Implementing peer support in our intensive care unit to improve the mental wellbeing of trainees

Introduction: Working on the intensive care unit (ICU) exposes staff to the suffering of patients and their families as a consequence of devastating illnesses and injuries, often leading to psychological trauma. The COVID-19 pandemic has amplified pressures on healthcare staff, resulting in deteriorating mental health and increased incidence of stress and burn out. The Intensive Care Society (ICS) has placed emphasis on peer support to combat this;recognising that working in a 'psychologically safe' environment improves wellbeing, enables safe and compassionate care, and reduces mistakes [1]. The aim of peer support is to improve wellbeing by offering a systematic, strategic approach to sustain staff who are coping well and provide initial support to those who are struggling. Method(s): Staff who have undertaken ICS training, under the supervision of a clinical psychologist, facilitate fortnightly meetings open to all ICU trainees. They also act as an initial contact to provide advice and guidance on addressing the psychological difficulties highlighted above. An anonymous screening questionnaire at the start of each session allows a moment of reflection for trainees prior to discussion. This, in addition to anonymous feedback, provides qualitative data to both audit the programme and inform improvement. Result(s): Participation in peer support is voluntary, nonetheless attendance at meetings has been excellent. Initial qualitative results indicate that most trainees feel 'nervous, anxious or on edge', 'question their capability at work' and are 'unable to stop thinking about work/a significant event at work' at least a few days per week. Feedback from trainees regarding the programme has been intensely positive. Conclusion(s): Anxiety and stress are high amongst ICU trainees which can lead to psychological harm if not addressed. Engagement from trainees in our programme has been good and feedback positive, emphasising the need for peer support in the ICU.

Psychological Aid to Victims of War and the Covid Pandemic 19 in Ukraine

The article reflects theoretical, methodological and methodical bases of psychological aid to victims of unexpected crisis-military situations on the background of coronovirus pandemics spreading. The essence of psychological self-help as a factor of stress-resistance and internal psychological potential of resisting psychological traumas in the conditions of war and viral pandemics with the propositions of effective methodological means of its conducting is revealed. In providing psychological aid, the cognitive-behavioral approach was deemed effective as the basic one, and it was suggested that integrative psychotherapeutic and comprehensive psychological approaches to crisis counseling in conditions of military conflict be applied, depending on the specifics of survivors' experience of acute emotional reactions and the complexity of the course of posttraumatic stress disorders of resistance to the action of a psychotraumatic factor. Neuropsychological correction deserves special attention in providing psychological aid in conditions of military conflict and pandemics, which allows a combination of an integrated bodyoriented psychological approach with neuro-psycho-correctional techniques and psychotherapeutic methods for effective restoration of the tone of the nervous system and stabilization of the psycho-emotional state. The main provisions of practical psychology that in conditions of war and pandemic COVID-19 the adaptive potential of psychological health of each person and psychological self-help is love, faith and hope. Psychological recommendations of educational character for the formation of basic skills to ensure psychological health in conditions of war and pandemic COVID-19 have been developed.

Simultaneous Individual Complicated Grief Treatment With a Couple

Persistent complex bereavement/complicated grief occurs when, after a period of 12 months following a death, there remains an ongoing intense yearning and sorrow for the deceased, preoccupation with the death and its circumstances, difficulty accepting its reality, and disruption in personal identity. This case study illustrates the successful application of Complicated Grief Treatment (CGT), a manualized research-supported intervention, with a husband and wife each receiving individual therapy simultaneously with separate clinicians. The core of CGT involves graded completion of imaginal and situational revisiting (i.e., exposure) exercises. To target maladaptive rumination and counterfactual thinking more explicitly, strategies from a research-based treatment for trauma, Cognitive Processing Therapy, were also incorporated for one member of the couple. To our knowledge, CGT has not been examined with couples receiving individual therapy delivered simultaneously. As such, practitioners have little information about how to proceed with cases where multiple members of the same family are experiencing complicated grief. We will detail the treatment provided, outlining the course of care for each member of the couple, highlighting unique adjustments made to tailor implementation to each individual and to deliver the intervention simultaneously. Quantitative and qualitative data show the effects of treatment on symptoms of complicated grief, depression, and relationship satisfaction.Copyright © The Author(s) 2022.

