Prolonged Exposure Therapy in the Time of COVID-19: Modifying PTSD Treatment for a Military Sexual Trauma Survivor Who Contracted COVID-19 Mid-Treatment

1 Theoretical and Research Basis for Treatment

Military veterans have particularly elevated rates of posttraumatic stress disorder (PTSD), stemming from experiences of combat exposure, military sexual trauma, and other traumatic life events (Ramchand et al., 2010). More than half a million veterans seek services for PTSD annually, representing 9.2% of all Veterans Affairs (VA) Healthcare System users and costing the VA $3 billion annually (Institute of Medicine, 2014). Beyond monetary costs, individuals with PTSD experience a multitude of negative consequences, including marital, family, health, employment, and substance use problems (Hoge et al., 2007; Jordan et al., 1992; McCarthy & Petrakis, 2010). Given this, efforts have been made to ensure effective treatment options are available for PTSD within VA. The VA/DoD Clinical Practice Guidelines for the Management of PTSD (Department of Veterans Affairs, & Department of Defense, 2017) and the International Society for Traumatic Stress Studies PTSD Prevention and Treatment Guidelines (Berliner et al., 2019) recommend individual, manualized, trauma-focused psychotherapies as first-line treatments for PTSD, including Prolonged Exposure (PE) Therapy (Foa et al., 2007, 2019) and Cognitive Processing Therapy (Resick et al., 2017). During the COVID-19 pandemic, these remain the recommended, gold-standard treatments for PTSD, although modifications and special considerations have been suggested for effective implementation (Hagerty et al., 2020).

When providing trauma-focused treatments during the COVID-19 pandemic, treatment engagement, including elevated rates of dropout and the low likelihood of trauma-focused treatments being initiated (Kehle-Forbes et al., 2016), are key to consider and intervene upon. Indeed, across multiple studies, VA clinicians report that the foremost barrier to the implementation of PE or CPT is veterans’ unwillingness or inability to initiate and complete these treatments (Cook et al., 2014; Osei-Bonsu et al., 2016; Zubkoff et al., 2015). Studies examining treatment attrition demonstrate that only 39% of veterans diagnosed with PTSD initiate psychotherapy within a year, with less than 9% completing treatment (Spoont et al., 2010). Many veterans receiving EBPs for PTSD (PE or CPT) drop out prior to receiving the active components of treatment (Fortney et al., 2015; Kehle-Forbes et al., 2016; Mott et al., 2014), making them unlikely to see symptom reductions, with general PE/CPT dropout rates within outpatient VA clinics hovering around 40% (Kehle-Forbes et al., 2016). Findings across studies are mixed, regarding what factors predict treatment dropouts; relevant to the veteran who will be discussed here, outpatient veterans are more likely to drop out of PE than CPT, and older veterans are less likely to drop out than younger veterans (Kehle-Forbes et al., 2016).

There are a number of factors that may help to increase individuals’ engagement with trauma-focused therapies more broadly, including during the COVID-19 pandemic. Shared decision making, which provides information about existing evidence-based treatments for PTSD and then allows veterans to choose which type of treatment they wish to initiate, can be helpful; veterans participating in shared decision making are more likely to elect to participate in an EBP for PTSD and to more rapidly initiate these treatments. (Hessinger et al., 2018). In the case described here, this process was utilized and veteran David (name and all identifying details have been modified to deidentify this case) elected to participate in PE (additional details provided below).

Important during the COVID-19 pandemic and the rapid transition to telehealth services, PE delivered via home-based telehealth, compared to standard, in-person PE, is equally effective in treating PTSD (Acierno et al., 2017) and increases access to care during a time when many individuals do not feel comfortable attending in-person therapy sessions. Moreover, guidelines have been published that provide concrete suggestions on delivering PE via telehealth during the pandemic (Wells et al., 2020). David elected to complete his full course of PE via telehealth, following a discussion of the effectiveness of telehealth and need for more rapid treatment initiation (i.e., not waiting for face-to-face services to resume) when the pandemic began.

Next, receiving support from loved ones to persist in trauma-focused treatment, especially encouragement to be willing to tolerate distress, doubles retention rates in trauma-focused treatment (Meis et al., 2019). David’s partner attended an initial intake session and David’s therapist gave her handouts about PE, including the treatment rationale. David reported his partner encouraged him to persist with PE, including completing his homework assignments, and checking in with his therapist when he was having urges to discontinue treatment. Moreover, David often jokingly asked his therapist whether she and his partner were in cahoots, because his partner used PE consistent language when encouraging him to persist in challenging situations.

Finally, David and his therapist had scheduled, weekly, 30-minute phone check-ins, in addition to his PE sessions, where they discussed homework completion, motivation to persist in treatment/urges to drop out, and current life stressors (including COVID-19) interfering with progress. David appreciated that these phone appointments allowed him to check-in about non-PE related concerns/stressors, feel more connected to and supported by his therapist, and maintain motivation to attend his PE sessions when struggling with urges to drop out; this is consistent with recommendations within qualitative work regarding strategies to reduce dropouts (Kehle-Forbes, 2020).

