Should I initiate Cognitive Processing Therapy or Prolonged Exposure with my patient during the COVID-19 pandemic? Patient-, provider-, and system-level factors for consideration?
Sarah L. Hagerty, PhD, Joseph Wielgosz, PhD, Jaclyn Kraemer, PhD, Hong Nguyen, PhD, Dorene Loew, PhD, and Debra Kaysen, PhD
August 31, 2020
“Should I initiate intensive trauma treatment with my new patient?” As clinicians providing care through the Trauma Recovery Services program at the Veterans Affairs Palo Alto Health Care System, this question has come up often among our team members during the COVID-19 pandemic. Our clinical team quickly realized that the pandemic context prompts unique considerations for providing trauma-focused mental health treatment. There is a useful body of public health literature to draw upon for guidance on how to approach the prioritization and provision of mental health during disasters (e.g., Mollica et al., 2004). However, the COVID-19 pandemic and gold standard treatments for posttraumatic stress disorder (PTSD) present some unique considerations, which prompt the need for a tailored decision-making framework. We outline 12 factors to consider when deciding whether and how to initiate Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) for the treatment of PTSD with a given patient-provider pair during the COVID-19 pandemic. Our analysis suggests that the key factors to consider fall under three categories: patient factors, provider factors, and system-level factors. We ground our discussion of each factor in available literature, and we offer recommendations for enhancing the indication for initiating treatment, including evidence-informed modifications to CPT and PE where appropriate.
What factors should be considered regarding the potential patient? We suggest that CPT or PE could be considered for a patient who meets criteria for PTSD regardless of whether the Criterion A trauma is directly related to the pandemic or a distal trauma, so long as the other diagnostic criteria are met (5th ed., APA, 2013). Importantly, some key studies suggest that trauma treatment is effective when implemented in contexts characterized by ongoing threat or environmental instability (e.g., Bass et al., 2013; Kaysen et al., 2020), thus the pandemic context alone should not be considered a rule out for engaging a patient in treatment. An additional patient-level factor to consider is the extent to which the patient’s basic needs are impacted by the pandemic. Consistent with public health best practices, effective mental health responses to disasters assume a hierarchical approach, such that basic needs (e.g., safety and shelter) take priority over specialty mental health interventions. We suggest that leveraging residential treatment options, if available, could be a useful way to meet the patient’s basic needs while allowing the patient to engage in treatment. Furthermore, the risks and benefits to the patient of delaying or initiating treatment should be weighed carefully. In particular, providers and care teams should assess whether life-threatening risks (e.g., suicidality, self-harm, substance use) could be managed effectively if trauma treatment were to be initiated during the pandemic. Management of these risks may require thoughtful planning given that the pandemic has shifted many care delivery models to telehealth.
The COVID-19 pandemic is somewhat unique compared to other disasters in that it does not discriminate between patients and providers. Thus, providers as well as patients are likely to be affected throughout the pandemic, including experiencing stressors that could interfere with the provision or receipt of care, respectively. For this reason, we suggest that the potential provider assess the extent to which they feel able and equipped to provide consistent, effective trauma therapy. Providers should evaluate, to the best of their ability given the information available at the time of consideration, whether they are likely to be able to complete a full course of CPT or PE with their prospective patient given their other personal and professional demands.
We also acknowledge that care delivery often occurs in the context of a system. In these cases, system-level factors should be considered in the decision process. For example, if care is being delivered over a telehealth modality, the system could enhance indication for treatment initiation if the system is able to help provide technological resources to patients and providers. Furthermore, the extent to which the system encourages a culture characterized by respect, mutual trust, and support among providers and leadership could increase the likelihood of successful care delivery, particularly during the pandemic where providers are likely to confront a host of personal and professional stressors.
Ultimately, we summarize the factors, suggested action steps, and proposed evidence-based modifications of CPT and PE in the form of a table and flow chart figure. It is our vision that our framework functions as a guide for engaging in structured, evidence-informed decision making. We encourage teams and providers to complement the framework with creativity and clinical judgment. We are hopeful that this serves as a useful tool that can help ensure sound, evidence informed decision making, which will ultimately benefit the patients we serve.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed).