Psychological Impact of Coronavirus (COVID-19) Disease on Cancer Patients

In this letter, the psychological impact of COVID-19 on cancer infected patients is dis-cussed. Cancer is a serious health-related problem nowadays. The 2019 pandemic of coronavirus disease has developed into an unheard-of pandemic. Given the havoc wreaked by this pathogen worldwide, many countries have implemented a severe, legally enforced method of social distanc-ing, in the form of a lockdown. Unless adequate preventive measures are taken, the cost of the pandemic and subsequent lockdown can prove to be irreparable. The obvious consequences of this lockout, such as the escalating levels of unemployment, imminent economic crisis, and extreme food scarcity faced by the sudden unemployed migrant labour population, have been widely report-ed. Cancer patients are a highly vulnerable group even during non-pandemic periods, often present-ing late in the course of their illness, without the services required to avail recommended care. The incidence of psychological complications and emotional distress is considerably higher in cancer patients than in the general population, and the trauma of both the pandemic and subsequent lock-down contributes significantly to their mental trauma. This analysis is geared at solving the chal-lenges faced by cancer patients in the face of this pandemic and subsequent lockdown, with a look at potential solutions that can be enforced.Copyright © 2021 Bentham Science Publishers.

Resilience in Heath Care workers during Disaster situation-Experience from tertiary care hospital during Covid 19 and future lessons

Aims and objective: To present a series of 5 cases of Stress Related Disorders in HCWs during the covid second wave where they bounced back and recovered fully, returned to work Methodology: Reporting 5 different cases of psychological trauma in healthcare workers working in the peak of covid pandemic as frontline workers -02 doctors, 02 Nurses, and 01 health assistant who reported symptoms of vague nature arising out of stress during handling of Covid 19 pts. All of them had clear cut psychological symptoms arising in close temporal relation to experiencing the trauma of handling covid patients and the agony and disaster that befell us during the covid second wave from April to Aug 2021. None of them had any past history of psychiatric illness or genetic loading of significance. None of them had any other significant live stressor in personal life or h/o drug abuse. Thus underlying the life threatening nature of Covid exposure as a healthcare worker and it's psychological implications. All of them were referred for vague symptoms like irritable mood, not able to function as before, physical symptoms of headache, marital discord etc. The exposure ranged from personal handling of serious covid patients to handling dead bodies in the mortuary to managing relatives of dying patients. No preventive distressing mechanism was available to them, the need of which is the learning from this study. Also, the remarkable recovery and resumption of functioning and return to duty shown by these frontline healthcare covid warriors with minimal support from the environment is a lesson in bouncing back from psychological trauma, a concept recognized as resilience. The Resilient HCWs ascribed their bouncing back to peer and organizational support during crisis, a sense of duty to care and psychoeducation as their driving force to early recovery, among other things Results: High index of suspicion, early intervention, empathetic handling, psycho education, behavioral modifications and cognitive counseling with a short course of anxiolytics and antitidepressants in few, helped all of them improve completely with return to almost normal functioning. Conclusion(s): The Covid experience has been a life threatening experience for HCWs involved in treatment of serious covid patients during covid pandemic esp the second wave. It has been a never before experienced reality, completely overwhelming and traumatogenic enough to cause psychological decompensation in some of them. For the few diagnosed, there would be many undiagnosed HCWs. The focus should be on high index of suspicion for stress related psychological trauma in HCWs and it's mitigation through early detection and support for complete recovery. The importance of systemic, family and peer support is emphasized.

14th German Endocrine Brain Immune Network, GEBIN

The proceedings contain 48 papers. The topics discussed include: mental and physical health in informal caregiving and associations with relationship quality between caregiver and care recipient - a pilot study;immune-mediated early endocrine response during tumorigenesis;characterization of circulating dendritic cells in major depressive disorder;immune age correlates with cardiorespiratory fitness, but not with general intelligence;investigation of the relationship between immune age and vaccination against SARS-CoV-2;the steroid hormone dehydroepiandrosterone (DHEA) counteracts the consequences of psychological trauma on immunocellular ageing and mitochondrial bioenergetics;prediction of antibody levels after COVD-19 vaccination: evidence for immune interoception;and temporal dynamics of cytokine changes in blood, cerebrospinal fluid and brain tissue of endotoxemic rats.

Crises in the Anthropocene.

