Originally posted on Forbes.com; read the original article here.
There is a clear mental health crisis and growing need for care in the United States. A recent Gallup poll showed American’s assessment of their own mental health is “worse than it has been at any point in the last two decades.” Take any group from college students to pregnant women and you will find data supporting their worsened mental health over the pandemic. With more need comes more demand for services. Yet, even before the pandemic, there was a shortage of mental health providers to meet the demand and that is only going to increase and cause further strain on an already broken system. For example, pre-pandemic there was a national psychiatrist shortage that was considered to be more severe than the shortage in any other specialty. This concerned Dr. Darrell G. Kirch, the President and CEO of the Association of American Medical Colleges (AAMC) as he looked at the mental health landscape. He said, “We face a broad range of mental health issues, including the acute problems of opioid addiction and increasing rates of depression and suicide. I think one of the great tragedies is that some of the most seriously mentally ill individuals are homeless or are caught in a revolving door between prison and the street.”
Looking to the future, Brit Barkholtz, MSW, LICSW, a clinical therapist in St. Paul Minnesota worries that the system is unable to handle the additional strain. She explains, “I keep seeing all of these articles saying ‘the next wave of the pandemic will be in mental health’ or ‘mental health will be the next frontlines’ or ‘a mental health crisis is coming’ and I’m like… are we not already there? Because I think we’re already there. Everyone I know has a full caseload and is booked months out, like if there is an even bigger wave coming I don’t know how the system handles that when it seems already at capacity.”
Other therapists across the country agree. They explain that there has been a steady and exponentially increasing demand for mental health services throughout the pandemic that has occurred at a pace that has been hard for them to maintain. Dr. Lisa Hayden, a Clinical Psychologist in Southern California, says that her caseload has been larger than it has ever been in 20 years. In order to accommodate more people, she was skipping all of her breaks and even trying to make her sessions shorter, like 45 minutes or 30 minutes, instead of 50 minutes. She notes, “[I] absolutely tried everything but telehealth is different than in person and I found myself mentally and physically exhausted at the end of each day. By December, I really need some time for my own family, as they were really showing the effects of long term stress.”
Brooke Huminski, LICSW, a psychotherapist in private practice in Rhode Island and Massachusetts, agrees and describes that in her practice she used to get 1-2 referrals a month, but lately she has been getting up to 3 referrals a week, mainly from parents wanting eating disorder treatments for their children. She finds it not only heartbreaking and hard to turn them away, but also challenging because she knows that her typical referral sources (other therapists) are also full. Early in the pandemic, she would rearrange her schedule to see more clients at odd hours of the day to try to accommodate them, but she, too, found it came with a cost to her own mental health and decided it was unsustainable. She no longer does this, but says it much harder to say no when a former client asks to be seen, however.
In addition to sheer volume, patterns that used to allow for breaks in schedules or spacing of clients no longer seem to exist. Tamara Hubbard, MA, LCPC, a Licensed Counselor & Family Therapist in private practice in the Chicagoland area, says that there are usually slower times for patients, like summer or holidays, and those times have not been slow this year. Instead, her caseload has just stayed consistently full. She also feels her clients have increased the frequency of sessions that they need. This was echoed by Brit Barkholtz who said that people who used to meet with her every other week now want to meet weekly and she is trying to find the balance between adding sessions and stretching her schedule to meet client needs, while also trying to preserve her own boundaries. She says in December 2020 she had 24 more appointments than in December 2019. She also had lower cancellations and a longer wait list. She adds, “It makes sense that people want to be seen more frequently; there’s the pandemic, obviously, but also here in the Twin Cities I saw a significant impact on the wellbeing of my caseload after the murder of George Floyd and during the subsequent local uprising, that was a really hard time for our community that we’re still all grappling with, and then you have the election, and now an insurrection at the capitol…of course people need more support right now.”
Some patients seem to be experiencing more acute presentations as well. Dr. Jessica Stern, Clinical Psychologist and Clinical Assistant Professor of Psychiatry at NYU Langone Health, says she has seen some increase in suicidal thoughts in her practices that she works in and has added additional weekday spots and longer workdays to accommodate some of the greater demand. Kelly Leuty, a Licensed Clinical Professional Counselor in St. Louis says she has seen more patients for post-inpatient treatment discharge appointments and more patients with more acute symptoms like more severe manic episodes or more psychosis. Ms. Leuty adds that she has been more “creative” with her schedule to help get all of her patients in, including working through her lunch hour, double booking clients who don’t normally need a full hour, booking over meeting times, or putting clients on a waitlist for cancellations.
Dr. Emilie B. Joseph, a Psychologist and Founder of Empowered Insights LLC in Washington D.C., has also changed her schedule and clinic rules over the pandemic to be more accommodating for patients noting that she added more slots, added back old clients, suspended late cancel fees, and coordinated reduced fees temporarily due to financial hardships. She points out that she has noticed her caseload has been full of more chronic, persistent mental health issues instead of episodic ones. She explains, “I partially attribute this to the pandemic and sociocultural and political distress because they are significant, ongoing stressors with no foreseeable resolution or end date.” This means that patients are likely to be seen for longer, however, and only adds to the therapist workload.
The Result of Increased Demand: Burnout
While it is not often talked about nearly half of psychotherapists report burnout in their jobs. Psychiatrists, too, have high rates of burnout. In fact, a recent study showed that 78% had scores equivalent to high levels of burnout and 16.1% screened positive for Major Depression. Tamara Hubbard explains, “I’m just going to be real here – sometimes I feel I’m managing well, and other times, I feel I’m not. Being a therapist and having insight into effective coping skills doesn’t mean I’m going to get through a global pandemic unscathed. I’ve absolutely felt more burnt out than normal these past 10 months. Who hasn’t?”
