‘It’s OK to not be OK’: For clients’ mental health, and their own, therapists managed intense new demands

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Over the course of the coronavirus pandemic, psychologist Carrie Spindel Bashoff says, she’s received more requests for therapy appointments than ever before.

As COVID-19 was beginning to take hold last year, stay-at-home orders halted sessions nationwide. But in the last six to eight months, many therapists in the region have had Spindel Bashoff’s experience: Requests for mental health appointments have increased, to the point where there’s more demand than supply. They say that’s because the pandemic has heightened anxiety and depression, and racial and political unrest is also compounding clients’ stress.

Though some retired clinicians are reentering the workforce to meet the need, many psychologists are still increasing their hours and, in some cases, referring clients to others. For example, Spindel Bashoff, a New Jersey psychologist, has taken a few more clients on to her already full schedule, and has had to turn some people away.

“There’s a lot of guilt of having to not be able to take on a new client. Then all the people we typically refer to, they’re full too,” she said.

In Haverford, in suburban Philadelphia, Ariane Thomas is facing a similar experience at her private practice.

“I’ve noticed clients who I hadn’t seen for quite a number of years reaching back out, because of the intensity of stressors that everyone has been experiencing. I think certainly the pandemic, and the racial unrest from last summer and continuing, and the stress of having to have some conversations around the racial unrest and the racial issues … Having to sit down and have those conversations has been quite demanding on our emotional resources,” said Thomas, who also is a professor at the University of Pennsylvania.

“In the past, there have been plenty of people who have reached out simply for wellness and maintenance, or just because they wanted the opportunity to process work stress. Now, all of those things are still real and true, but the stressors and the symptoms that people are experiencing are exacerbated by the pandemic, the racial unrest, the intensity of the election, and the way the election dragged on, and the fallout since the election, the attack on voting rights. It feels like it hasn’t quite let up. And as a result, neither has the request for support.”

Mental health professionals are trained to not internalize their clients’ feelings, but that’s been more difficult during such a stressful year, Spindel Bashoff said. The emotional, physical, and financial tolls of the pandemic have hit her clients — about 75% of whom are adolescents — hard, and it weighs on her shoulders, she said.

“I think the intensity of anxiety and depression has gone up a notch, which I think makes the workday much more intense,” Spindel Bashoff said. “I find that my brain is constantly going, and I’m not stopping and having enough time, or effectively refueling and calming my brain down. And it’s very sad to see people truly suffering, and not really being able to answer when this is going to be over.”

The stress is compounded by her own COVID-related anxieties. During the beginning of the pandemic, Spindel Bashoff counseled a client whose parent was hospitalized with the coronavirus. At the same time, her own parent was being treated in the hospital for the virus.

“If a client is going through a tough time that you yourself are actively dealing with, it’s hard to keep your personal reactions out of it,” Spindel Bashoff said. “And I find that to be a struggle, especially when my own family was experiencing some of the same difficulties that my clients were. It took a lot of energy to keep myself pulled together, and be very objective, and keep my clients as the priority of that moment, and keep all my stuff in until the end of the day.”

Combine a busier schedule, dealing with clients’ increased trauma, and handling their own pandemic-related stresses, and it can lead to feelings of burnout — or compassion fatigue — among mental health professionals.

Burnout, a word coined in the 1970s, is caused by the stresses associated with “helping” jobs, such as those in health care. But other overworked employees and homemakers can experience burnout, as well.

“I think for me, it’s working, working, working, working with little time to refuel,” Spindel Bashoff said. “Our mental energy, our physical energy, it’s as if it’s gas for a car. And … the more we work and our gas tank depletes without the time to refuel, that’s when burnout for me exists.”

Symptoms of burnout for anyone can include exhaustion, alienation from work-related activities, and reduced performance when handling various tasks. People experiencing burnout might also notice changes in appetite, sleep patterns, or concentration and motivation. They may feel more irritable, anxious, sad, or fatigued.

Therapists say they’re trying to strike a balance between meeting the increased demand for their services and managing their schedule in a way that does not lead to burnout. It’s a crucial balance, because if they don’t get a grasp on self-care, it can reduce their ability to properly care for their clients.

“If you’re coming to a session and you feel like you’re rested and you’re emotionally available, then you can have a little bit of — the term I use is rational detachment, that you can hear the person talking, you care, you care deeply, but you don’t feel overwhelmed by it,” said Laura Epstein, who practices in Rehoboth Beach, Delaware.

