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A Practice-Based Evidence Approach Pre, During, and Post COVID-19 During Psychotherapy

Internet Editor’s Note: I want to thank John Freedom for his helpful and constructive comments on this manuscript. It is very much appreciated.

This article discusses the use of a digital assessment and tracking approach pre, during, and post COVID-19 to monitor changes in emotional stability, depression, anxiety, happiness, affect, life balance, beliefs, spiritual awakening, the working alliance, outcome, and helpfulness/benefits of psychotherapy.  Using the online assessment systems developed by Pragmatic Tracker (PT) and Blueprint (BP), two clients who contracted severe cases of COVID-19 during psychotherapy were carefully assessed weekly showing significant changes pre, during, and post COVID-19 on some measures while none on others.  The clients were out of work from three to eight weeks. The typical healing process took about nine weeks before recovery to pre COVID-19 scores. Graphs in the article show these changes and can also be seen on the Pragmatic Tracker (PT) and Blueprint (BP) websites by clinicians. A variety of interventions following an ICBEST (integrative, cognitive, behavioral, energy, spiritual therapy) model were used.

Although a fair amount is known about the emotional and psychological (especially depression and anxiety) impact on people during the pandemic (Fitzpatrick, 2020) there is little research specifically on people with COVID-19 or with people undergoing psychotherapy who develop COVID-19.  This article begins to rectify that deficiency by tracking and assessing change digitally in some detail in two clients pre, during and post COVID-19 during psychotherapy using measures of emotional stability, anxiety, depression, affect, beliefs, happiness, outcome, the therapeutic alliance, the helpfulness/benefits of the psychotherapy, life balance and spiritual awakening.  Life balance measures the ability to easily reflect, sort out and clarify things in life, understand and connect with oneself and others, and easily engage in self-forgiveness, self-compassion, and self-love. Spiritual-awakening measures six dimensions of spiritual awakening such as an awareness of ones true nature, general spirituality, an awareness of a higher power that inspires ones actions, a general sense of awareness and inclusion of all things, a sense of inner, and unfolding perfection as well as love, empathy, and compassion.

Friedman (2018a, 2018b) discusses an approach to healing from anxiety, depression, and trauma. Contracting a serious case of COVID-19 could be considered a specific kind of trauma. Utilizing concepts of Savela (2015), this integrative approach can be considered a practiced-based evidence or feedback informed therapy approach.

Two clients of differing sexes, ages, races, occupations, health, marital, and vaccination statuses were being seen virtually during psychotherapy when they contracted severe cases of COVID-19. One client, Cindy”, was out of work for three weeks and lost her sense of smell and taste and the other, Bill” was briefly hospitalized with COVID-19, getting diagnosed with pneumonia and was out of work for eight weeks.  On a weekly basis, both had been given a series of questionnaires digitally using the PT and BP online assessment systems.

For confidentiality purposes, names and identifying information have been changed.

Bill, a 55-year-old, White, cisgender, male worked as a contractor and was married for 25 years. He was vaccinated.  Cindy, a 49-year-old, Black, cisgender, female, employed as a teacher was separated from her husband for one year. She contracted COVID-19 the day she was vaccinated.

Cindy and Bill provided narratives regarding their experiences. Cindy said, Prior to getting COVID-19, I was physically well but mentally/emotionally I was having anxiety in general because of the uncertainty of everything in the world from COVID-19. Then I was vaccinated and on the same day I tested positive for COVID-19. The first week was easy as I had no symptoms. I stayed positive and prayed to have mild symptoms…

…On the 7th day I was hit hard. I was bedridden for three weeks with symptoms of severe fatigue and diarrhea.   I lay in bed in silence. I couldnt bear to do anything such as being on my phone, TV, talking, reading etc. I lost my sense of taste and smell. There were days I wasnt sure I was going to pull through. After the third week I was very weak. Day after day, by 5:00 pm I was ready for bed. A lot of my hair fell out…

…Long term, my taste and smell are still only about 75%. My hair stopped falling out and is starting to grow back. My sleep pattern hasnt fully returned. I am tired early. Today I am grateful to have survived, I take nothing for granted. I am focused on taking care of myself and committed to my spirituality”.

