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One of the biggest changes to the mental health landscape since the onset of the pandemic has been the rapid and wide-scale switch from in-person therapy to telehealth. The adoption of telehealth may represent a silver lining to the pandemic, insofar as telehealth can increase the availability and convenience of psychotherapy. Born out of necessity to maintain physical distancing imperatives, this shift is likely to be permanent for at least some portion of mental health care provision. 
However, there are some drawbacks to telehealth, and it is not always preferred over in-person care (Goetter et al., 2019). Toward the start of the pandemic, when many were dealing with new stressors related both to the virus itself and its impact on society (e.g., job loss, school closures), telehealth temporarily became the only option for receiving mental health care.  This begs the question: how did the pandemic impact individuals’ ability to engage in PTSD therapy? In a recent study (McLean et al., 2021), we sought to answer this question by surveying individuals with PTSD enrolled in randomized clinical trials testing evidence-based treatments for PTSD. Interestingly, we found variability in how patients perceived the pandemic to affect their therapy participation. For most patients, the pandemic made attending therapy sessions more challenging, citing reasons such as difficulty focusing on therapy from home, experiencing interruptions during sessions (e.g., others living in the home), feeling less connected with their therapist through telehealth, having problems with technology, and experiencing greater daily stress. But a substantial minority of patients (26%) reported that the pandemic actually made attending sessions easier, citing the convenience and ease of attending sessions online without having to travel to and from appointments. 
In most exposure therapies for PTSD, clients are encouraged to approach trauma-reminders in real life (i.e., in vivo exposure) as part of “homework” in between therapy sessions, which typically includes going places where there are others in close proximity (e.g., crowded shopping mall). Thus, another important question is how did the pandemic impact individuals’ ability to engage in exposure-based therapy? Two thirds of participants reported that completing in vivo exposures, in particular, became more challenging. Because the overall impact on all therapy homework was minimal, this finding suggests that the pandemic restrictions had a negative impact on exposure therapy homework, in particular. This makes sense given that in vivo exposures had to follow CDC safety regulations (e.g., physical distancing, avoiding crowded areas) and options were more limited than before the pandemic. We also found that while overall, the pandemic seemed to have a slightly negative impact on participants’ ability to engage in treatment, the subset that had signed up for and started therapy in-person were particularly negatively impacted. This group likely experienced greater disruption in their care as they were forced to switch to telehealth part way through their course of treatment, as compared to those who had started, and chosen to start, treatment via telehealth. 

Our findings also suggest that the COVID-19 pandemic may have impacted therapy engagement indirectly through its impact on mental health. A negative effect of the pandemic on one’s PTSD symptoms and daily dress were each related to challenges engaging in therapy. Thus, the COVID-19 pandemic seems to have negatively impacted engagement in PTSD care in two ways: (1) directly, for example by making session attendance and homework completion more challenging, and (2) indirectly, by impacting PTSD symptoms and daily stress. The findings point to the potential value of tracking the impact of COVID-19 for clinicians wanting to keep their patients engaged in care and for treatment researchers who want to understand the effect of the pandemic on treatment outcomes. 

Reference Article 

McLean, C. P., Back, S. E., Capone, C., Morland, L., Norman, S. B., Rauch, S. A. M., Schnurr, P. P., Teng, E., & Acierno, R. (in press). The Impact of COVID-19 on Psychotherapy Participation Among Individuals with PTSD Enrolled in Treatment ResearchJournal of Traumatic Stress.

Discussion Questions 

  1. Patients in the study endorsed pros and cons to moving to virtual care during the pandemic. What do you see as pros and cons, based on what you’ve learned or on your personal experience delivering or receiving telemental health? 
  2. What types of pandemic experiences do you think are important to assess in trauma work going forward? 
  3. As in-person therapy becomes more available again, how do you think this will impact care engagement? 

About the Authors

Carmen P. McLean, PhD
is a Clinical Psychologist at the Dissemination and Training Division of the National Center for PTSD and a Clinical Associate Professor (Affiliate) at Stanford University. Her research focuses on making effective PTSD treatment available to more people. 
Sonya B. Norman, PhD
is Director of the PTSD Consultation Program for the National Center for PTSD and Professor in the Department of Psychiatry in the University of California San Diego School of Medicine. Her research focuses on treating PTSD and other common sequelae of trauma.
Sudie E. Back, PhD
is a Professor in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina and a Staff Psychologist at the Ralph H. Johnson VA in Charleston, SC. Her research focuses on the treatment of PTSD and co-occurring substance use disorders.


Goetter, E. M., Blackburn, A. M., Bui, E., Laifer, L. M., & Simon, N. (2019). Veterans’ Prospective Attitudes About Mental Health Treatment Using Telehealth. Journal of Psychosocial Nursing and Mental Health Services. 57, 38–43. https://doi.org/10.3928/02793695-20190531-02
McLean, C. P., Back, S. E., Capone, C., Morland, L., Norman, S. B., Rauch, S. A. M., Schnurr, P. P., Teng, E., & Acierno, R. (in press). The Impact of COVID-19 on Psychotherapy Participation Among Individuals with PTSD Enrolled in Treatment Research. Journal of Traumatic Stress.