Recent publications include additional recommendations and considerations for trauma-focused treatments during the COVID-19 pandemic (e.g., Banducci & Weiss, 2020; Hagerty et al., 2020; Wells et al., 2020). Although these publications came out after treatment had already been initiated with David, they include important considerations, moving forward, for treating PTSD during the pandemic. Hagerty et al. (2020) suggest the importance of considering patient, provider, and system-level factors when initiating PE or CPT during the pandemic. Patient-level factors to consider, prior to initiating PE/CPT during COVID-19 include: (1) patient diagnostic status (meeting diagnostic criteria for PTSD), (2) the impact of the pandemic on the patient, (3) how effective PE or CPT is likely to be if there are ongoing pandemic-related threats/stressors, (4) how likely the patient is to complete treatment, (5) the patient’s ability to complete exposure exercises, and (6) the relative risks/benefits to initiating versus delaying treatment (Hagerty et al., 2020).

Provider-level factors to consider include: (1) professional demands on the provider associated with the pandemic, (2) the impact of the pandemic on the provider’s ability to effectively provide PE/CPT, and (3) the provider’s access to resources to effectively deliver PE/CPT during the pandemic (Hagerty et al., 2020). Finally, system-level factors include: (1) the capacity of the healthcare system to support coordinated, flexible, and evidence-informed responses and decision making during the pandemic, (2) logistical and technological support to deliver treatment, and (3) the culture of the system and how the system encourages a culture of support and respect (Hagerty et al., 2020). Although we did not systematically consider all of these factors prior to initiating PE with David, we will discuss how they are relevant throughout the description of the case and the course of treatment.

Prolonged Exposure therapy was selected by David as the trauma-focused treatment he wished to initiate. PE was developed based on emotional processing theory, which argues that PTSD develops due to pathological fear structures (e.g., David believed that if he ate food from a restaurant, he would be drugged and sexually assaulted) that develop following trauma exposure and that maintain symptoms of PTSD (e.g., avoidance), thus interfering with natural recovery (Foa & Kozak, 1986). Within the context of emotion processing theory, recovery happens when these pathological fear structures (e.g., “I will be drugged and assaulted if I order food from a restaurant”) are activated within exposures (e.g., eating take out), so that these fear structures can be modified by incorporating new information (e.g., I ate take out ten times and was not assaulted), thereby altering trauma-related cognitions (e.g., eating take out is safe”) and emotional responding (e.g., decreased anxiety). As individuals complete imaginal and in vivo exposures, they are exposed to information, via their experiences, that activate an emotional response and change the underlying fear structure based on learning that occurs (Foa & Kozak, 1986; Foa et al., 2007, 2019). Thus, successful emotional processing includes activation of an emotional response, within/between session extinction of the emotional response, and changes in PTSD related cognitions (Craske et al., 2014; Foa et al., 2019).

Prolonged Exposure therapy includes psychoeducation about PTSD; breathing retraining to decrease autonomic arousal; repeated recounting of the trauma to gain a different perspective on the traumatic experience, and to teach individuals that their trauma memories are not dangerous and do not need to be avoided; and in vivo exposures to feared real-world situations to decrease fear responses to trauma reminders in the environment.

As a treatment, PE generally involves 10 to 14 90-minute sessions, delivered 1 to 2 times per week; treatment can be extended to enhance reductions in PTSD symptomatology. Further, during the COVID-19 pandemic, it has been suggested that the duration of individual sessions may need to be extended (e.g., 100 minutes, rather than 90 minutes) to accommodate technological challenges that may come up during the delivery of PE via telehealth (Wells et al., 2020). As will be discussed below, the number of therapy sessions provided was substantially increased for David, following him contracting COVID-19 mid-treatment and due to initial technological challenges throughout treatment. Additionally, relevant to David, PE was initially developed for and tested among sexual assault survivors, with a substantial body of research supporting the use of PE among survivors of sexual assault (Rothbaum et al., 2005). Thus, PE was the ideal treatment for David for a number of reasons, including the strong evidence base for PE, David’s selection of this treatment through shared decision making, the support of his partner to persist through distress associated with PE, the effectiveness of PE when delivered via telehealth, and the development of PE as a treatment for sexual assault survivors.

2 Case Introduction

David is a heterosexual, cisgender, biracial, male, Navy veteran in his mid-60s, who sought treatment for PTSD, secondary to military sexual trauma (MST), beginning in February 2020. He had not previously participated in any mental health treatment through the VA Healthcare System, or in the private sector, although he had previously initiated and quickly discontinued mental health treatment on several occasions during the prior decade. Upon entering into PTSD treatment, David reported 3 years sobriety from alcohol and cocaine, through participation in Alcoholics Anonymous (AA). Although he had maintained sobriety for 3 years, he was worried engagement in PTSD treatment might precipitate a relapse to substance use, so cravings and urges for substances were monitored throughout treatment and continued engagement in SUD treatment (e.g., AA) was encouraged. He had previously been married once; he and his ex-wife divorced due to his substance use and emotional volatility during their marriage. At treatment initiation, he was in a committed relationship with his partner. David had a past history of legal issues tied to his substance use (arrested and served time in jail due to physical aggression when drinking, several DUIs); since becoming abstinent from substances, he had not experienced legal issues. David was on disability, due to physical injuries sustained at work and was living with his partner in an apartment he rented. He was assaulted more than 40 years prior to seeking treatment for his PTSD and noted at intake that his MST had negatively impacted every aspect of his life.

