Practice Tips for Therapists during the COVID-19 Coronavirus Pandemic

Behavioral Health Partners

Practice Tips for Therapists during the COVID-19 Coronavirus Pandemic
By: Aaron Weiner, PhD, ABPP, Director of Addiction Services

The coronavirus (COVID-19) has turned the world of psychotherapy upside down. Immediately, practitioners must make a difficult decision about whether to continue to treat your patients’ in-person, via teletherapy, or to suspend treatment until social distancing recommendations are relaxed.

However, beyond this major determination we still have our core responsibility to treat those under our care; a task made significantly more complex by a tidal wave of anxiety, as well as the drastic changes in social behavior and norms that are occurring across the world.

However, as the winds shift, we must shift with them.  Please consider the recommendations below for practicing psychologists and psychotherapists who are continuing to care for patients through this crisis. 

Tips related coronavirus-related treatment considerations for a number of common psychiatric conditions that we see in outpatient treatment as well as clinic logistics for when restrictions are lifted. When possible, I have also included links to specific resources that may be of assistance.

I hope that something in this article will resonate with your clinical sensibilities, and be another tool to add to your belt as we work to help our communities weather this storm. 

Considerations for Treatment of Specific Psychiatric Conditions

  • Depression
    • Social distancing may create barriers to engagement in any recommended behavioral activation. Brainstorm and have suggestions ready for alternative activities that are easily accessible and do not involve social contact (e.g., learn an instrument, join and interact with online communities, study cinema history by watching AFI’s Top 100 Movies, engage in yoga via a smartphone app, etc.)
    • The current pandemic may exacerbate any existing sense of hopelessness or nihilism. Educate and explore the concept of confirmation bias as it pertains to negative news, as well perspective-set by reflecting on past crises that have resolved over time. To use an old adage: “this too shall pass.”
  • Anxiety
    • Please refer to my previous blog post for general recommendations related to coronavirus anxiety management.
    • Help the patient notice if they are perseverating on the coronavirus. If the patient is thinking, speaking, and worrying about the coronavirus to the exclusion of everything else, it will only exacerbate their anxiety, and leave no room for positivity and calm.
    • This crisis is uniquely challenging, as it pushes on both the primal fight, flight, and freeze reaction, while also being an ambiguous and potentially invisible threat.Helping the patient discern between reasonable concern and anxious fixation could be a useful component of treatment.
    • Multiple mindfulness meditation apps have released free content to help with coronavirus-related coping, including my two favorites, 10% Happier and Headspace.These are helpful tools to assist (you and) your patients with coping with strong feelings, and particularly if mindfulness is part of your treatment plan.The free content is located within each mobile app, as well as online here for Headspace, and here for 10% Happier. Headspace is also offering a free full subscription for 2020 to all healthcare providers with an NPI number – access to the free subscription is located here.
  • Obsessive-Compulsive Disorder (OCD)
    • The coronavirus pandemic may be particularly difficult for patients with cleanliness-related OCD, and they may see it as justification for their obsessive behavior.It will be critical to level-set with these patients that, even within the current new normal regarding hand hygiene and sanitizing procedures, obsessive behavior is still possible.Extra care may be required to ensure that the patient does not backslide.
    • If patients are struggling with what is a reasonable versus excessive response in a given situation, try establishing a list of concrete, observable events that would warrant hand hygiene (e.g., after completing a necessary grocery trip and returning to their car).
  • Post-Traumatic Stress Disorder (PTSD)
    • The COVID-19 pandemic may confirm a patient’s worst fears about the world being an inherently dangerous place, as well as inflate the chances that events such as the pandemic justify being either hypervigilant or reclusive.This is an opportunity to review the difference between possible events versus likely events, as well as the true odds of catastrophic outcomes occurring with infection (i.e., mortality rates).
    • Similar to previous recommendations for treatment of OCD, it will be critical to help patients with PTSD differentiate between reality-based responses and history/trauma-based responses to levels of danger and risk, given that the baseline level of social distancing and guardedness in society has been (rightfully) elevated.
    • The pandemic may also exacerbate any current mistrust of authority, if the patient has been following news related to early governmental downplaying of infection risk, false claims of virus containment, and false claims of available testing to those who want to be tested for COVID-19.As with the previous points, is important to acknowledge the realities of the current situation, while still helping clients differentiate between confirmation bias and true risk during these extenuating circumstances.
  • Substance Use Disorders (SUDs)
    • Given the increased level of anxiety in the general population, there's a strong possibility that individuals with SUDs will gravitate more strongly to their habitual coping mechanism and are at increased risk for relapse. It is important to acknowledge this with patients, provide additional support if possible, and continue to encourage them to use the coping strategies they have developed during their treatment with you.
    • Peer-support meetings may be cancelled during this time, or patients may not feel comfortable attending them. Given this, ensure that patients are aware of virtual peer-support options – both 12-step fellowships and SMART recovery have online options for their meetings. Online 12-step meetings can be found at 12step.org and In The Rooms, and online SMART Recovery Meetings can be found here.
    • Dr. Nora Volkow, Director of the National Institute on Drug Abuse (NIDA), recently published a useful article highlighting how individuals with SUDs of all types are an at-risk population for more severe coronavirus complications.
  • Attention-Deficit Hyperactivity Disorder (ADHD)
    • Two common traits of patients with ADHD, impairment related to impulsivity and inattention to detail, are areas of particular concern related to the current pandemic.It will be important to help patients with ADHD develop routines to help adhere to virus prevention and hygiene recommendations per the CDC, for both their health and the health of those around them.
    • In the absence of strong internal regulation, I would recommend utilizing automated external cues to help develop habits. Smartphones are excellent for this, and patients can experiment with solutions to determine which approach is most helpful to them. Options for this are abundant, but my go-to strategies include:
      • Using silent timers on smart watches or cell phones to alert the patient after a certain period of time has passed
      • Using habit-forming apps, such as Loop Habit Tracker or Streaks, to use notifications and data-based feedback to help reinforce changes
      • Automate reminders to fire given certain external cues with apps such as IFTTT or Shortcuts (iOS only).Examples of this type of automation include a reminder to sanitize your hands every time your phone disconnects from your car’s Bluetooth connection (i.e., you turn your car off and are preparing to exit), or connect to your home WiFi network when you arrive home.