Bill said, “My job is quite stressful. After contracting COVID-19 I was out of work for two months and bed ridden for roughly four weeks. I was unable to sleep for more than one hour for about two to three weeks. I was exhausted…

…My initial emotional and psychological experience with contracting COVID-19 became terrifyingly traumatic. I repeatedly felt a sense of emotional insecurities. I couldn't simply rely on myself like normal because I felt physically drained. I felt burdensome to others because people couldn't come near me out of fear of catching COVID from me. These times were spent alone as loved ones couldn't be near me and it left me in a very dark place; a place of loneliness…

…During the first week of contracting COVID-19, I felt weak and exhausted. I often couldn't muster the strength to make it past the bathroom in the morning.  There were many times I'd stay in the bathroom on the phone entertaining my mind until I had the strength to leave. I coughed phlegm profusely and suffered from body aches that attacked my joints and lungs. Over the second and third weeks I continued with all of the first week symptoms however, they were more intense. I was unable to breathe normally. I was scared. [ZRN1] . My thoughts became increasingly foggy. I wasnt able to recall the names of colleagues and students. I often became confused regarding the time and day of the week. I lost all my appetite and drank electrolytes...

…In addition, my oxygen levels fell to 80% during the third week and I went to the ER at the nearest hospital. I was informed that I had COVID-19 Pneumonia and given the steroid Prednisone for just over 30 days, with supplemental CPAP oxygen treatments for 30 days. The lasting physical effects from my COVID-19 Pneumonia experience have left me with an occasional cough followed by labored breathing spells, similar to an asthma attack.”

Both clients filled out the Friedman 5 Factor Personality Scale with an Emotional Stability subscale (Friedman, 2020); the Generalized Anxiety Disorder-6 item (GAD-6; Spitzer et al., 2006)) scale; the Patient Health Questionairre-9 item (PHQ-9; Kroenke et al., 2001); the Friedman Affect and Friedman Belief Scales -short form (Friedman, 2021; the Friedman Life Balance Scale (Friedman, 2020); the Friedman Spiritual Awakening Scale (Friedman, 2020); the Clinical Outcomes in Routine Evaluation-10 items (CORE10; Barwick et al., 2013); the Working Alliance Scale (WAI; Horvath & Greenburg, 1989) and the Friedman Helpfulness and Beneficial Therapy Scale (Friedman, 2020).

Showing the assessment scores on the various scales nine weeks before, during, and after COVID-19 in three-week increments would most effectively show the changes that took place during these time periods. The graphs of change purposefully do not show the whole course of therapy but rather the time around COVID-19. Moreover, the article will briefly mention but not focus on the treatment being given during this period and some clinical implications for treating COVID-19 clients during psychotherapy.

Changes Pre, During, and, Post COVID-19

Table 1 demonstrates the changes that took place in the Friedman Emotional Stability Subscale over the course of 27 weeks (nine before, nine during and nine weeks after COVID-19). COVID-19 was experienced by both clients in all graphs between week nine and 10. The graphs show that at that point in therapy (week 1-9) both clients prior to COVID-19 had high scores on emotional stability (13-15) but dropped down markedly to scores of 8-10. Cindys scores started to rise after 3 weeks (scores of 13-15) but Bills scores took a lot longer (8, 7, 9) over the next nine weeks before returning to normal. Bill was briefly hospitalized and missed a week of therapy even though his sessions were by telehealth. He said he was too weak to participate.  Cindy often had sessions while in bed during this time. She was unable to walk downstairs.  Emotional instability elevated quickly for Bill and Cindy after COVID-19 and then decreased over time to a low level of distress.