3 Presenting Complaints

David met diagnostic criteria for PTSD, as well as for alcohol and cocaine use disorders, in remission, at the onset of treatment. When initially presenting for treatment, David reported that his AA sponsor, family members, and romantic partner had suggested he seek treatment for anger. He reported intense and ineffective displays of anger across multiple contexts (e.g., “road rage” where he instigated verbal and physical fights with individuals whose driving behavior upset him; threatening employers when provided with feedback about his job performance; shouting at police officers when pulled over during traffic stops; yelling at his primary care physician when told about medical conditions, etc.). Because of difficulties effectively controlling behavior in the context of feeling intense anger, his adult children had limited contact with him; his daughter noted that she “never knew which version I’d get” when describing his mood volatility.

He also reported that his life had become very constrained due to his PTSD. Because his MST was drug-facilitated, he avoided eating out at restaurants, had an extremely restricted diet, would not eat food prepared by friends or family members, and would not eat foods that looked “suspicious” (foods with multiple colors/textures) because he was frightened of being drugged/poisoned and assaulted again. His diet was also restricted because of avoidance of foods that reminded him of semen (e.g., mayonnaise, soft cheese, yogurt, creamy foods, etc.). He generally avoided individuals who reminded him of his perpetrator, or stimuli that reminded him of the military more broadly (e.g., the VA, other veterans, military clothing/hats, military patches, military movies, etc.). At the beginning of the COVID-19 pandemic, he reported his avoidance of other people and his reluctance to leave his home was due to his PTSD, not due to fears about contracting COVID-19. Finally, he reported frequently perceiving danger in his environment and constraining family members’ behavior because of this fear. This included never allowing his children to go to friends’ homes when they were growing up, worrying about his partner leaving the home without him present and encouraging her to remain at home, and ensuring he was armed with some type of weapon (e.g., pocket knife, hand blade, hand gun) to protect his family when leaving his home. When he initially met with his therapist, they had a detailed discussion about the necessity of leaving his knife in his vehicle when coming to VA appointments.

When David initiated treatment, he had little insight as to how his experience of MST was tied to his presenting concerns. Across the course of treatment, he expressed amazement at how restricted his behavior had become, due to PTSD-related avoidance, noting that he previously had no idea why he perceived the world as being dangerous, as well as why he was always on edge and irritable. He reports previously seeing himself as being justified at the daily rage he felt, the behavioral constraints he placed on family members over the prior four decades, and his restricted patterns of eating.

4 History

David reported an uneventful and happy childhood; his parents were caring, he succeeded academically and athletically, and he dated regularly during his adolescence. He joined the military when he was 18-years-old and was raped 8 months into his deployment when his ship was docked in the Philippines. He describes going out to a bar with a couple of friends the night of his assault. He does not recall what happened at the bar; there is a gap in his memory that he attributes to being drugged. He recalls waking up in a dingy hotel room and seeing a male torso above him raping him. Although he is unsure what he was drugged with, symptoms he reports are consistent with high doses of Rohypnol, or Ketamine. He describes his entire body feeling completely numb and having no motor control: “I couldn’t feel my arms or legs, or do anything to move them. I wasn’t even sure I had arms or legs at that point.” He notes he could feel something inside of him, but he described the sensation as being similar to when a dentist is extracting a tooth with Novocain: “There was pressure, but the sensations did not match the intensity of what was going on.” He felt horrified and wondered whether he was paralyzed or severely injured, given that he could not feel parts of his body, move his limbs, speak, or even change his field of vision: “I couldn’t even move my eyes to see who was raping me.” Throughout the assault, he was in and out of consciousness, wondering whether he was dying, or would be killed by his perpetrator. Toward the end of the assault, when his perpetrator kissed him, he saw his perpetrator’s face and realized he was being assaulted by a man in his unit.

Following his assault, he began binge drinking every time his boat went to port. His behavior became erratic and aggressive; “I lost trust in myself and my fellow Navy men to protect me.” He was temporarily put in the “brig” (Navy jail aboard the ship) on multiple occasions for drunkenness and fighting. He received informal reprimands on several occasions from senior leadership (these reprimands were not formally documented in his military records) and noted one commander suggested he seek mental health services, which he refused.

He requested leave, but was denied; he had hoped to go home and seek the support of his family after the assault. Following his assault, he served an additional 16 months in the Navy, prior to discharge. Upon returning to civilian life, both his aggressive behavior and alcohol use escalated. Due to sexual dysfunction he experienced following his assault, he began using cocaine when engaging in sex to reduce inhibitions. Over time, cocaine use increased, as he began using cocaine to avoid sleeping and the horrifying nightmares that would follow. This pattern of aggressive behavior and substance use continued until he was eventually court mandated to participate in substance use treatment in his late 50s. He elected to engage in AA and benefitted substantially; he quit drinking and using cocaine completely. Although aggressive behavior persisted, it was at a lower intensity level than when he was actively drinking and using, so did not cause further legal problems.

