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Implementing PE During the COVID-19 Pandemic: Tips and Adaptations

Stephanie Y. Wells, Ph.D., Emily R. Wilhite, Ph.D., Leslie A. Morland, PsyD & Carmen P. McLean, Ph.D.

September 14, 2020

The COVID-19 pandemic has brought new stressors (e.g., social isolation, fear of illness, financial stress) and increased the potential for traumatic exposures (e.g., sudden loss of a loved one, serious illness, intimate partner violence), which makes it critical to continue to provide evidence-based PTSD treatments. Home-based clinical videoconferencing (CVT), often referred to as telehealth or teletherapy, allows providers and patients to deliver and receive effective PTSD treatment that has been adapted for safe delivery during the pandemic. This allows providers to meet synchronously (i.e. patient and provider meet via video in real time) even when they are located in different locations.

Utilizing Prolonged Exposure Therapy (PE) During the Pandemic

Prolonged exposure therapy (PE) is a gold-standard short-term trauma-focused therapy that typically lasts between eight to fifteen 90-minute sessions (Foa et al., 2019). PE activates negative trauma-related emotion networks via imaginal and in-vivo exposure to facilitate extinction of fear responses and thereby promote corrective learning (Foa & Kozak, 1986). Fortunately, PE can be delivered via home-based CVT with high efficacy (Acierno et al., 2017; Morland et al., 2020) and in-vivo exposures can be adapted to adhere to physical distancing guidelines. We outline below some of the clinical considerations when providing care via this modality and also provide suggestions for flexible adaptation.

Optimizing Exposure Techniques During the Pandemic

Imaginal Exposure

Imaginal exposure (IE) is a core ingredient of PE and is largely unchanged when provided through CVT. However, because only part of the patient’s body is in the camera’s field of view, providers may need to check-in more often to assess for and eliminate safety signals and behaviors that could undermine the intervention. Additionally, it is important to work with the patient to create a private and quiet space during sessions to minimize distractions and effectively engage in IE. For patients living in shared spaces, a noise machine or other noise cancelling devices may be considered to increase privacy.

In-Vivo Exposures

In-vivo exposures inside the home. Due to the shift to videoconferencing for much of our daily lives including school, work, and therapy, patients can take advantage of the videoconferencing platform for in-vivo exposures by meeting with friends, family, or groups via telehealth. Below we also outline several possible in-vivos to address different themes:

Trust: Share something personal with someone; ask someone in the home to care for a loved one or pet
Social connection: spend time with a loved one in person (if already living with the person) or on video; set up an online dating profile if single and wanting to date; call a friend; write a letter or send a card to someone
Assertiveness: make a request or assert a boundary to another person in your home or through technology; call a customer service representative and make a request
Guilt or shame: disclose verbally or in writing something they feel guilty or shameful about to someone they trust
Anger: respectfully express feelings of anger to someone; discuss a controversial topic
Anxiety: interoceptive exposures
Grief/loss: read the obituary or look at photos of a deceased loved one; visit a memorial or gravestone of a loved one).
Being out of control: allow a family member to make decisions or surprise the person with plans
Safety: store guns unloaded and locked or remove from the home; leave curtains open; sit facing away from doors and windows
Orderliness: Leave dirty dishes in the sink; leave clutter out; arrange spice cabinet, fridge, and pantry randomly
Perfectionism: Send a text or an email with a typo; mispronounce words; admit you don’t know something to someone
Small spaces: sit in the shower or closet for a prolonged period of time; ride elevators in apartment buildings when possible using safety precautions (e.g., wash or sanitize hands afterwards).
Sensory stimuli: cook raw meat that may look like flesh; watch videos with trauma-related noises (e.g., explosions, airplanes)

In-vivos outside of the home. Although local public health guidelines may vary across regions, some in vivo exposures can be safely practiced outside of the home. Importantly, during all outdoor in vivo exposures, patients should adhere to public health recommendations including remaining 6 feet way from others at all times, wearing a mask to help prevent the risk of transmission, and washing their hands after being outside the home. Some example in vivos include:

Going to grocery stores while reducing safety behaviors (e.g., avoiding eye contact, rushing)
Taking social distanced walks outdoors alone or with others or meeting at an outdoor park
Sitting in a parked car in areas with loud noises (e.g., near an airport or train station), in hot places (e.g., desert), or near locations that remind an individual of the traumatic event
Eating outdoors at a restaurant with back to exit and while avoiding scanning behaviors (only applicable where outdoor dining is available and at restaurants where public health guidelines are being followed)
Driving on a freeway at different hours of the day for different levels of traffic or be a passenger in a car to practice being out of control
Making small talk and eye contact with a store employee or other customers
Going with friends or family to a drive in movie theater

Considering Health Disparities with CVT

The COVID-19 pandemic has propelled mental health to use CVT, which comes with many benefits including increased access to flexible care for many individuals unable to attend treatment sessions in-person (e.g., people living in rural areas and people at home with children) or during traditional hours. Despite the benefits, CVT also highlights existing health inequities that affect access to mental health services provided through CVT. Factors like access to equipment and wireless Internet may be prohibitively expensive or not available in certain regions for some individual with PTSD. Cell phones, tablets, and computers may be shared by several family members who may also be home during the pandemic, making it difficult to have CVT sessions. Some resources are available to address these disparities:

The VA Health Administration can provide WiFi enabled tablets to Veterans for healthcare appointments.
The COVID-19 Telehealth Program is providing $200,000,000 (USD) in funding as a part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The purpose of this aid is to help providers deliver services to patients in their homes or other locations during the COVID-19 pandemic. Nonprofit and public health agencies are eligible for funding through the CARES COVID-19 Telehealth Program (https://www.fcc.gov/covid-19-telehealth-program).

