing and telephone are widely available and allow for social connection even in a time of physical distancing. Alternatively, providers could encourage group-based modalities of CPT or other treatments in order to begin cultivating a sense of social cohesion and connectedness. Thankfully, group-based treatments, including CPT, have also been shown to be feasible, acceptable, and effective even when delivered via telehealth (Gentry et al., 2019; Morland et al., 2011). Although we have needed to creatively tailor our treatment plans during COVID-19, we are fortunate that research continues to help us identify areas to target, such as social support, for continued growth and symptom relief among the traumatized individuals we treat.
References
Brancu, M., Thompson, N. L., Beckham, J. C., Green, K. T., Calhoun, P. S., Elbogen, E. B., Robbins, A. T., Fairbank, J. A., & Wagner, H. R. (2014). The impact of social support on psychological distress for U.S. Afghanistan/Iraq era veterans with PTSD and other psychiatric diagnoses. Psychiatry Research, 217(1–2), 86–92. https://doi.org/10.1016/j.psychres.2014.02.025
Fischer, E. P., McSweeney, J. C., Wright, P., Cheney, A., Curran, G. M., Henderson, K., & Fortney, J. C. (2016). Overcoming Barriers to Sustained Engagement in Mental Health Care: Perspectives of Rural Veterans and Providers: Overcoming Barriers to Mental Health Care. The Journal of Rural Health, 32(4), 429–438. https://doi.org/10.1111/jrh.12203
Fortney, J. C., Pyne, J. M., Kimbrell, T. A., Hudson, T. J., Robinson, D. E., Schneider, R., Moore, W. M., Custer, P. J., Grubbs, K. M., & Schnurr, P. P. (2015). Telemedicine-Based Collaborative Care for Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry, 72(1), 58. https://doi.org/10.1001/jamapsychiatry.2014.1575
Gentry, M. T., Lapid, M. I., Clark, M. M., & Rummans, T. A. (2019). Evidence for telehealth group-based treatment: A systematic review. Journal of Telemedicine and Telecare, 25(6), 327–342. https://doi.org/10.1177/1357633X18775855
Holder, N., Shiner, B., Li, Y., Madden, E., Neylan, T. C., Seal, K. H., Lujan, C., Patterson, O. V., DuVall, S. L., & Maguen, S. (2020). Cognitive Processing Therapy for Veterans with Posttraumatic Stress Disorder: What is the Median Effective Dose? Journal of Affective Disorders, 273, 425–433. https://doi.org/10.1016/j.jad.2020.04.030
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Morland, L. A., Hynes, A. K., Mackintosh, M.-A., Resick, P. A., & Chard, K. M. (2011). Group cognitive processing therapy delivered to veterans via telehealth: A pilot cohort. Journal of Traumatic Stress, 24(4), 465–469. https://doi.org/10.1002/jts.20661
Morland, L. A., Mackintosh, M.-A., Greene, C. J., Rosen, C. S., Chard, K. M., Resick, P., & Frueh, B. C. (2014). Cognitive Processing Therapy for Posttraumatic Stress Disorder Delivered to Rural Veterans via Telemental Health: A Randomized Noninferiority Clinical Trial. The Journal of Clinical Psychiatry, 75(05), 470–476. https://doi.org/10.4088/JCP.13m08842
Morland, L. A., Mackintosh, M.-A., Rosen, C. S., Willis, E., Resick, P., Chard, K., & Frueh, B. C. (2015). Telemedicine vs. In-person delivery of cognitive processing therapy for women with posttraumatic stress disorder: A randomized non-inferiority trial. Depression and Anxiety, 32(11), 811–820. https://doi.org/10.1002/da.22397
Price, M., Gros, D. F., Strachan, M., Ruggiero, K. J., & Acierno, R. (2013). The role of social support in exposure therapy for Operation Iraqi Freedom/Operation Enduring Freedom veterans: A preliminary investigation. Psychological Trauma: Theory, Research, Practice, and Policy, 5(1), 93–100. https://doi.org/10.1037/a0026244
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Reference Article
Campbell, S.B., Erbes, C., Grubbs, K.M., & Fortney, J. (In press). Social support enhances PTSD treatment outcomes in telemedicine-based treatment for rural veterans. Journal of Traumatic Stress.
Questions for Discussion
What are your thoughts about the role of social support in treatment outcomes for PTSD?
- How might rurality influence individuals’ reports of social support and its impact on PTSD treatment?
- How does social support play a role in treatments for PTSD delivered remotely or via telehealth?
Author Note: The views expressed here are those of the author and do not necessarily reflect the position or policy of the VA, the United States government, or any of the institutions with which the author is affiliated.
About the Authors
Sarah B. Campbell, Ph.D., is a licensed clinical psychologist specializing in evidence-based psychotherapy for PTSD and couple-based therapies for both relationship distress and PTSD at the VA Puget Sound Health Care System-Seattle division. She is an acting assistant professor in the Department of Psychiatry and Behavioral Sciences in the University of Washington School of Medicine and an affiliated investigator with the Seattle-Denver Center of Innovation in Veteran-centered and Value-Driven Care in Health Services Research and Development. She was recently awarded a VA Career Development Award to investigate social support assessment and enhancement among Veterans with PTSD.