5 Assessment

David reached out to this provider, who serves as the facility MST Care Coordinator, after seeing this provider’s name on a poster discussing MST at the VA medical center. Three initial sessions were dedicated to collecting background information and completing psychodiagnostic assessment. David met diagnostic criteria for PTSD, secondary to MST and alcohol and cocaine use disorders, in remission. He also reported chronic pain associated with his PTSD (tooth grinding) and noted that he had not gotten a colonoscopy in 15+ years because it triggered a frightening flashback on the last occasion he completed one.

PTSD diagnosis was determined using the Clinician Administered PTSD Scale (CAPS-5; Weathers et al., 2018), a semi-structured assessment of PTSD, administered at intake (CAPS-5 total symptom severity score at baseline = 61). The CAPS-5 has been tested and validated in military samples and CAPS-5 total severity scores have high internal consistency, inter-rater reliability, and good test-retest reliability (Weathers et al., 2018). Moreover, there is good convergent validity with PCL-5 scores (Weathers et al., 2018). David also completed the PTSD Checklist for the DMS-5 (PCL-5; Blevins et al., 2015), a 20-item self-report measure of PTSD symptoms (Total Score range = 0–80), with strong internal consistency, test-retest reliability, convergent and discriminant validity (Blevins et al., 2015; Bovin et al., 2016; Wortmann et al., 2016), including among military members. Response options on the PCL-5 range from 0 (not at all) to 4 (extremely); a total cut off score of ≥ 31 indicates probable PTSD (Bovin et al., 2016; Wortmann et al., 2016). A decrease of at least 10 points on the PCL is considered clinically significant change (Monson et al., 2008). David’s score on the PCL-5 at baseline was 69, indicative of very severe symptoms of PTSD, consistent with the functional impairments he reported and with the CAPS assessment. Although he reported multiple Criterion A traumatic events across the lifespan, PTSD symptom severity assessment on the CAPS-5 and PCL-5 focused on his MST. The following PTSD symptoms described below are based on what he described within the context of the baseline CAPS-5 assessment.

He endorsed the following Criterion B PTSD symptoms: (1) disturbing and unwanted memories about his MST 2 to 3 times/week, which he found to be (2) incredibly distressing (feels angry, anxious, sad, and ashamed for 3–60 minutes after thinking about his MST), (3) leading to chest pains, racing heart, increased blood pressure (he regularly monitored his blood pressure), nausea, and headaches. He also reported having (4) nightmares of being raped (during nightmares, he would scream, thrash, wake up in a pool of sweat, and be awake for 2–3 hours afterwards) 20/30 days during the month prior to the CAPS assessment. He reported his partner often would wake him up when he was having nightmares because he would be screaming and thrashing.

He endorsed the following Criterion C symptoms: (1) avoiding talking or thinking about the memory during the prior 40+ years (therapy was the first time David disclosed his MST), including using distraction and substance use (previously drinking/cocaine use) to push away memories; and (2) avoiding stimuli that reminded him of his MST, or that made him feel unsafe due to his MST (e.g., hyper-masculine men, eating food from restaurants, crowds, sleeping without a gun under his bed/leaving his home without a weapon, eating many types of foods, physical intimacy, wearing Navy-related clothing items, getting emotionally close to others, wearing clothing or engaging in behavior that he thought would cause others to perceive him as being gay, etc.). He spent the majority of his time at home because he felt unsafe elsewhere.

He endorsed the following Criterion D symptoms: (1) having strong, negative, inflexible beliefs about himself, others, and the world (“If I don’t have complete control over the food I consume, I will be drugged and assaulted,” “I can’t trust anyone,” “If I am alone with a man, I will be assaulted”), (2) self-blame for being raped, despite being drugged and physically unable to move or speak (“It’s my fault I was raped because I didn’t fight back”), (3) strong, frequent, and unmanageable feelings of fear, horror, anger, guilt, and shame, (4) loss of interest in activities he previously enjoyed following MST (e.g., playing the guitar, running, reading novels, hiking, interacting with family members, etc.), (5) feeling distant and cutoff from loved ones (e.g., his daughter, his partner, etc.), and (6) difficulties experiencing positive feelings like love and happiness. He did endorse difficulties recalling certain aspects of his MST; however, it was unclear during baseline assessment whether this was due to avoidance, or due to memory gaps as a result of being drugged during the assault; thus, this symptom was not included.

He endorsed the following Criterion E symptoms: (1) feeling irritable/angry and showing it in his behavior (past month verbal aggression on multiple occasions, past month aggressive/unsafe driving on several occasions, past month breaking of yardwork tools when angry), (2) risk-taking behavior (e.g., driving his motorcycle at 90 mph because it makes him feel “invincible”), (3) being constantly hypervigilant (e.g., will not sit with his back to the door inside his home; will only sleep on his left side, so as to face his bedroom door; installed elaborate alarm system and booby traps around his home, and checks locks on doors multiple times daily), (4) being easily startled (e.g., his partner broke a mug, leading to him “jumping out of my skin and running out of the bedroom carrying my pillow like an M16”), (5) having difficulties concentrating (e.g., cannot watch TV because loses track of storyline, has difficulties with conversations with others), and (6) sleep disturbance (sleeps 1–4 hours/night).