Table 2 shows changes that took place in the GAD-6 anxiety scale over 27 weeks. Both clients were in the normal range on anxiety (4 or under) prior to COVID-19.  However, after contracting COVID-19 their scores jumped up over three weeks to the moderately serious anxiety range (11-14). Cindys anxiety score of 14 dropped down rapidly over three weeks to 3 but went back up to 10 over the next three weeks (see week 16) before dropping down to low levels of anxiety for nine weeks (scores of 0 to 1). Bills anxiety score dropped more gradually and steadily from 11 to 8 to 4 to 5 to 3 and 3 over three-week increments. Eventually both clients returned to their normal levels of anxiety (a score of 4 or less). Although a little less smoothly than the emotional stability measure, Bill and Cindys anxiety levels increased markedly after contracting COVID-19 and then decreased over time into the normal range.

Table 3 indicates the changes on the PHQ-9 depression scale before, during, and after COVID-19 during the psychotherapy sessions.

Both clients had low depression scores (0 or 1) prior to contracting COVID-19 but immediately after it their scores were in the moderately serious depression range. In this case Bill had the higher score (13) than Cindy (10) over three weeks but his depression score dropped to 4 and 2 over the next six weeks. Cindys score dropped from 10 to 3 then 4 and finally to 2 and 0, 0. Eventually both clients returned to a normal low level of depression. During the depression stage the clients often reported being exhausted, worn out, very fatigued, low energy and sometimes irritable. Frequently it was hard to get out of bed even to go downstairs or eat.  Bill and Cindys depression levels as can be seen in Table 3 increased substantially after contracting COVID-19 and then decreased over time back into the normal range.

Table 4 demonstrates the changes in the Friedman Negative Affect Scale. This scale has five subscales (hostility, guilt, sadness, fear, and fatigue) of three items each. Both clients had scores in the normal range (0) during the first nine weeks on the graph (week 1 on the graph covers 3 weeks) but increased markedly into the moderate to high range after COVID-19 (scores of 21-23). Bills score decreased into the normal range (3,3,0,0,0) over the next series of weeks while Cindys scores (13,5,3,3,0) decreased more gradually. Both Bill and Cindy eventually returned to a normal negative affect level (score under 4) six to nine weeks after developing COVID-19.

Table 5 shows changes in the Friedman Positive Affect Scale. This scale has five positive affects (jovial, self-assurance, attention, peace, and love) with three items each. Both clients had high scores (50 to 60 out of 60) prior to getting COVID-19. Cindys score dropped more dramatically to 25 than Bills (39), but also increased more rapidly (56, 58, 60, 59, 60). Bills score dropped further to 35, before gradually increasing to 40 and then the low 50s. Both clients returned to a normal range of positive affect over time following COVID-19. This indicates that not only do the negative affects (depression, anxiety, etc.) increase and then return to normal, but the positive affects (peace, joy, etc.) decrease and return to a normal range over time.

Table 6 shows changes in the Friedman Happiness subscale. This scale is one item on the Friedman Well-Being Scale short form.  The graphs shows that Bills reported happiness score barely dropped at all (9 to 8) over the course of these 27 psychotherapy sessions despite getting COVID-19. Cindys reported COVID-19 happiness score dropped from 9 and 8 to 6 after COVID-19. It then stayed there for three weeks and finally went up to 8 for the next nine weeks. A score of 6 is about average on this assessment measure and 8 is moderately high in reported happiness.  Cindys overall happiness was more impacted by COVID-19 than Bills happiness though eventually her happiness level returned to her baseline level of moderately happy.

Table 7 indicates the changes in the Friedman Life Balance and Friedman Belief Scales across the 27 weeks.  The Friedman Life Balance Scale has 3 subscales of five questions each (reflect, clarify, sort; understand self and others and self-forgiveness, compassion, love) plus 2 spirituality questions. The Friedman Belief Scale short form has 10 questions about positive beliefs and 10 questions about negative beliefs (20 in all). Prior to COVID-19 (week 10) both clients had moderate to high scores on both scales. There is a slight dip in the life balance scores both for Bill and Cindy at week 10 and 13. Still, those scores were well above the average score of 53 at those times. The scores on the Friedman Belief Scale maintained their high level of 72-80 before, during and after COVID-19. Thus, unlike the more affective measures in Tables 1 to 6, the life balance and belief measures showed little to no change over the 27 weeks. This is an atypical finding.  Usually affect and belief measures correlate highly with each other. It may be because COVID-19 has a strong somatic impact that influences affect more than beliefs.

