ISTSS Logo
 
Home > Public Resources > Trauma Blog > 2020 - May > Continuing to Deliver Gold-Standard Treatment: Cognitive Processing Therapy during COVID-19

Continuing to Deliver Gold-Standard Treatment: Cognitive Processing Therapy during COVID-19

Stefanie T. LoSavio and John C. Moring

May 17, 2020

In response to COVID-19, mental health providers have had to quickly and creatively adapt treatment delivery, with many transitioning to telehealth. Like those in other professions, many clinicians have likely found the shift to video-based work challenging (e.g., Jiang, 2020; Skalar, 2020). With the stress of using a new treatment delivery format, there is a risk of drift from evidence-based practice. However, this need not be the case. Despite the challenges inherent in adapting to COVID-19, providers can use telehealth to effectively deliver gold-standard treatment.

Is Treatment Effective via Telehealth?

One of the most well-studied and effective treatments for posttraumatic stress disorder (PTSD) is Cognitive Processing Therapy (CPT; Resick, Monson & Chard, 2017). As many readers will know, CPT is a trauma-focused, evidence-based, cognitive-behavioral treatment in which clients learn skills to identify and examine their “stuck points,” or erroneous beliefs about the causes and consequences of their trauma. Research has shown that CPT is effective across many populations, settings, and formats, including telehealth. Indeed, CPT delivered via telehealth has been shown to significantly reduce PTSD symptoms, with outcomes no different than when delivered in-office (e.g., Maieritsch et al., 2015; Morland et al., 2014, 2015). These data can be reassuring for clinicians shifting to telehealth in response to COVID-19, and can be helpful to share with clients to instill confidence in therapy.

Should I Deliver Trauma-Focused Treatment during a Global Crisis?

Many practitioners may wonder if now is the “right” time to deliver trauma-focused treatment. After all, many people are facing significant stressors such as loss of employment, health concerns, and limited access to coping resources. Certainly, at this time, some clients may need support, crisis management, problem-solving, or other interventions to address acute stressors. But for many clients, the present time could be ideal to engage in an intensive treatment like CPT, given more available time, for example. Some clients may also feel “triggered” by recent COVID-19 events, increasing motivation to address pre-existing trauma issues.
For clients who are unsure if they want to work on their trauma right now (or providers who are unsure if now is the right time for their clients), it can be helpful to keep in mind that completing CPT and reducing PTSD symptoms is associated with a myriad of other benefits, including decreased substance use, decreased depression and suicidal ideation, and improved functioning (e.g., Bryan et al. 2016; Dondanville et al., 2019; Resick et al., 2008; Wachen et al., 2014). Therefore, targeting PTSD may put clients in a better position to cope with COVID-19-related stressors.

Can I Deliver a Structured Therapy during a Global Crisis?

The research tells us that CPT can be delivered effectively via telehealth, but, of course, adjustments will be necessary for those more accustomed to delivering care face-to-face. Some of the biggest challenges will likely be logistical, for example, how to get therapy materials back and forth with clients. Fortunately, there are many creative solutions to enable CPT delivery. For example, if you have purchased the latest version of the CPT manual, an electronic version of the therapy materials is available to download from the publisher’s website (Resick, Monson, & Chard, 2017). There is also a free app that can be used to accompany CPT, “CPT Coach,” which clients can use to complete measures, fill out worksheets, and review handouts. These resources limit the need for printing and delivering hard copies of materials and allow for electronic transmission between clients and providers.

Other challenges may be how to address COVID-19-related distress that may arise during treatment. While it is important to remain trauma-focused during CPT and adhere to treatment fidelity, it is also possible to integrate COVID-19 related issues into treatment. For example, erroneous beliefs about COVID-19 can be added to the Stuck Point Log and targeted using the same CPT skills used to address other beliefs. Other realistic and appropriate reactions to COVID-19, such as grief, can be labeled as natural emotions and processed.

Conclusions

Practitioners are working hard to maintain continuity of care and address the emerging mental health needs of our communities. Our field is fortunate to have frontline providers who have learned evidence-based treatments and are adapting their delivery to continue to provide care. While circumstances are challenging for both clients and providers, we are seeing that gold-standard treatment for PTSD can be effectively delivered via telehealth.