Bass, J. K., Annan, J., McIvor Murray, S., Kaysen, D., Griffiths, S., Cetinoglu, T., Wachter, K., Murray, L. K., & Bolton, P. A. (2013). Controlled trial of psychotherapy for Congolese survivors of sexual violence. New England Journal of Medicine, 368(23), 2182–2191. https://doi.org/10.1056/nejmoa1211853
Kaysen, D., Stappenbeck, C. A., Carroll, H., Fukunaga, R., Robinette, K., Dworkin, E. R., Murray, S. M., Tol, W. A., Annan, J., Bolton, P., & Bass, J. (2020). Impact of setting insecurity on cognitive processing therapy implementation and outcomes in the eastern Democratic Republic of the Congo. European Journal of Psychotraumatology, 11(1), 1735162. https://doi.org/10.1080/20008198.2020.1735162
Mollica, R., Cardozo, B. L., Osofsky, H., Raphael, B., Ager, A., & Salama, P. (2004). Mental health in complex emergencies. The Lancet, 364(9450), 2058–2067. https://doi.org/10.1016/S0140-6736(04)17519-3
Hagerty, S.L., Wielgosz, J., Kraemer, J., Nguyen, H.V., Loew, D. and Kaysen, D. (2020), Best Practices for Approaching Cognitive Processing Therapy and Prolonged Exposure During the COVID‐19 Pandemic. Journal of Traumatic Stress. doi:10.1002/jts.22583
Questions for Discussion
- One key patient-level factor to consider is patient risk. What are some important risk-related factors to consider when weighing risks associated with initiating trauma treatment during the pandemic versus delaying/not initiating treatment?
- In order to successfully implement CPT or PE with a patient, the provider must demonstrate personal and professional capacity to provide care. As a provider, what are some key indicators that signal that you may not currently have capacity to engage effectively in trauma treatment delivery?
- Delivery of trauma treatment often takes place in the context of a system (e.g., care team, treatment center, hospital, or broader healthcare organization). What are some ways in which the system in which you practice could support effective delivery of CPT or PE?
About the Authors
Sarah L. Hagerty, Ph.D. recently completed her clinical internship at VA Palo Alto, where she treated veterans with posttraumatic stress disorder in the Trauma Recovery Services Program. Starting in September, she will be a post-doctoral research fellow at Stanford University/the Sierra Pacific MIRECC. Sarah completed dual PhDs in Clinical Psychology and Neuroscience at University of Colorado Boulder. Her research focuses on transdiagnostic mechanisms shared among psychiatric disorders, such as posttraumatic stress disorder and alcohol use disorder. Sarah is passionate about providing clinical care, and she hopes to leverage clinical science research to move the field towards a personalized medicine approach.
Joseph Wielgosz, Ph.D. is a postdoctoral research fellow at the Sierra Pacific MIRECC, VA Palo Alto Healthcare System and Stanford University. His research focuses on using digital health and neuroscience-informed approaches to improve evidence-based treatment of PTSD and related emotion disorders, as well as mindfulness-based interventions for emotional health. Joseph completed his doctoral training at the University of Wisconsin-Madison and clinical internship at the VA Ann Arbor Healthcare system with a focus on clinical treatment of PTSD and comorbid conditions including mood disorders, substance use, and insomnia.
Jaclyn Kraemer, Ph.D. Clinical Psychologist at the Palo Alto VA Health Care System (PAVA) in the Trauma Recovery Services (TRS) since 2014. Clinical Coordinator of the PTSD Intensive Outpatient Program in the TRS and SUD-PTSD Specialist for the PAVA. Specializes in evidence-based treatments for PTSD and trauma (Prolonged Exposure and Cognitive Processing Therapy), SUDs (CBT and Contingency Management), and co-occurring diagnoses (Dialectical Behavior Therapy); group psychotherapy; and program development/implementation.
Hong Nguyen, Ph.D. is a clinical psychologist in the Trauma Recovery Service at the VA Palo Alto Health Care System. Dr. Nguyen’s work focuses on the provision of evidence-based treatments for PTSD and the development and dissemination of Dialectical Behavior Therapy programming and training in residential and outpatient settings. She is also passionate about multicultural and diversity issues in mental health and is engaged in program development, research, and trainings related to these topics.
Dorene Loew, Ph.D. is a psychologist in the Trauma Recovery Service at the VA Palo Alto Health Care System where she has served in various capacities since 1995. She conducted her graduate studies at the University of Vermont, and internship at the VA Palo Alto. Current areas of interest include the application of dialectical behavior therapy and third wave interventions, particularly mindfulness and self-compassion skills training, in promoting resiliency and reducing suffering in trauma-exposed individuals.
Debra Kaysen, Ph.D. is a Professor at Stanford University, in the Department of Psychiatry and Behavioral Sciences and is a researcher at the VA Palo Alto Healthcare System, National Centers for PTSD. Dr. Kaysen’s area of specialty both in research and clinical work is in increasing access to effective treatments for those who have experienced traumatic events, across various populations, comorbidities, and settings. Dr. Kaysen is currently the President of the International Society for Traumatic Stress Studies (www.istss.org).