General On-Site Logistical Recommendations

* These recommendations are for therapists in states that are not on a lockdown and considerations for therapists when restrictions are lifted on in person visits.  

  • Telehealth. If you are in a state not on lockdown and are still seeing patients in-person, call your representatives to advocate for Telehealth therapy coverage during this crisis.  
  • Lose the waiting room. Assist in social distancing by developing a temporary check-in workflow that circumvents the need for sitting in a public waiting room.One possible mechanism for this could be having patients wait in their cars, and having therapists call them when they are ready to be seen.Try to think outside the box to design a process that would work in your practice.
  • Remove and/or space-out waiting room chairs. Even with a modified workflow, many patients will likely still need to use the waiting room area (e.g., patients without their own transportation).Removing and spacing-out chairs to be at least 6-10 feet apart will help maintain recommended social distance.
  • If possible, prop open the outer door to your suite. Leaving the door ajar removes the need for patients to use their hands to open the outer door.Also consider installing a foot door opener.
  • Use chairs for therapy that can be easily sanitized. If possible, utilize a chair that has a surface that can be easily wiped down, such as plastic, leather, or some sort of non-permeable cover over the cushion(s).It is far more difficult to sanitize cloth or fabric, and even if it’s a little less comfortable, patients may appreciate the option to sit on a chair that has been sanitized.
  • Waive late-cancel fees, and message this out to your patients. This will help assuage any concerns related penalties for a late cancel, and encourage sick patients to stay home.
  • Wipe down high-touch surfaces frequently, and wipe down your office after each patient. This likely goes without saying, but pay special attention to handles, writing utensils, clipboards, and other high-touch clinic areas. Also make sure to sanitize or wash your own hands after each patient.
  • Have hand sanitizer available to patients. This also likely goes without saying, but have hand sanitizer available in multiple places around your office, including by the front door. This will be a noticed and appreciated gesture.

If you have any questions or want to add your own recommendations, reach out to us at lindenoaksmarketing@eehealth.org.

Take care, stay safe, and thank you for your dedication and service during this difficult time.

Aaron Weiner, PhD, ABPP
Licensed Clinical Psychologist
Director of Addiction Services
Linden Oaks Behavioral Health