PTSD: National Center for PTSD

For Mental Health Providers: Working with Patients Affected by the Coronavirus (COVID-19) Outbreak

The COVID-19 outbreak may present a range of challenges for patients in your care such as (1):

• Anticipatory anxiety
• Social distancing to prevent the spread of the disease
• Quarantine of those who have been exposed to the disease
• Isolation of those found to be infected
• Distress associated with having the virus or a family member having the virus
• Grief for those who may have lost a loved one to the virus
• Loss of income, housing instability, and food insecurity
• Childcare issues

There are many ways that these challenges might affect patients with existing mental health issues. For instance (2):

• Longer durations of quarantine (more than 10 days) have been associated with posttraumatic stress symptoms, avoidance behaviors, and anger
• Quarantine status has also been associated with frustration at poor or insufficient public health information, not having adequate supplies or access to healthcare, increased stigma and rejection from others, boredom and a sense of isolation from the world, and greater fears of infecting family members than those who are not quarantined (particularly if pregnant or a parent of young children)
• Financial loss has also been shown to result in serious distress and risk for negative psychological symptoms such as anger and anxiety. Having to depend on families for financial support has been shown to be particularly difficult and a risk factor for conflict, PTSD, and depression

Providers can help mitigate risk for patients by:

• Checking in on them regularly
• Providing accurate and up to date public health information
• Empathizing with stress reactions
• Fostering their patients' ability to cope with distress
• Conveying that patients CAN take meaningful steps to manage their own stress reactions

How to Talk with Patients About COVID-19

Mental health providers are well trained to help people manage their distress. Here are some additional suggestions for providing care in the context of the COVID-19 pandemic. When meeting with a patient, whether in person or via technology (i.e., telephone, video teleconference, email, text), consider the following strategies:

• Stay informed regarding COVID-19 through the Centers for Disease Control (CDC) website so that you have the most up-to-date, reliable information to share. VA providers can access a dedicated Sharepoint site: https://dvagov.sharepoint.com/sites/VACOVHAPublicHealth/HCI/SitePages/Home.aspx


• Begin by addressing the current context of the COVID-19 outbreak and tailor treatment to the patient's specific context and stress reactions at each contact. The approach might vary depending on how patients are reacting. By taking a person-centered approach, providers can avoid making assumptions about how the patient is reacting. For instance, patients who are inclined to take preventive measures may feel validated and resilient, whereas other patients may experience negative reactions based on a variety of perceived stressors, such as:
  • Disagreement with recommended or imposed limitations on their activities
  • Insufficient financial, physical, or emotional resources for preparedness efforts
  • Potential reminders of past traumas or losses
  • Extended restriction of work, leisure, or social activities
  • Loss of health, income, resources, family or friends, or normal routines
  
  
• Tailoring COVID-19-related comments to the patient's specific reactions may help them feel validated and understood, which could increase motivation and sense of control. Some suggested language, with prompts for specific circumstances, is:
  
  "Before we get started today I just want to check in with you to see how are you doing [in the current context of the COVID-19 outbreak]; [since you have been quarantined]; [since you've tested positive]; [since you've recovered]; [since your family member tested positive]; [since we spoke last]. What are the biggest stressors for you right now? What is helping you to cope with the current situation?"


• Providers using a manualized protocol may need to collaborate with their patients to determine whether they will move forward with an existing course of treatment, modify or adapt it in some way, or take a break from a patient's prior presenting complaint(s) and focus on the current context. Some suggested language is:
  
  "Given what you just told me, let's talk about what makes the most sense for you right now. We could stay focused on our current course of treatment or stop the treatment for a bit and focus fully on helping you manage the reactions you are having now related to the virus. I don't want us to lose the progress we have been making, but I also want to make sure I am helping you in the best ways that I can. We could also just take a break for a session or two to focus on new skills that you could use and then come back to the specific treatment. What are you thinking might be most helpful to you?"


• Providers can offer strategies for patients to use to manage their reactions to the virus. Some suggested language is:
  
  "It sounds like you would like some help managing your current reactions. We can definitely do that. There are many things we can try. Let's spend the next XX session(s) applying the skills you already have that might be useful and practicing some new skills as well."


• The COVID-19 outbreak is similar to natural disasters and other events with widespread impact in that providers are also affected by the event and may be facing the same challenges as some of their patients. While it is necessary to maintain appropriate clinical boundaries, limited acknowledgement of this shared experience may be appropriate depending on your patient and their circumstances. At the same time providers should be careful not to assume their patients are having the same reactions to the outbreak that they are (e.g. saying "it must be hard being on self-quarantine"). Some suggested language is:
  
  "This is a really hard time for a lot of people right now, how are you doing?"
  "I have been ordered to telework. It's taken some time to figure out how to work in these circumstances, but as the days go by, I am figuring it out. What challenges are you facing working at home?"
  "I also find that there are times when I get anxious thinking about the future. When this happens I remind myself .... I try to .... Let's talk about what might be most helpful for you?"

Printable Handout

For Mental Health Providers: Working with Patients Affected by the Coronavirus (COVID-19) Outbreak

Download a PDF of this page which discusses tips for talking with patients about COVID-19 and treatment considerations, including a stress management framework.

Considerations About How to Modify Treatments

Providers who decide to move forward with an existing treatment model should discuss potential modifications to the model that map more closely onto the patient's current challenges with the COVID-19 outbreak (3,4). These modifications will be very specific to the individual treatments. For example, in Prolonged Exposure, providers would not recommend a patient expose themselves to crowds when the Centers for Disease Control and Prevention (CDC) is recommending social distancing.