2022 was a year of crises, not just one but multiple intersecting crises that caused traumatic stress in billions of people worldwide. COVID-19 is still not over. New wars have started, and the climate change impact is bigger than ever. Will the Anthropocene be an era of continued crises? This past year the European Journal of Psychotraumatology (EJPT) has again tried to contribute to how to prevent or treat the consequences of these major crises as well as other events and we will continue to do so the year to come. For instance, we will have special issues or collections addressing these big issues, such as climate change and traumatic stress, or early intervention after trauma or in times of conflict. In this editorial, we also present the past year's excellent journal metrics regarding reach, impact, and quality and the ESTSS EJPT award finalists for best paper of 2022 and look forward to 2023.

2022 was a year of multiple intersecting crises causing traumatic stress to billions of people around the world.European Journal of Psychotraumatology (EJPT) aims to contribute to how to understand, prevent or treat the consequences of these major crises.EJPT's editorial team again achieved excellent journal metrics regarding reach, impact, and quality in 2022.

Psychotraumatology of the war in Ukraine: The question of the psychological care of victims who are refugees or who remain in Ukraine

The war in Ukraine is a major poly-traumatic event, which leads to massive population displacements. The question of the evaluation and psychological care of psychotraumatised people is an urgent matter. As many countries hosting refugees are well endowed with a good number of psychologists, some of these interested professionals should mobilise themselves and make themselves known to carry out these clinical acts. Priority should be given to trained and experienced psychologists to support victims. The language barrier will have to be overcome. Initially, it would be desirable to make contact or get closer to local and national refugee centres to facilitate these operations. Face-to-face or remote consultations, as developed during the Covid-19 pandemic, are possible. Reinforcements of the number of available and dedicated psychologists, including remotely, from the countries hosting the most refugees, are also desirable. The issue of detection, assessment and care of psychologically traumatised people who remained on the Ukrainian territory is probably even more massive. Whether non-combatants or combatants, part of the international psychological community should mobilise, in addition to local colleagues, to provide them with this psychological help. These humanitarian actions would be feasible depending on the evolution of the conflict. Whether it is psychological support for refugees or people still on the Ukrainian soil, models for organising and coordinating these actions must be carefully considered and implemented in an evolving way to optimise their effectiveness. © 2022

A review of high dependency unit admissions in a busy maternity hospital

Introduction: Due to the COVID-19 pandemic, critical care demands on our health service have come into focus. In our stand-alone maternity hospital, patients requiring more than single organ support must be transferred to a general adult hospital for critical care, however those requiring single organ support or increased levels of monitoring are cared for in our high dependency unit. This is best practice for our patients but must be staffed appropriately.We sought to quantify our burden of HDU admissions, and to ascertain our reasons for admission. Methods: We retrospectively examined our critical care admissions over a four-month period from July 2021 to October 2021. We separated our analysis into two groups- those admitted for obstetric reasons or those admitted for non-obstetric reasons (i.e. gynaecology patients). Results: Over the four months we examined there were 2642 births, including 832 caesarean sections. In that time, 33 women were admitted to our HDU for obstetric reasons, and six women were admitted for reasons related to a gynaecology procedure. Among our obstetric patients, preeclampsia was the most common reason for admission (48%), and postpartum haemorrhage was the second most common (39%). Sepsis was the most common reason for admission amongst our gynaecology patients. Discussion: The HSE guidelines for critically ill women in obstetrics in 2014 recognised that quantifying high dependency care needs for obstetric patients is challenging, as most are managed within their local maternity HDUs and are not included in national data [1]. The overriding principle in the care of sick postpartum women is to keep the woman and her baby together, if possible, to maximise bonding and ease psychological trauma [2]. Therefore, it is important that these patients are kept in their maternity hospital as far as is safe for them. We hope that by auditing our hospital’s critical care needs, we can ensure it is staffed appropriately, and more importantly that our staff receive the appropriate training in the management of the most common critical care issues.