Table 8 shows that the changes in the Friedman Spiritual Awakening Scale were minimal or not at all over the 27 weeks. The Friedman Spiritual Awakening Scale has six subscales of three questions each (true nature; spirituality, higher power/inspired action; awareness/inclusion, perfection/inner unfolding and compassion, empathy, love) Both clients had high to very high scores between 80 and 90 across all 27 weeks with 54.72 being an average score (Friedman, 2020). Bills score did dip a little bit at week 13, however, and then recovered. Overall, there was relatively little change during or after COVID-19 on these measures. This indicates that life balance, beliefs and spiritual awakening changed little or not at all despite Bill and Cindys experiences with COVID-19. This might be considered a strength helping their overall recovery. It may or may not be like other clients with strong COVID-19 reactions.

Table 9 indicates the changes in coping with the pandemic, energy, and CORE-10 outcomes (Barwick et al., 2013). The CORE-10 outcome measure is a 10-item assessment measure with questions covering anxiety, depression, trauma, physical problems, functioning, and risk to self. Clients are asked each week how well they are coping with the pandemic and how much energy they have on a 10-point scale. Bill missed filling out these measures during the first few weeks since he was very exhausted and weak due to COVID-19, only Cindys scores are reported. Her coping score dropped from 9 and 10 to 6 at week 10 and 13 after she contracted COVID-19 and then recovered to scores of 8, 8, 10, 10. Her energy level dropped to a score of 5 after getting COVID-19. Her scores then gradually increased to 7, 6, 7 and finally improved to 9 and 8.

Cindys CORE-10 outcomes score (the lower the score the better) soared to 10 from 1, 3 and 3 when she got COVID-19 (week 10); then dropped to 4 at week 13 and finally dropped back to 2 for week 16, 19, 22, and 25.  Basically energy and coping with COVID-19 decreased substantially before increasing again after six to nine weeks and the measure of outcome in psychotherapy (a distress measure) increased markedly and then decreased over six to nine weeks.

Table 10 demonstrates the changes in the ability to sleep. This is a one question item scored on a 10-point scale. Both clients had high scores pre-COVID-19 (9 and 10) indicating their ability to sleep which dropped significantly over the next six weeks to 5, 6 and 7. Bill recovered his sleeping ability completely with scores of 10 at week 16, 19, 22 and 25. Cindy, however, never fully recovered her sleeping ability with scores of 7,7, 8 and 8. She found this upsetting, of course. It is unclear why Bill fully recovered his sleeping ability and Cindy only partially did.

Table 11 indicates changes in the WAI. The WAI (Horvath & Greenberg, 1989) is a 12-item scale with 3 subscales covering goals, tasks, and bonds in psychotherapy. For both clients their scores were very high at all sessions (scores of 59 or 60) before, during, and after COVID-19. This indicates that the working alliance between therapist and client stayed high even during the clients’ worst experiences of COVID-19 and therefore COVID-19 experiences had no effect on the working alliance. One factor contributing to Bill and Cindys strong recovery over time may have been this strong working alliance because the working alliance has been shown to have a significant moderate correlation with therapeutic outcome (Flückiger & et al., 2018).

Table 12 demonstrates potential changes in the perceived benefits and helpfulness of psychotherapy. Each week clients are asked two questions on a 10-point scale indicating how much they perceive they are benefitting from the psychotherapy and how much they perceive they are being helped. At the beginning of therapy sometimes these scores are relatively low. However, both Bill and Cindy gave scores of 10 at all sessions. Consequently, COVID-19 had no impact on these measures.  This is consistent with the high working alliance scores which also did not change.


