'We Are Therapists. After 6 Months of Lockdown, We're Almost at Breaking Point'

Across the U.S. and the world, we are all currently seeing COVID-19 pervade every aspect of our lives, from employment to education and our relationships.

As a psychotherapist and a psychiatrist based in North Carolina and St. Louis respectively, we have a particularly unique perspective on the way that the virus has affected many lives. Quarantine and lockdown has meant our work has picked up to a frenzied pace. Since the end of March, we have been working from home and have felt both connected and alone as we met up with our patients through the illuminated reflection of the computer screen.

We are seeing so many people that are crying out for help and we are very aware that many of those people will be told to, "find a therapist!" Like many of our colleagues across the country, we are seeing more people turning to mental health professionals than ever before.

The emotional toll of facing chronic stress, uncertainty and risk of mortality individually would cause mental health strain in "normal" times. But those factors compounded during a global pandemic create a perfect storm for a mental health crisis.

And these are not just our anecdotal observations, we are seeing the real time effects of the pandemic on mental health.

In one study, to manage high rates of psychological issues reported (57 percent acute stress disorder, 48 percent depression and 33 percent anxiety), 26 percent of frontline healthcare workers utilized talk therapy and 16 percent accessed online support groups. And, these numbers are likely to only increase as the effects of stress and trauma are often not felt or recognized immediately.

As this pandemic has progressed, we have noticed our job is not the same as it used to be and have begun to wonder who is looking out for the mental health of those trained and dedicated to support the growing needs of our country? In many ways, mental health professionals are frontline workers during this pandemic, too.

We both have patients in two of the highest risk groups during the pandemic; frontline healthcare workers and college students. Therapists and psychiatrists like us are facing the very same stressors and traumas as their patients, but we were both trained to keep our eye on the patient and leave our own problems at the door. Previously, if we had a hard day, or a patient's story might be a bit harder to hear, we could tolerate it because our job and our training taught us ways to compartmentalize.

With our boundaries defined and emotional distance guardrail up, we create a frame to allow patients to talk freely and safely without our problems entering into the conversation. Before COVID-19 hit, we had a drive or train ride home to shake off the stress of the day and switch over from professional to personal. We typically exhaled then.

Therapists, Therapy, burnout

That feels almost impossible now. Working from home, during the pandemic, every story feels personal.

It is no longer one patient who might remind us of ourselves, our family, or our friends and their struggles, it is every single one of them. Some may call this countertransference, which is a therapist's emotional reaction to the patient, but others might just say it is heightened empathy. Right now, we're facing the same struggles in our personal lives, too.

A 40-year-old patient managing her roles as researcher, nurse, and mother of two young children, says that she and her partner are trying to stave off resentment as they negotiate who takes on the new role of home school teacher. We understand it acutely because one of us (Stephanie) has grappled with the exhaustion of the endless small decisions of parenthood during a pandemic.

When a 21-year-old patient tells us he misses his friends and wishes he could see them or arrange a spontaneous party like he used to, we get it, because we miss our friends, too.

And, when we discuss uncertainty, existential dread and grief, over and over, we feel it too. We both know there are no simple solutions to these worries and decisions, each carries weight. It has, at times, felt like we are advising ourselves just as much as our patients.

In previous years, we would have days where we had less sleep and noticed our depleted energy in session, but we've never had to be so attentive to our energy levels as we are now. In July, we both found that our eyes grew heavy and sleepy by midday. Additional cups of coffee were just not cutting it. Naps, walks in nature and vacations became "must haves" rather than luxuries, as we worked to stave off burnout and compassion fatigue.

Therapists, Therapy, burnout
Therapists, Therapy, burnout
Dr. Stephanie Zerwas (left) and Dr. Jessi Gold are mental health professionals. They are experiencing first-hand the stress and pressure that is being placed on therapists during the pandemic.

We provide psychoeducation to our patients about how the sympathetic nervous system winds us up, and the parasympathetic system winds us back down, but we're working really hard to regulate ourselves too. Because we don't have experience providing therapy during a pandemic, sometimes we have to regulate our own reactions, in the moment, in sessions with patients.

We are practicing mindfulness, journaling, exercising, and trying to cope, just as our patients are. We also are failing at it, just as they are, and those days can feel frustrating. We know we are there to be a model of self-regulation and emotional wellness. Yet, even with these challenges, somehow we still show up and are present, because that is our job.

Our patients are more curious, though, as to how we really are doing. As all therapy has switched online and is done from home, they have more of a window into our personal lives than ever before. They don't want us to just brush them off and say a classic therapist-like response of "what makes you ask that question?" They actually are genuinely worried about how we are facing this stress.

There is the maternal patient who, being older than you, worries about you a bit like her own child sometimes, and who uses part of her appointment time to make sure you too are sleeping and taking care of yourself through the pandemic .

Or the young patient who has already known so much grief and loss in her short life and admits that she worries that you, her therapist, will be diagnosed with COVID-19 and will die. All of a sudden, your allergy cough in session takes on a brand new meaning.

Then they turn and say: "How are you? Really, how are you?" We are aware that part of this is because they want reassurance that you will be present and consistent in ways that they may not have had from the other figures in their life.

The answer to that question, though, is always a paradox. Admitting we aren't OK, normalizes it, and makes us all feel OK. By sharing that we know what it feels like to be vulnerable and confused, we can also model how to be strong and resolute. Yet, by sharing too much, it can feel like the safe space we have cultivated for them becomes too much about us.

Burnout in therapists and psychiatrists is not new, but there is something different with COVID-19 that we need to start talking about before the rush to mental health services becomes even greater and the burden to "heal" shifts solely to our shoulders.

We have to find ways to help mental health clinicians manage these unique challenges as home seeps into work and work seeps into home. Whether we call it compassion fatigue, burnout, vicarious trauma, or just plain old exhaustion, this crisis is going to require all of us to take better care of ourselves.

Yes, we can hold up those who hold up others, like the nurses and healthcare workers working with those sick with the virus. But sometimes we need to be held up, too.

We know that many mental health professionals may have been encouraged in training to seek help and maybe got busy or prioritized other things. But now, we should all be prioritizing ourselves, too. There may have been difficult periods before where we could block it all out and just do our jobs, but we can't this time. This time is different.

If we don't, we risk not being helpful or present for our patients, because we are not present for ourselves. The more we ignore it, the bigger it becomes, and the more burned out we feel. We might beat ourselves up for missing an opportunity for connection or making mistakes. We risk abandoning ourselves while trying to be there for others. We risk becoming depressed and needing treatment ourselves, too.

We believe that therapists everywhere need to recognize that we, too, have limits. No amount of self care or work-life balance is ever going to replace social safety nets or real systemic change.

No amount of extra hours, free services, or lost sleep is ever going to take care of everyone who needs it. It feels that a further wave of people with mental health issues is coming, thanks to this pandemic.

As therapists, we need to be sure while we serve who we can, we are also advocating for a system that works for the people who use it and those who work in it.

As mental health professionals, we simply have to stop setting ourselves on fire just to keep everyone else warm.

Jessi Gold (@drjessigold), MD MS is an Assistant Professor and the Director of Wellness, Engagement, and Outreach in the Department of Psychiatry at Washington University in St Louis.

Stephanie Zerwas (@sczerwas), PhD is an Associate Professor in the Department of Psychiatry, University of North Carolina Chapel Hill, psychologist in private practice at Flourish Chapel Hill, and founder of Project Parachute.

All views expressed in this piece are the writers' own.

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