Psychotherapy in Dealing with Crises in the COVID-19 Pandemic

In the article, a theoretical analysis of the study of crisis states and the methodological foundations of crisis psychotherapy, taking into account foreign and domestic experience, is carried out. Based on the results of empirical studies, modern foreign and domestic researchers have established that crisis conditions during the COVID-19 pandemic are accompanied by suicidal reactions, depression, neurotic conditions with post-traumatic stress disorders, exacerbation of psychosomatic diseases, psychopathological disorders.Psychological approaches in psychotherapy together with crisis psycho-psychotherapeutic interventions for working with acute crisis states and crisis psychotherapy of clients in the post-quarantine period are considered.The concepts of a crisis state, the features of the influence of "covid" psychotrauma on the mental and psychological health of a person, and the provision of psychological assistance in crisis situations during the COVID-19 pandemic are described in detail. It is noted that in working with crisis conditions during the COVID-19 pandemic, modern foreign and Ukrainian specialists prefer cognitive-behavioral psychotherapy.At the theoretical and methodological level, it has been proved that psychotherapy of post-traumatic stress disorder (PTSD) is close to crisis psychotherapy and is aimed at reintegration of mental activity disturbed by the "conductive" psychotrauma and restoration of psychological adaptation to a certain extent.The psychotherapeutic model of psychological crisis intervention in the context of the COVID-19 pandemic is based on a biopsychosocial approach and requires a comprehensive and integrated use of crisis psychotherapy methods with the integration of neuropsychotic methods and Internet technologies into the entire therapy process.

Psychological Impact among Physical Therapists during COVID-19 in Western KSA

Background: COVID-19 pandemic exposed health care providers such as physiotherapists to psychological disorders as depression and anxiety. Purpose: the purpose of this study was to determine the prevalence of psychological impact among physical therapists during COVID-19 in western Kingdom of Saudi Arabia (KSA). Methods: Researchers performed a cross sectional survey-based study targeting physiotherapists in western KSA during the COVID-19 pandemic by using an online questionnaire. The questionnaire composed of three parts personal, occupational, and psychological. One hundred and ten Physical therapists replied who were working at 18 public and health hospitals of the Western region of KSA providing direct care for patients during the COVID-19 pandemic. Data analysis: Descriptive statistics of mean, standard deviation and percentage were utilized in presenting the subjects characteristics and collected data. Chi-square statistics was utilized to examine psychological injury with subject characteristics. The level of significance was set at p < 0.05 for all tests through the statistical package (SPSS) version 25. Result: One hundred and ten physiotherapists [(60%) females and (40%) males] participated in this study. The results showed that male physiotherapists (63.69%) had higher frequency of psychological disorders in comparison with female physiotherapists (40.9%). Conclusion: The COVID-19 pandemic had a bad effect on psychological aspect of physiotherapists in western KSA.

Prevalence of Depression, Anxiety and Stress among Health Care Students at the Time of COVID-19: An Online Cross-sectional Study

Introduction: Health care students have baseline elevated rates of anxiety, depression and burnout. However, not much is known regarding COVID-19's psychological impact on home-confined medical & nursing students. Aims: This study aimed at assessing the prevalence of stress, anxiety and depression among health care students in Erode district, Tamilnadu during lockdown due to the outbreak of COVID-19. Materials and Methods: This descriptive cross-sectional study was conducted via an online survey completed by students studying an MBBS and a Nursing degree in Erode district, Tamilnadu. The validated previously published Depression, Anxiety and Stress Scale (DASS-21) questionnaire was used as a part of the online survey to assess students' stress, anxiety and depression scores. The data were evaluated using descriptive statistics, the Mann-Whitney U test, and the Kruskal-Wallis test. Results: A total of 273 health care students (males: 29.3%, females: 70.7%) completed the survey. 50.9% of students are MBBS students, and 49.1% are nursing students. From those surveyed, the prevalence of depression, anxiety, and stress in different levels was 40.3% (110), 41.4% (113), and 30% (82), respectively, which are higher during lockdown. Mean depression (10.25 vs 7.75, p=0.05), anxiety (8.53 vs 6.6, p=0.05) and stress (11.76 vs 9.30, p=0.05) scores were higher among females than males. Final year students are having more depression (F=10.37, p=0.04), anxiety (F=9.93, p=0.05), and stress (F=9.97, p=0.05) than others, and it is confirmed using one-way ANOVA F-test. Conclusion: During the COVID-19 epidemic, stress, anxiety, and depression levels among health care students in Tamil Nadu were high. As a result, immediate and suitable psychological therapies for healthcare students should be undertaken to prevent the psychological harm caused by the COVID-19 epidemic, which might negatively impact their learning.