Finally, particularly during the pandemic with family members or housemates at home during the day, patient’s may not have access to a quiet and private space for the duration of a therapy session. Providers are encouraged to help patients problem solve such barriers and consider atypical spaces (e.g., a parked car), times (e.g., after children are asleep), and schedules (e.g., making some sessions 60-minutes) to protect continuity of care and therapeutic momentum.

Conclusions

PE delivered through home-based CVT offers a way to safely and flexibly implement exposure practice that can decrease avoidance and increase social engagement. Improving PTSD symptoms could allow individuals with PTSD to be less distressed and more able to manage the day to day stressors and emotional challenges of the pandemic.

References

Acierno, R., Knapp, R., Tuerk, P., Gilmore, A. K., Lejuez, C., Ruggiero, K., Muzzy, W., Egede, L., Hernandez-Tejada, M. A. & Foa, E. B. (2017). A non-inferiority trial of prolonged exposure for posttraumatic stress disorder: In person versus home-based telehealth. Behaviour Research and Therapy, 89, 57–65. https://doi.org/10.1016/j.brat.2016.11.009

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20—35. https://doi.org/10.1037/0033-2909.99.1.20

Foa, E. B., Rothbaum, A. O., Hembree, E. A., & Rauch, S. A. M. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences (2nd ed.). Oxford University Press.

Morland, L. A., Mackintosh, M. A., Glassman, L. H., Wells, S. Y., Thorp, S. R., Rauch, S. A., Cunningham, P.
B., Tuerk, P. W., Grubbs, K. M., Golshan, S., Sohn, M. J., & Acierno, R. (2019). Home-based delivery of variable length prolonged exposure therapy: A comparison of clinical efficacy between service modalities. Depression and Anxiety, 37(4), 346–355. https://doi.org/10.1002/da.22979

Reference Article

Wells, S.Y., Morland, L.A., Wilhite, E.R., Grubbs, K.M., Rauch, S.A., Acierno, R. and McLean, C.P. (2020), Delivering Prolonged Exposure Therapy via Videoconferencing During the COVID‐19 Pandemic: An Overview of the Research and Special Considerations for Providers. Journal of Traumatic Stress, 33: 380-390. doi:10.1002/jts.22573

Questions for Discussion

What other in-vivo exposures may be helpful or possible during COVID-19?
What strategies have you used to overcome barriers to PTSD treatment, such as PE, during COVID-19?
What other solutions may be helpful to overcome disparities for access to telehealth?

About the Authors

Stephanie Y. Wells, Ph.D., is a clinical psychologist and currently works as a Research Psychologist at the Durham VA Health Care System and VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center. She also works as a Research Interventionist at Duke University. She specializes in PTSD treatment outcome research and her research aims to improve PTSD treatments, increase access to care through novel-delivery modalities, and increase treatment engagement. Clinically, she specializes in treating PTSD and related disorders, such as anxiety and mood disorders.

Emily R. Wilhite, Ph.D., is a clinical psychologist and currently works as a Staff Psychologist at the 28-day Substance Abuse Residential Recovery Treatment Program (SARRTP) at the VA San Diego Healthcare System (VASDHS). She also collaborates on treatment outcome research through the Veterans Medical Research Foundation at the VASDHS. Clinically, she specializes in the concurrent treatment of PTSD and substance use disorders.

Leslie A. Morland, PsyD, is a Professor of Psychiatry at University of California, San Diego (UCSD) and the Director of Telemental Health (TMH) at the San Diego VA Medical Center. Dr. Morland has substantial experience and expertise in designing and implementing federally funded clinical studies that examine the utility of technology to increase access to evidence-based PTSD services.

Carmen P. McLean, Ph.D., is a licensed clinical psychologist at the dissemination and Training Division of the National Center for PTSD at the Palo Alto VA Healthcare System and a Clinical Associate Professor (Affiliate) position at Stanford University. Dr. McLean is a licensed Clinical Psychologist, an Associate Editor for Cognitive Behavioral Practice, and the 2018 recipient of the Anne Marie Albano Early Career Award for Excellence in the Integration of Science and Practice from the Association of Behavioral and Cognitive Therapies. She has published over 100 articles and chapters on topics related to PTSD and anxiety. Her research examines ways to increase the reach of exposure therapy for PTSD by addressing implementation barriers and testing eHealth and mHealth interventions.