This would be a great time to network with colleagues and see how they are adapting treatments. Providers using an evidence-based PTSD treatment can review the National Center for PTSD's online lecture, "Treating PTSD During the COVID-19 Virus Outbreak." (available in the Previous Lectures section). The Skills for Psychological Recovery Field Guide offers additional strategies for teaching simple disaster-related coping skills that have been found to be related to better recovery from adverse events.

It may also be appropriate to spend some time discussing how the skills the patient has been learning in their existing treatment can be helpful in managing their reactions. Providers might say:

"Let's take some time to apply the strategies we've been practicing to your reactions related to the coronavirus outbreak."

The rest of the session could be devoted to using an existing model to help develop the patient's skills to manage both prior and current challenges by brainstorming ways to apply those skills to their current situation and then proceeding with the treatment protocol.

A Framework to Help Patients Manage COVID-19 Reactions

There are five evidence-informed elements that have been shown to be related to better outcomes in situations of ongoing threat: increased sense of safety, calming, connectedness, self-efficacy, and hope (5). It is not necessary to have all elements in place but implementing some of them may help patients deal with the stress caused by the COVID-19 virus. Providers can use the five elements framework to assess patients by asking them whether their current life conditions have had an impact on each of these elements, and also by asking them their preferred strategies for improving these five elements in their life. The article, Managing Stress Associated with the COVID-19 Virus Outbreak for patients, (also in Spanish) has specific strategies related to the COVID-19 outbreak. Here are some talking points to guide the discussions:

1. Increasing Sense of Safety. Finding ways to increase sense of safety can moderate biological reactions that create panicky feelings and make it hard to function. Help patients increase their sense of safety by sharing trusted information and resources on how they can protect their health and well-being. Help patients to prepare for a range of possible scenarios.
2. Cultivating Ways to Calm Oneself. In the face of a pandemic, calming is particularly important. Remaining overly anxious or grief-stricken can interfere with making decisions and taking care of self and others. Calming strategies are very personalized, but in the context of a pandemic suggest the following strategies to patients:
   • Calming actions such as breathing exercises, meditation, exercise, stretching, yoga, prayer, music, writing in a journal, or spending time outdoors.
   • Engaging in satisfying or rewarding activities.
   • Reduction of unhelpful strategies which seem to help in the short term but can make things worse in the long term, such as exclusive reliance on alcohol to relax, or excessive exposure to the news, particularly prior to sleep.
   • Practice helpful, less extreme ways of thinking, with the goal of modifying thoughts so that they are both realistic (i.e., "bad things might happen") and helpful (adding to the thought, "but if they do, I can handle it with help."). A table of specific pandemic-related unhelpful and helpful thoughts is available (4). For more information about how to walk a patient through choosing more helpful thoughts, see the Skills for Psychological Recovery Field Guide.
3. Staying Connected with Others as Much as Possible. Social support has been found to be a strong protective factor in adverse life situations. Help patients increase their social support by suggesting flexible, creative, and feasible ways to access support, whether by phone, email, text messaging, or video calls.
4. Improving Sense of Self-Efficacy. Self-efficacy is a feeling that one has the skills or resources to get through difficult times. In the context of a pandemic, providers can help patients enhance self-efficacy by suggesting they seek out mentoring or information to help make decisions and take actions, learn about the most common early warning signs of serious illness that require medical care, revise priorities and expectations, make concreate plans to mitigate stress reactions, and set achievable goals related to the impact of the outbreak and the pandemic response.
5. Remaining Hopeful. Hope has been defined by researchers as the expectation that things can work out, optimism about some aspect of the situation, or a connection with something greater than oneself. It is related to improved outcomes in extended threatening situations. Help patients be more hopeful by encouraging them to change negative thoughts to more helpful ones. Remind them to keep a long-term perspective while remaining focused on the present and the positive actions one can take in the moment. Paying attention to what inspires or increases gratitude has also been linked to better outcomes, as does making time for engaging in actions that support personal values, faith or spirituality.

References

1. Reissman, D. B., Watson, P. J., Klomp, R. W., Tanielian, T. L., & Prior, S. D. (2006). Pandemic influenza preparedness: Adaptive responses to an evolving challenge. Journal of Homeland Security and Emergency Management, 3(2). https://doi.org/10.2202/1547-7355.1233
2. Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet, 395 (10227), 912-920. https://doi.org/10.1016/S0140-6736(20)30460-8
3. Ruzek, J. I., Walser, R. D., Naugle, A. E., Litz, B., Mennin, D. S., Polusny, M. A., Ronell, D. M., Ruggiero, K. J., Yehuda, R., & Scotti, J. R. (2008). Cognitive-behavioral psychology: Implications for disaster and terrorism response. Prehospital and Disaster Medicine, 23(5), 397-410. https://doi.org/10.1017/S1049023X00006130
4. Berkowitz, S., Bryant, R., Brymer, M., Hamblen, J., Jacobs, A., Layne, C., & Watson, P. (2010). Skills for Psychological Recovery: Field operations guide. National Center for PTSD & the National Child Traumatic Stress Network. Available on www.nctsn.org and www.ptsd.va.gov
5. Hobfoll, S. E., Watson, P. J., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., Friedman, M., Gersons, B. P. R., de Jong, J. T. V. M., Layne, C. M., Maguen, S., Neria, Y., Norwood, A. E., Pynoos, R. S., Reissman, D., Ruzek, J. I., Shalev, A. Y., Solomon, Z., Seinberg, A. M., & Ursano, R. J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70(4), 283-315. https://doi.org/10.1521/psyc.2007.70.4.283