He reports that these symptoms began following his MST and have been present the past 40+ years (Criterion F). These symptoms causes clinically significant distress and substantial functional impairments in social, occupational, and general functioning (Criterion G).

6 Case Conceptualization

Within the PE framework, the majority of David’s symptomatology was understood and discussed with him based on behavioral theory. The main target of treatment was avoidance and discussions frequently explored the short-term benefits (e.g., immediate reductions in anxiety) versus long-term costs (e.g., dramatic constraints on day-to-day behavior, massive amount of energy required to maintain a complex variety of avoidance behaviors, maintenance of high levels of anxiety over time, interference with relationships, etc.) of avoidance. As one example, there were 20+ avoidance-related behaviors he engaged in at home, in an effort to prevent himself from being poisoned, or to detect poisoning were it to occur (e.g., lining up salt and pepper shakers at a particular angle to detect whether they had been moved, pressing some of the air out of the milk carton to detect whether it had been opened since he last used it, keeping the toothpaste cap ¾ of the way screwed on, etc.). This complex assortment of behavior required constant awareness and tracking, to ensure he had not missed anything. If he was suspicious of food items, medications, or toiletries in his home, he would immediately throw them away. He also encouraged family members to engage in these behaviors and became angry if they did not.

When conceptualizing his avoidance and safety behaviors, David and his therapist frequently discussed principles of classical and operant conditioning, although not using that particular language. All of his avoidance behaviors could be tied to his trauma experience itself, via classical conditioning. That is, anything that was present at the time of his MST, that reminded him of his MST, or that he associated with his MST, triggered the same emotions, physical sensations, and thoughts that he experienced at the time of his MST. Regarding operant conditioning, his avoidance behaviors were explained via negative reinforcement, in that, avoidance of trauma triggers led to immediate reductions in anxiety, thereby increasing the likelihood of future avoidant behaviors.

His anger outbursts were discussed and conceptualized as a fight/flight response “gone wrong.” We frequently discussed how his anger was triggered in situations where he felt unsafe and that his default response was to push down fear and associated behaviors, and to feel anger and engage in aggressive behaviors: “I automatically choose fight over flight when I feel threatened.” He resonated deeply with this explanation and was able to connect, with the support of his therapist, that he misattributed his inability to fight back during his assault to the fear he felt at the time (in reality, he could not move because he was drugged). Thus, he saw fear as a weakness, which is a belief that was further reinforced by the hypermasculine military culture he was embedded within. He saw anger as something that made him powerful and ready to defend himself against danger. In the later phases of treatment, psychoeducation was provided around the utility of different emotions, including why feeling fear is helpful. He initially was unable to come up with any reasons as to why is might be evolutionarily adaptive to feel fear. Through discussing a variety of potentially dangerous situations that resonated with him (e.g., walking through a dark alley, at night, alone, in a bad neighborhood, with headphones on, carrying a handful of cash), he was able to understand that fear is helpful when it makes us aware of actual danger in our environments and leads us to avoid these objectively unsafe situations.

7 Course of Treatment and Assessment of Progress

David’s Course of PE Treatment

There were a number of factors impacting David’s course of treatment, such that many aspects of his treatment timeline did not occur in accordance with the above description of a “normal” course of treatment. Although initial assessment and treatment planning sessions occurred in-person, session 1 of PE occurred via telehealth, due to a spike in COVID-19 cases in Massachusetts at the beginning of the pandemic, and conversion to telehealth within the VA Boston Healthcare System for the majority of outpatient care.

During the first several sessions, there were numerous technological difficulties that slowed progress. First, David needed two devices to participate in sessions; the PE Coach and VA Video Connect (VVC) apps cannot not be used simultaneously, so David used his smart phone to record the session on the PE Coach App and his partner’s smart phone to connect to the VVC App. Second, poor cell phone connectivity was a challenge; the therapist ordered David a VA-issued iPad after session 4 to facilitate effective engagement in treatment. Third, the therapist was unable to access and play PE psychoeducational videos from her home computer until session 4, due to an inability to access the VA network, so David was unable to view the “Pam’s Story” video until session 4. Fourth, the therapist was working from home throughout the pandemic and having technological challenges, leading to conducting portions of two sessions (session 1 and session 2a) over the phone and without video. These provider-level and system-level factors have been identified in the literature as factors that could suggest the utility of pausing or reconsidering initiating trauma-focused treatment (Hagerty et al., 2020). However, David and the provider agreed to continue with PE, with the understanding that the course of treatment would likely take longer due to these technological challenges. The therapist elected to slow/delay certain aspects of treatment until technological elements were fixed (e.g., watched “Pam’s Story” during session 4, instead of during session 2) and certain aspects of treatment were extended (i.e., more than 14 treatment sessions were conducted and there was a 6-week break in the normal treatment protocol at session 8). Luckily, David was very motivated to participate in PE and recover from his PTSD, so was willing to persist through this period of upheaval at the beginning of the pandemic.