Reduction in Bloodborne Pathogen Splash Exposures after Implementation of Universal Masking and Eye Protection for COVID-19

Background. While splashes to the eyes, nose and mouth can often be prevented through appropriate personal protective equipment (PPE) use, they continue to occur frequently when PPE is not used consistently. Due to the COVID-19 pandemic, we implemented universal masking and eye protection for all healthcare personnel (HCP) performing direct patient care and observed a subsequent decline in bloodborne pathogen (BBP) splash exposures. Methods. Our healthcare system, employing >12,000 healthcare personnel (HCP), implemented universal masking in April 2020 and eye protection in June 2020. We required HCP to mask at all times, and use a face shield, safety glasses or goggles when providing direct patient care. Occupational Safety tracked all BBP exposures due to splashes to the eyes, nose, mouth and/or face, and compared exposures during 2020 to those in 2019. We estimated costs, including patient and HCP testing, related to splash exposures, as well as the additional cost of PPE incurred. Results. In 2019, HCP reported 90 splashes, of which 57 (63%) were to the eyes. In 2020, splashes decreased by 54% to 47 (36 [77%] to eyes). In both years, nurses were the most commonly affected HCP type (62% and 72%, respectively, of all exposures). Physicians (including residents) had the greatest decrease in 2020 (10 vs. 1 splash exposures [90%]), while nurses had a 39% decrease (56 vs. 34 exposures). Nearly all of the most common scenarios leading to splash exposures declined in 2020 (Table). We estimated the cost of each BBP exposure as $2,940;this equates to a savings of $123,228. During 2020, we purchased 65,650 face shields, safety glasses and goggles (compared to 5303 similar items in 2019), for an additional cost of $238,440. Specific activities identified as leading to bloodborne pathogen splash exposures, 2019 vs. 2020. Conclusion. We observed a significant decline in splash-related BBP exposures after implementing universal masking and eye protection for the COVID-19 pandemic. While cost savings were not observed, we were unable to incorporate the avoided pain and emotional trauma for the patient, exposed HCP, and coworkers. This unintended but positive consequence of the COVID-19 pandemic exemplifies the need for broader use of PPE, particularly masks and eyewear, for all patient care scenarios where splashes may occur.

Interdisciplinary physical therapy group for COVID-recovered patients: A case series report

BACKGROUND AND PURPOSE: The novel coronavirus (COVID-19) created a large population of survivors with prolonged post-infection symptoms, impacting their quality of life (QOL) with little known about their long-term recovery. Physical therapy is theorized to reduce mortality rates of patients who have been hospitalized with COVID-19;however, there is limited evidence and a critical need for ongoing research to determine best practice within this large, complex and emerging patient population. The disease process impacts all three domains outlined by the International Classification of Functioning, Disability and Health (ICF) - impairment, activities, and participation. Increased psychological symptoms of fear, uncertainty and guilt are also prevalent due to social isolation and the novelty of the disease process. In order to achieve optimal outcomes, a high level of coordination of services with other healthcare providers is necessary. Highly trained, multidisciplinary teams in rehabilitation settings implementing evidence-based recommendations is crucial for better management of survivors of COVID-19. The purpose of this case series is to describe the novel and successful interdisciplinary team approach in the outpatient rehab clinic setting for individuals post-COVID. CASE DESCRIPTION: In the case series, 4 females and 7 males ages 34-67 participated in an 8-week COVID-19 recovered group while enrolled in an intensive interdisciplinary outpatient rehab clinic setting. All patients were previously hospitalized and completed acute inpatient rehab. Patients participated in one, 55-minute group session per week with co-treating physical therapists (PT), psychologists and occupational therapists. Group participants received two to eight hours of additional PT weekly in the clinic. Within the group, patients participated in moderate intensity cardiovascular exercise through use of the Borg Rating of Perceived exertion (RPE) scale. Interdisciplinary education regarding the disease process, activity pacing, coping strategies and psychological trauma post-COVID-19 were provided with incorporation of peer support. OUTCOMES: Pre- and posttreatment assessments of 6-minute walk test (6MWT) and 10- meter walk test self-selected velocity (10MWT SSV) were performed. 6MWT change of 255.78 feet (paired t-test, P- value = 0.002);10 MWT change of 0.27 m/s (paired t-test, P-value 0.001). Ten patients required an assistive device (AD) at the onset of the group. Ninety percent of participants transitioned to a lesser restrictive device within the eight weeks. DISCUSSION: This case series demonstrates the benefits of an outpatient interdisciplinary program through significant improvements in patient's self selected walking speed, cardiovascular endurance and progression to lesser restrictive AD. In conclusion, the outcome of this case series supports the effectiveness of an interdisciplinary team approach to improve functional mobility in patients who are COVID-19-recovered.