Although not the focus of this paper, the overall model of psychotherapy used to treat Cindy and Bill is called ICBEST (Friedman, 2015) which stands for integrative, cognitive, behavioral, energy and spiritual therapy.  For example, some of these approaches include the positive pressure point techniques (Friedman, 2010; Friedman 2016) which is a variation of the emotional freedom techniques (Church, 2018); integrative forgiveness therapy (Friedman, 2010; Friedman 2015); an integration of eye movement desensitization and reprocessing (Shapiro, 2017) and accelerated resolution therapy (Kip & et al., 2013), both of which use bilateral eye movements. Cognitive-behavior therapy and a practice-based evidence or feedback approach is also utilized. The author’s approach includes weekly digital assessments by the client which provides client feedback and helps to monitor change (Friedman, 2021). The spiritual component focuses on love, compassion, forgiveness, peace, intuition, and healing based on A Course in Miracles, (ACIM, 2007 & Friedman, 2010). In the author’s approach major clinical goals include enhancing the client’s love, compassion, forgiveness, and peace which are positive affects and using the therapist’s and often the client’s intuition to facilitate change and healing.

Clinical Implications: COVID-19 can be contracted suddenly and unexpectedly in any client, ranging in severity. When severe, it would be wise to treat it as an ongoing trauma in a clients life that impacts not only them but their immediate family (parents, spouse, and children), close friends, students, colleagues, employees, and employers. Client's often feel isolated and alienated from their social network because they may and sometimes do transmit COVID-19 to others. It is ongoing.

Calls by the therapist between sessions, especially at first can be very helpful and reassuring. It is perceived by the client as very caring. A major teaching taught to all clients is that “Every communication is either a communication of love or a call for love” (A Course in Miracles, 2007; Friedman, 2010) Experiencing distressing feelings associated with COVID-19 symptoms can easily been considered as a call for caring and love.

Some clients will benefit from knowing that you are praying or offering blessings for them. (Piedmont & Friedman, 2012) . This is a good time to use whatever conventional and maybe unconventional trauma techniques clinicians can know or learn. One of the goals needs to be to help clients who are dysregulated and feeling unsafe to self or co-regulate their emotions and for the therapist to create a safe space for them to share. (Porges, 2017). Sessions with spouses or even children may be beneficial at some point in the therapy.  This is an uncertain time for the client, but also the therapist. The therapist can use digital assessments like Pragmatic Tracker (PT) and Blueprint (BP) to help monitor the clients perceptions, attitudes, affects, beliefs, relationships, and the working alliance with the therapist during this challenging period of time. Graphs of change in PT and BP show visually the clients progress. Especially during challenging circumstances, the therapist needs to be able to stay calm and be at peace. (A Course in Miracles, 2007; Friedman, 2010). This will facilitate the practice of self-care.


This article showed how a Practice-Based Evidence Approach was used with two clients during psychotherapy who were strongly affected by COVID-19. One or both clients had physical symptoms of severe fatigue, breathing problems, loss of taste, smell and hair, weakness, diarrhea, exhaustion, coughing, difficulty walking and sleeping, and pneumonia. Emotionally, they were depressed, anxious, irritable, guilty, fearful, overwhelmed, helpless, and hopeless at times.

Most variables that showed marked changes during COVID-19 over three to nine weeks (such as measures of anxiety, depression, energy, and negative affect) reverted to the positive range within six to nine weeks, except for sleep in one case. It is unknown whether this pattern characterizes all COVID-19 clients whether in or out of therapy. Due to the small sample size, generalizations cannot be inferred.

It is known that social support is a big asset in coping with COVID-19 (Fitzpatrick et al., 2020) and psychotherapy is a specialized form of social support. An ICBEST integrative model of psychotherapy (integrative, cognitive, behavioral, energy, spiritual therapy) was briefly described along with some psychotherapeutic interventions.  More research is necessary in this important area. Some clinical implications were discussed to help facilitate change immediately after the clients contracted severe cases of COVID-19.

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