Given the pandemic, David and his therapist worked together to select a variety of creative, yet objectively safe, in vivo exposures, which would activate PTSD-related fear structures, while avoiding exposure to COVID-19. David’s avoidance behaviors early on in treatment were solely PTSD related; he was not concerned about contracting COVID-19. Thus, his therapist had to ensure selected in vivo exposures safely exposed him to PTSD-related fear structures, while ensuring he did not engage in exposures that would put him at risk of contracting COVID-19 (e.g., eating take-out food from a restaurant to target his fear of being drugged and assaulted, rather than eating food within a restaurant, to reduce the risk of contracting COVID-19, while exposing him to PTSD-related fear). Given that David’s PTSD-related avoidance had generalized to numerous situations, it was easy to select numerous in vivo exposures that would not increase his risk of contracting COVID-19 (see Table 1 for examples; see Wells et al., 2020 for additional suggestions).

OPEN IN VIEWER

Table 1.

Brief Selection of David’s In Vivo Exposures during COVID-19.

In vivo exposure item	Anticipated anxiety at session 2b of PE	Anticipated anxiety at session 16 of PE
Sending a text message to daughter	50	5
Calling daughter on phone	75	10
Attending an AA meeting on Zoom	50	10
Calling therapist spontaneously between sessions	75	20
Taking a walk outside in neighborhood	50–90	0–20
Eating take out food from a restaurant	80	10–20
Eating soft, creamy foods	90	50
Looking at military-related patches/emblems/bumper stickers	90	5
Being around military members in uniform	95	20
Laying in bed facing away from the door	75	25
Laying in bed without a gun under bed	90	30
Sitting in dining room with back to door	50	0
Being hugged from behind by partner	40	5
Sitting in living room with blinds open and back to window	70	0
Eating a meal at friends’ homes (sitting outside)	90	30
Eating unfamilar foods	90	50
Not engaging in checking/safety behaviors to avoid being drugged (e.g., lining up food containers to detect if they were moved; throwing away open containers of condiments after 2 weeks; hiding medications to avoid contamination/tampering)	95	40

Impact of COVID-19 on Assessment Process and Tracking of Progress

During a usual course of PE, veterans complete the PCL-5 weekly as a paper-based, self-report assessment. Due to the COVID-19 pandemic and the upheaval involved in converting to telehealth and electronic forms, PCL-5 administration occurred less frequently earlier on in treatment, and across various modalities (i.e., via paper-based forms, verbal report over the phone, PE Coach app, and online platform). Additionally, David struggled with completing digital versions of the PCL-5. His therapist tried administering the PCL-5 verbally at the beginning of sessions, but found administration took 10+ minutes, which in combination with technological challenges, could occupy the first 20 minutes of a session. Given this, his therapist elected to prioritize active elements of treatment (i.e., exposures) over assessment, to ensure David was getting an effective dose of treatment.

Baseline assessment and treatment planning occurred prior to the pandemic and during in-person sessions (five pre-treatment sessions, in total, to complete required VA assessments for new patients, psychoeducation about PTSD, and shared decision making in selecting a trauma-focused treatment). Thus, PCL-5 at baseline (see Figure 1; PCL-5 completed as a self-report measure using paper-based assessment), mid-treatment (PE session 8; therapist read PCL-5 questions to David during his telehealth session and he verbally provided ratings), later session (PE sessions 10–16; David completed the PCL-5 assessments on the PE Coach app and verbally reported total scores to his therapist at the beginning of each session), and post-treatment assessments (1–2.5 month follow-ups; David completed these assessments on the new VA Mental Health Check-Up website, allowing his therapist to see individual symptom counts) were obtained across various platforms.

OPEN IN VIEWER

Figure 1.

PTSD symptoms over the course of treatment.

8 Complicating Factors

Beyond some of the complicating factors noted above, there were additional factors that made David’s course of treatment challenging. During treatment, he developed a painful tooth abscess and cracked a couple of dental implants, due to nightmare-related tooth grinding/clenching. He required emergency dental surgery and a course of antibiotics around session 6 of PE. After he recovered from COVID-19, a long-standing argument with a neighbor in his apartment complex led to him wanting to disengage from PE treatment. Following a series of arguments, his neighbor used homophobic language and threatened to rape David and kill him. David worried his neighbor had somehow overheard his PE sessions, due to the threat of rape made by his neighbor, and did not want to report the incident to the police because of fear that they would guess he was a sexual assault survivor. Within the context of PE, his therapist validated the distress and anxiety he felt following the frightening threat from his neighbor, and then came up with a plan to report the threat from his neighbor to the police, as an in vivo exposure assignment. During a weekly phone check-in appointment, David practiced making his police statement out loud to his therapist three times, to increase his comfort and willingness to seek law enforcement support. Ultimately, he filed a restraining order against his neighbor and felt validated within his interaction with the police, which was helpful, given his multiple negative prior interactions with law enforcement.