Wellbeing and clinical videoconferencing satisfaction among patients in psychotrauma treatment during the coronavirus pandemic: cross-sectional study.

Background: The coronavirus pandemic appears to put psychiatric patients with pre-existing symptomatology at risk of symptom increase, but evidence is scarce. While the pandemic and stringent governmental measures have accelerated the use of clinical videoconferencing (VCT), patient satisfaction with VCT is unclear. Objective: Aim of the study was to assess the wellbeing of patients in psychotrauma treatment during the coronavirus pandemic and to evaluate their use of and satisfaction with VCT. Method: This study used data from a routine outcome monitoring assessment completed by patients in treatment at a specialized psychotrauma institute and administered before the easing of governmental measures in June 2020. Wellbeing (Brief Symptom Inventory, Cantril Ladder, perceived stress level, and symptom change), VCT use and VCT satisfaction, and their association with demographic variables (gender, age, education level, and refugee status) were analysed. Results: Of the 318 respondents (response rate 64.5%), 139 (43.7%) reported a symptom increase, which was associated with a higher coronavirus-related stress level and general psychopathology as well as lower life satisfaction. There were significant effects of age and education level on wellbeing. VCT was reported to have been used by 228 (71.7%) patients. VCT satisfaction ratings were higher among women and those with lower levels of stress (r = -.20, p < .01) and general psychopathology (r = .21, p < .01). No difference in treatment satisfaction was found between patients who used VCT versus those who did not (mean difference = -.09 95% CI: -.79 to .62, p = .81). Conclusions: The coronavirus pandemic has aggravated mental health complaints according to a substantial percentage of patients in psychotrauma treatment. Although VCT was found to be acceptable, face-to-face treatment may remain necessary for specific target groups with limited access to VCT (such as refugees) and patients with high levels of general psychopathology.

Antecedentes: La pandemia por el coronavirus parece incrementar el riesgo de un aumento de síntomas a los pacientes psiquiátricos con sintomatología preexistente, pero la evidencia es escasa. Si bien la pandemia y las estrictas medidas gubernamentales han acelerado el uso de la videoconferencia clínica (VCT, por sus siglas en inglés), la satisfacción del paciente con la VCT no está clara.Objetivo: El objetivo del estudio fue el de evaluar el bienestar de los pacientes en tratamiento por psicotrauma durante la pandemia por el coronavirus; además, evaluar su uso y su satisfacción con la VCT.Método: Este estudio empleó los datos de las evaluaciones rutinarias de control clínico de un instituto especializado en psicotraumatología completadas por pacientes y realizadas antes de la flexibilización de las medidas gubernamentales en Junio del 2020. Se analizaron el bienestar (Inventario Breve de Síntomas, Escalera de Cantril, nivel de estrés percibido y cambio de síntomas), el uso de la VCT, la satisfacción con la VCT y su asociación con variables demográficas (género, edad, nivel educacional y condición de refugiado).Resultados: De los 318 encuestados (tasa de respuesta del 64,5%), 139 (43,7%) reportaron un aumento de síntomas, lo cual se asoció con niveles de estrés asociado al coronavirus más altos y con psicopatología general, así como con una menor satisfacción con la vida. Hubo efectos significativos entre la edad y el nivel educativo sobre el bienestar. 228 (71,7%) pacientes reportaron haber usado la VCT. Los índices de satisfacción con la VCT fueron más altos entre las mujeres y entre aquellos con menores niveles de estrés (r = −.20, p < .01) y de psicopatología general (r = .21, p < .01). No se encontraron diferencias entre la satisfacción con el tratamiento en pacientes que usaron la VCT en comparación con aquellos que no lo usaron (diferencia media = −.09 IC del 95%: −.79 a .62, p = .81).Conclusiones: La pandemia por el coronavirus ha agravado las quejas de salud mental en un porcentaje importante de pacientes en tratamiento por psicotrauma. A pesar que se halló que la VCT era aceptable, el tratamiento presencial puede seguir siendo necesario para grupos específicos con acceso limitado a la VCT (como los refugiados) y para los pacientes con altos niveles de psicopatología general.