Megan Gerber and Sadie Elisseou are Primary Care Physicians; and Zachary Sager is a Hospice and Palliative Care Physician at the New England Geriatric Research Education and Clinical Center; all at the Veterans Affairs Boston Healthcare System in Massachusetts. Jessica Keith is a Clinical Psychologist at Bay Pines Veterans Affairs Healthcare System and an Associate Professor of Psychology at the University of Central Florida College of Medicine in Orlando. Megan Gerber is an Associate Professor of Medicine at Boston University School of Medicine. Sadie Elisseou is an Instructor in Medicine and Zachary Sager is an Instructor in Psychiatry, both at Harvard Medical School in Boston. Correspondence: Megan Gerber (meggerbe@bu.edu)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Catastrophic events, such as natural disasters and pandemics, may serve as both newly traumatic and as potential triggers for survivors who have endured prior trauma.25,26 Increases in depression, PTSD, and substance use disorder (SUD) are common sequalae, occurring during the event, the immediate aftermath, and beyond.25,27 In 2003, quarantine contained the spread of Severe acute respiratory syndrome (SARS) but resulted in a high prevalence of psychological distress, including PTSD and depression.27 Many veterans may have deployed in support of humanitarian assistance/disaster relief missions, which typically do not involve armed combat but may expose service members to warlike situations, including social insecurity and suffering populations.28 COVID-19 may be reminiscent of some of these deployments as well.
The impact of the current COVID-19 pandemic on patients is pervasive. Those with preexisting financial insecurity now face additional economic hardship and health challenges, which are amplified by loneliness and loss of social support networks.26 Widespread unemployment and closures of many businesses add to stress and may exacerbate preexisting mental and physical health concerns for many; some veterans also may be at increased risk.29 While previous postdisaster research suggests that psychopathology in the general population will significantly remit over time, high-risk groups remain vulnerable to PTSD and bear the brunt of social and economic consequences associated with the crisis.25 Veterans with preexisting trauma histories and mental health conditions are at increased risk for being retraumatized by the current pandemic and impacted by isolation and unplanned job or wage loss from it.29 Compounding this, social distancing serves to protect communities but may amplify isolation and danger in abusive relationships or exacerbate underlying mental illness.26,30
Thus, as we expand our use of telehealth, replacing our face-to-face visits with virtual encounters, it is critical for clinicians to be mindful that the pandemic and public health responses to it may result in trauma and retraumatization for veterans and other vulnerable patients, which in turn can impact both access and response to care. The application of trauma-informed principles to our virtual encounters has the potential to mitigate some of these health impacts, increase engagement in care, and provide opportunities for protective, healing connections.
In the setting of the continued fear and uncertainty of the COVID-19 pandemic, we believe that application of a trauma-informed lens to telehealth efforts is timely. While virtual visits may seem to lack the warmth and immediacy of traditional medical encounters, accumulated experience suggests otherwise.19 Telehealth is fundamentally more patient-focused than traditional encounters, overcomes service delivery barriers, offers a greater range of options for treatment engagement, and can enhance clinician-patient partnerships.6,31,32 Although the rapid transition to telehealth may be challenging for those new to it, experienced clinicians and patients express high degrees of satisfaction with virtual care because direct communication is unhampered by in-office challenges and travel logistics.33
While it may feel daunting to integrate principles of TIC into telehealth during a crisis-driven scale-up, a growing practice and body of research can inform these efforts. To help better understand how trauma-exposed patients respond to telehealth, we reviewed findings from trauma-focused telemental health (TMH) treatment. This research demonstrates that telehealth promotes safety and collaboration—fundamental principles of TIC—that can, in turn, be applied to telehealth visits in primary care and other medical and surgical specialties. When compared with traditional in-person treatment, studies of both individual and group formats of TMH found no significant differences in satisfaction, acceptability, or outcomes (such as reduction in PTSD symptom severity scores34), and TMH did not impede development of rapport.19,35
Although counterintuitive, the virtual space created by the combined physical and psychological distance of videoconferencing has been shown to promote safety and transparency. In TMH, patients have reported greater honesty due to the protection afforded by this virtual space.31 Engaging in telehealth visits from the comfort of one’s home can feel emotionally safer than having to travel to a medical office, resulting in feeling more at ease during encounters.31 In one TMH study, veterans with PTSD described high comfort levels and ability to let their guard down during virtual treatment.19 Similarly, in palliative telehealth care, patients reported that clinicians successfully nurtured an experience of intimacy, expressed empathy verbally and nonverbally, and responded to the patient’s unique situation and emotions.33