Finally, during the course of treatment, we worked on increasing David’s willingness to meet with psychiatry to discuss medications for sleep and nightmares, as well as to meet with the MST Care Coordinator at the Veterans Benefits Administration (VBA), in order to apply for disability compensation for his PTSD. Around session 16, David was informed that he had received a 100% service-connected disability for his PTSD from the VBA, which was incredibly validating for him. Indeed, he reports that it was “Less about the money I’d be getting, and more about the fact that the VA believed this happened to me, that it wasn’t my fault, and that I had been harmed by the experience.” He was tearful discussing how validating he found this acknowledgement. Medication compliance continues to be an ongoing treatment target.

9 Access and Barriers to Care

The rapid transition to telehealth for all outpatient care was initially very challenging, as there were multiple unanticipated technological barriers. However, David was very motivated to engage in PTSD treatment and to reclaim his life, so was willing to persist through these challenges. Furthermore, his therapist was able to leverage resources available within the VA Healthcare System to problem solve around technological barriers (e.g., PTSD Consultation Team in VA; VA iPad loaner program, etc.). Given that this veteran tested positive for COVID-19 2 days after his PE session 8 appointment, the therapist was relieved that their appointments had occurred over telehealth during the pandemic, given the level of exposure to the virus the therapist would have experienced during a 90-minute in-person session.

The VA Healthcare System is unique, in that it offers free care for all veteran survivors of MST, for any condition that was caused or exacerbated by their experience of MST, regardless of income level, service connection status, discharge status, and length of service in the military. This is connected to the passing of Public Law 102-585 in 1992, which established and mandated care options for MST survivors across all VA medical centers and to the recent Deborah Sampson Act of 2020, which allows the receipt of care regardless of discharge status. Because of this, David was able to access free MST-related therapy, psychiatry, and dental care. The removal of financial barriers substantially increases access to care and helps to engage MST survivors in much-needed care. Within the VA Boston Healthcare System, where David accessed care, 99.2% of veterans have been screened by their primary care or mental health providers to assess whether they have experienced MST (Military Sexual Trauma Support Team, 2019a). At the Boston VA, 1,463 veterans reported MST to their providers during the fiscal year 2019 screener, including 843 women (45.6% of women served at Boston VA) and 620 men (2.7% of men served at Boston VA), indicating that MST survivors do seek care at VA for their MST-related conditions (Military Sexual Trauma Support Team, 2019b). During fiscal year 2019, female MST survivors attended 19.9 mental health appointments and male MST survivors attended 17.6 mental health appointments (unfortunately, data are not collected that examine rates among transgender or gender non-conforming individuals), indicating strong levels of engagement with mental health services among MST survivors (Military Sexual Trauma Support Team, 2019b).

10 Follow-Up

Follow-up care with David has been ongoing, due to some continued subthreshold symptoms that David and his therapist agree would benefit from treatment. Since completing PE 4 months ago, David has attended biweekly therapy focused on effectively coping with residual anger, avoidance, sleep, and nightmares. Additional challenges have emerged more recently, following David beginning a multi-month cross country trip with his partner, which has led to exposure to new foods, people, and other previously avoided stimuli. He reports he never would have taken this trip previously, or been able to enjoy this type of trip, due to PTSD-related avoidance. However, he reports he has been consistently exposing himself to new situations, which has led to continued reductions in anxiety and generalization of benefits from the PE treatment. The residual symptoms he endorses are consistent with what is observed in the literature; there are persistent challenges with hypervigilance, nightmares, and sleep among individuals successfully treated with PE who no longer meet diagnostic criteria for PTSD (Tripp et al., 2020).

As mentioned above, David has continued practicing eating unfamiliar foods in new contexts, and maintaining discontinuation of food-related safety behaviors, as his bi-weekly homework assignment. He has ordered take out from several new/unfamiliar restaurants and ate birthday cake prepared for him recently by a friend’s wife. Additionally, cognitive restructuring around anger cues (e.g., challenging the thought that other drivers on the road are cutting him off because they want to “control, dominate, and threaten” him) has been helpful in disrupting his quick progression to aggressive behavior in the context of feeling threatened while driving. There has also been discussion around how aggressive driving actually makes him less safe, rather than more safe (he initially perceived himself as “taking back control” and “dominating” other drivers on the road when engaging in aggressive driving behavior, rather than recognizing that cutting others off made him less safe). He has reported reductions in “road rage” behavior, which is consistent with lower self-reported scores on PCL-5 item 15 (“Irritable behavior, angry outbursts, or acting aggressively”) over time (e.g., he rated this item as being a 1 “a little bit bothersome” currently, versus a 4 “extremely bothersome” previously).

Motivational interviewing has been provided around difficulties with psychiatric medication compliance and medical appointment attendance, as these are specific interventions aimed at reducing nightmares and improving sleep; this has also been discussed within the avoidance framework. He meets with his psychiatrist monthly and reconnected with primary care and dental ~4 months ago (there was a pause in these services when he contracted COVID-19, and avoidance thereafter due to fear of re-contracting COVID-19 at the VA). He initiated prazosin for nightmares with his psychiatrist 3 months ago and reports moderate compliance (takes prazosin ~75% of the time. He has noted a reduction in the number of nightmares he experiences weekly, on average, and that he has begun having dreams that are non-MST related for the first time in 40 years. His psychiatrist also initiated sertraline about 3 months ago, which David discontinued after three doses, due to experiencing nausea and dizziness on the days when he took it. There are ongoing discussions with his psychiatrist regarding his medication regimen.