“It’s definitely more challenging during a pandemic. The types of stress that people are under is so high, and the level of stress that we’re under is so high. That’s where it’s really important to be keeping a really good eye on your own stress level, so that you’re available for your clients.”

Counseling during a pandemic

There are about 12 people on Epstein’s waitlist, and she turns away about five people per week. New clients have waited about six months for an appointment, so she encourages people to accept referrals to other therapists.

“I think it takes an emotional toll. You go into this field, you want to help people. Some of the people really seem like they really need to talk to somebody — that is hard,” Epstein said.

“I’ve been very self-reflective and mindful about how many hours I can work, and to remind myself that if I work more than I really know I can, I’m not going to be able to help anybody,” she said. “But that feeling with the phone call that you have to disappoint somebody — you definitely feel that.”

Keeping an eye on her schedule, and having a supportive husband, family, and friends, have prevented burnout, Epstein said. But that doesn’t mean this past year has been easy.

“I don’t personally feel like I’ve experienced burnout, but I definitely think that I have seen times where I felt like, ‘OK, you need to keep a better eye on how you’re handling this. You need to make sure you’re taking time for yourself, take some time off, take a few days off,’” Epstein said.

“Typically, not during a pandemic, if you’re meeting with clients, some of them are going to be having a difficult time and some of them are going to be doing well. And there were times during the pandemic where every single person you were talking to was in crisis or close to that,” she said.

“Maybe I was stressed, maybe I was worried, ‘Is someone in my family going to get sick? Am I going to get sick?’ And so, you’re talking to people who are severely stressed — and you are personally stressed as well,” Epstein said. “To come home at the end of a very long day and then maybe you’d have clients call you that night in a crisis … you’re just trying to wind down for the evening, but then you still have more work to do.”

Mental health professionals are human and experience pain and hardships, just like anyone else. But many psychologists say this last year marked the first time therapists experienced the exact same problems at the exact same time as their clients.

Ariane Thomas said the past year challenged her self-care in ways she had never experienced before in her entire career.

“I am a single mother of a middle-school boy, as well as being a caregiver for an aging parent. So that, in addition to being a Black woman, a professional, and a helping profession at that, I felt like I was giving a lot of myself outward, I was giving myself to the people I care for, to the people I teach, to the people I nurture, to the people that I provide services for. And what I didn’t feel like I was doing was taking enough good things in to sustain,” Thomas said.

“But I knew that this was different, this year felt different. I think for all of us, it just was unprecedented in terms of the experiences, and the way that we had to dig deep into our resources and into our reservoirs of resilience,” she added. “I had to ask for help and get some good things from other people. I had to ask for support. I had to ask for guidance when it came to some of my more challenging cases, and seek consultation on those. That’s the ethical and responsible thing that I needed to do as a professional. And I did it. And I also needed to do it as a human being.”

Peggy A. Rothbaum, who practices in North Jersey, said this new pandemic territory reminds her of the challenges of 9/11.

“When I woke up on 9/12, the first thing I thought was, ‘Wait, I have to find a psychologist who has experience dealing with this, so I can get some extra supervision.’ Well, nobody had any. It was new to everyone,” she said.

It can be helpful to share an experience with a client, but mental health professionals must not let their personal lives affect how they provide care, said psychologist Marla Deibler, of the Center for Emotional Health of Greater Philadelphia in Cherry Hill and Princeton.

Deibler’s practice of 25 clinicians has reached maximum capacity, with about 250 people on its waiting list. She currently sees more clients than normal, and is working about 60 hours a week between patient care and practice management.

“I think it can be very useful for clients to understand that we’re humans too, and we’re going through this as well, and that we can share a little bit of what that’s like,” Deibler said. “But … it’s important for us to keep our own stuff in check, and separate ourselves when necessary, because if we’re too close to the situation and we’re too caught up in our own processes, we’re less able to help other people.”

Yet the pandemic has forced her to disclose some of her own responses to it when that’s beneficial to the client.

“We treat a lot of obsessive-compulsive disorder. And throughout the pandemic, those with contamination concerns have really been heightened because of the changing way in which we view contamination right now,” Deibler said.

“Whereas I would never in the past give my own disclosure about my own practices, I am now sometimes, as a frame of reference, if a patient asks me, ‘Are you wiping down groceries now at this point? Because I’m getting caught up in wiping down groceries,’ I might say to them, ‘Well, let’s look at what the CDC says … they’re not recommending wiping down groceries at this point. And personally, in my life, I’m not wiping down groceries.’”