Yet, most therapists initially felt trying to fit in more and more patients and change their schedules to do so was simply part of their job. Brit Barkholtz said it was not really over accommodating, but much like other healthcare workers, she was simply “answering the call of her profession” in the pandemic. She says, “With telehealth, especially, it ends up being so easy to just add an extra appointment here, extra appointment there, next thing you know you’ve added five more to your week than you’d planned. I don’t regret it because I know people need it and I’m just trying to be as helpful and supportive as I can, but it can be a lot. I’m not sure if it’s burning me out, I don’t really know where the line is between stress, exhaustion, burnout, whatever. But everyone’s stressed and exhausted right now, you know?”
With this mindset of prioritizing their clients and helping others, many therapists failed to notice that their adjustments intended to help their patients actually affected their own mental health until they saw the signs of burn out. They then had to later shift their practices to prioritize their own well being. Dr. Joseph said she had to take three weeks off at the end of the year. During that time, she “recuperate[d] and strategize[d] for the new year to implement boundaries around my caseload that would prevent the burn out I experienced last year.” Ms. Hubbard, too, noted that she would catch herself burning out and need to take time off periodically, even just for a day or two, to help her get back to work and cope better. She says that though she initially was able to accommodate clients by adding slots or extra sessions and packing her days, that pace was going to burn her out too quickly and she adjusted. She explains, “As with many of us in the healthcare professions, who likely choose our careers because we enjoy helping people, it’s so hard to want to help everyone at the same time that we’re feeling incredibly exhausted. While I may have chosen to ignore or undervalue my exhaustion prior to the pandemic, I’ve now learned that the best way to be an effective therapist is by taking care of myself and respecting my own boundaries. Once I started doing that, my burnout level began to balance out and I was able to be more present with my clients again.” In order to do this, she says she had to practice more of what she preached and learn to create better boundaries. In other words, even if she wanted to help every client who called, she limited her caseload to manageable numbers and chose not to add extra days or evenings no matter how hard that felt for her. She also has had to adjust her own expectations around productivity and self-efficacy, and has learned to pay more attention to her own needs.
Another challenge for therapists right now is that anything a client is experiencing, including working from home, having kids at home, having a spouse at home, and the trauma of the world events, they as the therapist could also be experiencing. This is only compounded if they identify as a member of a minoritized group themselves. Dr. Stern notes, “This has definitely been a difficult time to be a therapist because everyone we are treating is experiencing such a universal and existential crisis, all while experiencing the world’s pain ourselves.” Ellie Herman LCSW, a Licensed Clinical Social Worker in Pennsylvania, adds “One of the most tricky aspects of my job right now is that we are all experiencing trauma together. Many of the stressors clients bring up are stressors we all share currently. I, and other therapists, are processing the goings on in the world while also counseling.” In other words, it is much harder to create distance and leave work at work and home at home.
There is, as Dr. Hayden notes, also a degree of guilt in feeling overwhelmed at all, but, therapists are also human, and are living through a pandemic, where their lives have been impacted. As Ms. Huminski points out, sometimes working can serve as a coping skill as it can be rewarding and add to her sense of purpose and meaning. It can also help distract from worries and challenges in her own life. But other days, she says, she can feel burnt out and fatigued by it. Sarah Isaacs, a therapist from Raleigh, NC, notes some of her own burnout comes from not seeing people get better right now. She says, “One of the most rewarding parts of my job is seeing the changes people make in their lives and with all of this going on we are all just maintaining. It is draining.”
Outside of work, to cope, many therapists turn to friends, family, and self-care. Ms. Herman focuses on sleep and has tried blue light glasses to help with the long lengths of screen time of telehealth, while Ms. Leuty credits group chats and social media for helping her stay connected. Nearly universally, however, the therapists endorsed utilizing their own therapist during the pandemic for support, whether they had one prior to the pandemic or resumed again during. Ms. Herman says she started to see one in October and it has been a source of strength to help her cope. She says, “Therapy is self-care. We help clients learn about themselves everyday, and to engage in our own therapy allows us that gift and perspective as well.” Ms. Isaacs says it is hard to stare at a screen for any more time during the day and to make appointments, but she prioritizes it, because it is important to stay well. Dr. Stern adds that therapy, “provides you a space that is yours [and], as therapists, we are consistently absorbing other people’s emotions and experiences, so seeking out your own therapist allows you to release your own.” That space is desperately needed, particularly now.
Of note, however, just because therapists get their own help when they need it, does not mean patients should worry about them handling their problems in session. Ms. Huminski adds, “It can be hard writing and speaking honestly about this as I don’t want my clients, prospective clients, or colleagues to worry about me. I’m old enough to have experienced that stigma. If there’s a message I want to be clear about is that therapists (and all healthcare workers) can both hold space to help others AND have their own challenges. The important part is that they’re addressed and cared for. The danger for all of us comes when the stigma is too high to ask for that help or take that time off.” Ultimately, patients should feel comfortable asking therapists for help, and therapists should also notice that burnout is real and they, too, should prioritize themselves and ask for help, especially in a global pandemic.
Long before Covid-19, psychiatrists warned that the retirement of more than half the current workforce was on the horizon and the need to train new mental health workers was critical. The pandemic and increasing provider distress are only accelerating a trend that was in place for quite some time. Therapists are a limited resource and, cannot, no matter how much they try, make up for a broken mental health system with extra hours, night and weekend accommodations. With wait times increasing and trauma lasting long after the pandemic, it will only be more difficult to see them. But, it will also not be their fault.
To put it simply, as Brit Barkholtz says, “[They] are human. [They] care. [They]’re doing the best [they] can.” It is time to start investing in fixing the mental health system and increasing the pipeline to help give therapists the support they truly need and clearly deserve.