If interested in more information, readers are encouraged to read an article in press in the Journal of Traumatic Stress, which includes many more practical tips on how to deliver CPT via telehealth, including navigating logistical challenges and integrating COVID-19-related reactions into treatment:

Moring, J. C., Dondanville, K. A., Fina, B. A., Hassija, C., Chard, K., Monson, C., LoSavio, S. T., Wells, S. Y., Morland, L. A., Kaysen, D., Galovski, T. E., & Resick, P. A. (2020). Cognitive processing therapy for posttraumatic stress disorder via telehealth: Practical considerations during the COVID-19 pandemic. Journal of Traumatic Stress. Advance online publication. https://doi.org/10.1002/jts.22544

References

Bryan, C. J., Clemans, T. A., Hernandez, A. M., Mintz, J., Peterson, A. L., Yarvis, J. S., Resick, P.A., and the STRONG STAR Consortium. (2016). Evaluating potential iatrogenic suicide risk in trauma-focused group cognitive behavioral therapy for the treatment of PTSD in active duty military personnel. Depression and Anxiety, 33, 549–557. doi: 10.1002/da.22456

Dondanville, K. A., Wachen, J. S., Hale, W. J., Mintz, J., Roache, J. D., Carson, C., ... & Resick, P. A. (2019). Examination of treatment effects on hazardous drinking among service members with posttraumatic stress disorder. Journal of Traumatic Stress, 32, 310-316.

Jiang, M. (2020, April 22). The reason Zoom calls drain your energy. BBC. Retrieved from https://www.bbc.com/worklife/article/20200421-why-zoom-video-chats-are-so-exhausting

Moring, J.C., Dondanville, K.A., Fina, B.A., Hassija, C., Chard, K., Monson, C., LoSavio, S.T., Wells, S.Y., Morland, L.A., Kaysen, D., Galovski, T.E., & Resick, P.A. (in press). Cognitive processing therapy for posttraumatic stress disorder via telehealth: Practical considerations during the COVID-19 pandemic. Journal of Traumatic Stress.

Morland, L.A., Mackintosh , M.A., Greene, C.J., Rosen, C., Chard, K., 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. Journal of Clinical Psychiatry, 75, 470-476. doi: 10.4088/JCP.13m08842

Morland, L. A., Mackintosh, M., 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, 811-820. doi: 10.1002/da.22397

Resick, P. A., Galovski, T. E., Uhlmansiek, M. O. B., Scher, C. D., Clum, G. A., & Young-Xu, Y. (2008). A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology, 76, 243-258.

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. New York, NY: Guilford Press.

Skalar, J. (2020, April 24). ‘Zoom fatigue’ is taxing the brain. Here’s why that happens. National Geographic. Retrieved from https://www.nationalgeographic.com/science/2020/04/coronavirus-zoom-fatigue-is-taxing-the-brain-here-is-why-that-happens/#close

Wachen, J. S., Jimenez, S., Smith, K., & Resick, P. A. (2014). Long-term functional outcomes of women receiving cognitive processing therapy and prolonged exposure. Psychological Trauma: Theory, Research, Practice, and Policy, 6, S58-S66.

Discussion Questions:

  • What are your concerns about delivering evidence-based treatment during COVID-19, and how do they fit with the research data?
  • How might reactions to COVID-19 be similar or related to clients’ other trauma-related beliefs?
  • How might clients who have resolved their PTSD symptoms through cognitive behavior therapy be better prepared to cope with the stress of COVID-19?
Author Note: The views expressed here are those of the authors and do not necessarily reflect the position or policy of the VA, the United States government, or any of the institutions with which the authors are affiliated. 

About the Authors:

Stefanie T. LoSavio, Ph.D., ABPP is a licensed psychologist specializing in cognitive behavior therapy for PTSD. She conducts research at Duke University Medical Center and the Durham VA Health Care System and trains mental health providers in evidence-based, trauma-focused treatments. In her research, Dr. LoSavio studies the role of cognitive and emotional processing in recovery from stressful and traumatic events, mechanisms of trauma-focused treatments, and adaptations to treatments and training methods to increase the reach of evidence-based treatments.
 
John C. Moring, Ph.D., is a licensed psychologist and specializes in evidence-based therapy for combat-related PTSD and comorbid health conditions, such as chronic pain and posttraumatic headache. As an Assistant Research Professor at the University of Texas Health Science Center at San Antonio, Dr. Moring is a KL2 Scholar (NIH NCATS) and currently studies the overlapping neurobiological mechanisms responsible for PTSD and tinnitus.