Since completing PE, he has completed the PCL-5 on four occasions (PCL-5 = 33, 25, 30, 22, over time), with symptoms remaining substantially lessened, as compared to baseline (PCL-5 = 69).

11 Treatment Implications of the Case

This case highlights the patient-, provider-, and system-level factors identified for consideration within Hagerty et al. (2020). Specifically, when initiating trauma-focused treatment with individuals during the COVID-19 pandemic, it is important to consider for whom these treatments might be recommended, as well as how these treatment would effectively be completed. Given that there are high rates of therapy dropouts among individuals with PTSD more broadly (e.g., Kehle-Forbes et al., 2016) and that individuals who receive a full course of treatment do better than those who drop out prematurely, it is wise to consider which patients will persist and how the clinician and the system can encourage treatment completion during a global pandemic. Although the pandemic clearly had a massive impact on David, it may be that he was willing to persist in and return to the difficult task of exposure therapy because he had already begun to experience benefits from PE prior to contracting COVID-19. Further, there were a variety of in vivo exposures he could safely and effectively complete during the pandemic.

As in all good clinical practice, having a clear and informed discussion with patients regarding what treatment involves and how treatment will fit into their lives, is critical. An assessment of how the global pandemic is impacting clients’ day-to-day lives and current levels of stress, above and beyond the PTSD symptoms already being experienced, can provide insight as to whether initiating trauma-focused treatment would make sense. Further, thinking critically and collaboratively about how therapy homework assignments would be completed, how the patient would persist if new stressors emerged, and whether the costs of delaying treatment outweigh the benefits of delaying, helpfully intervenes on patient-level factors noted by Hagerty et al. (2020).

As we are almost a year into this global pandemic, and as much of therapy has converted to telehealth, many providers may be more comfortable with new modalities of providing care than at the beginning of the pandemic. Many of the technological difficulties encountered early on in working with David have become much easier to manage across the course of the pandemic. The initial conversion to full telehealth and remote work proved challenging for many who were less familiar with these modalities, or who did not have full technological capacities early on in the pandemic to effectively work from home. At this stage of the pandemic, many providers may have an increased capacity to provide these treatments remotely, as compared to the beginning of the pandemic, because of familiarity with the technology, improvements in the technology, practice with conducting these treatments with patients remotely, and increased comfort of providers. However, personal factors, including individual, familial, or community illness, can still have an impact, especially given rising rates of infection that are now occurring at the beginning of 2021. Therefore, providers need to be aware of personal, technological, or other barriers to providing trauma-focused treatment during the pandemic and to ensure a plan is in place to address these barriers, prior to suggesting initiating these treatments. Furthermore, institutional and system-level support is critical for success.

12 Recommendations to Clinicians and Students

Clearly, this was not a standard course of PE provided to a veteran during “normal” times. However, this case does highlight a number of important and interesting factors to consider when implementing PE. First, the general recommended course of PE is 10–14 sessions. Given that David experienced an additional Criterion A stressor in the midst of treatment, and that PCL-5 and imaginal exposure scores remained elevated at Session 12, a collaborative decision was made to continue with imaginal exposures, so that additional extinction and symptom improvement would occur. Although extinction of fear associated with trauma memories often occurs rapidly in PE, this was not the case for David. On the one hand, this could have suggested the need for a different treatment modality; on the other hand, this lack of extinction made sense given additional stressors and given the 6-week break in protocol when David contracted COVID-19. If patients are struggling with extinction within PE, it is relevant to consider what is getting in the way and whether these struggles make sense given the context of the patients’ lives and environments. This may be especially relevant to consider during the current global pandemic, when breaks in protocol may be necessary, or when additional stressors may be encountered. For David, we continued considering and discussing the stressors arising and his means of coping within a PE-based theoretical orientation, which was reinforced during weekly therapy and phone check-in appointments. This included discussing how avoidance in response to certain stressors (e.g., attending medical appointments, seeking a restraining order from the police for his threatening neighbor, walking around outside with a mask) was not effective, and problem solving around how to approach these challenging situations.

Second, this case seems to suggest that additional support outside of weekly PE sessions was necessary to retain David in treatment. He spontaneously reported that the weekly phone check-ins were key for keeping up his motivation and ensuring he completed homework (often homework non-compliance was reported during the phone sessions, resulting in discussion/problem solving to ensure completion prior to the next PE session). He also noted that these phone check-ins let him know that the therapist cared about him as a person and was willing to discuss other stressors that could have led to treatment dropout and that often did not fit in during a standard PE session.

Finally, this case suggests that it is possible to continue to utilize effective, evidence-based treatments for PTSD during a global pandemic. It is critical to consider and problem solve, from the beginning of treatment regarding how to retain clients through global challenges to safety due to the pandemic, and to be flexible as a provider, to implement these treatments. However, the benefits of these treatments to clients makes the extra effort worth it as a therapist, when we get to witness the incredible life changes our clients make.