Practicing self-care

Mental health professionals have self-care routines to prevent burnout. But many of those routines — like going to group fitness classes or meeting with friends and family at a restaurant — have been disrupted. The winter was particularly difficult, because it was too cold to engage in outdoor activities that are safer.

That made preventing burnout more challenging. Still, mental health professionals say they’re finding new ways to handle stress — whether it’s meditation and mindfulness, taking bubble baths, or going on bike rides.

“I think when the pandemic first started … It was a little bit of a break, and I spent more time with my family, said George James, a marriage and family therapist at the Council for Relationships in Philadelphia. “Then it got to a place where I was just seeing a lot of people, and the hours were really long. And I realized that I wasn’t putting any boundaries in my schedule. And then I changed that to where I can have consistent dinner time, consistent time with my family, and that made things a lot better.”

“Before the pandemic … I would take a break or go on a trip — something that would help me recharge and be fresh for my clients. But with the pandemic and trying to be safe, I didn’t have those trips,” added James, who also is a professor at Thomas Jefferson University.

“And then I was able to figure it out, and that really made a difference,” he said. “I remember just taking a day trip with my wife, and we just drove down to Baltimore and back. We went to the arboretum, and no one was there, and we got to walk around the harbor on a day when there was hardly anybody there. And that just was amazing for me and my ability to be present for my clients.”

Many of the therapists interviewed for this article said that they’re in a position to practice what they preach, but that those skills have been used more frequently this past year.

“Sometimes, we can work ourselves too much and we don’t pay attention to our own basic needs. So making sure that we eat well, exercise, get sleep … practicing self-compassion when things are hard. Things are hard sometimes — and that’s OK,” Deibler said.

Rothbaum said over the 30 years she’s been in practice, she has paid to confer with a senior psychologist. It’s an opportunity to talk about any stress she feels. Charity work also has given Rothbaum peace of mind. During the beginning of the pandemic, she began raising money from artwork she does, to give to The Elizabeth Coalition to House the Homeless, a nonprofit. She also started to deliver face masks.

“The stresses are there, and every once in a while, it gets to me where I think, ‘Oh, my God, we’re in the middle of a global pandemic.’ So, yeah, the stress is there, but I think that because of the ways I’ve developed to manage it, I’m able to minimize it,” Rothbaum said.

The future of mental health and therapy

Many mental health professionals believe the demand for therapy will extend well beyond the end of the pandemic.

“I believe that we don’t know the full impact of the pandemic, that many people are still in survival mode, and that’s when people don’t seek care,” said Deirdre Waters, who has a private practice and a nonprofit, the Behavioral Health Institute of Monmouth County.

“So all the people who are really kind of living day to day, coping with the devastation of loss and financial concerns, rising unemployment — there’ll be an increase in care. Also, we don’t fully know the consequences of social isolation and how it has impacted our elders and adolescents,” Waters said.

But mental health professionals also say they hope that the light shed on mental health during the pandemic will lead to increased acceptance of mental illness and getting therapy.

“I noticed, for instance, this one professional football team that’s supporting mental health with an ad that’s saying, ‘It’s OK to not be OK.’ That’s huge,” said Reading psychologist Jeffrey Sternlieb. “It gives people some permission to normalize the reaction.”

There’s also been a greater push to increase access to mental health care, the therapists interviewed for this article said.

Mental health professionals want lawmakers to reduce restrictions around providing therapy across state lines. Depending on state law, many psychologists are licensed solely in their home states. Even if appointments are via telehealth, they can only provide therapy for clients who live in the same state as one in which they are licensed. Interstate inter-jurisdictional legislative agreements would allow them to practice across state lines if they and their states were part of a compact, the therapists said.

Mental health professionals also hope telehealth will continue once the pandemic is over, as well as increased reimbursement, so they can afford to accept in-network insurance carriers.

Though the demand for therapy exceeds availability, telehealth has improved access — especially in rural areas, and for people with transportation issues.

“Historically in this country, we undervalue mental health. Oftentimes, it’s something that we don’t think about unless we absolutely need it. And then we’re stunned that our mental health benefits may not be equal to our medical benefits, or we don’t have the same kind of standards of care,” Marla Deibler said.

“I think we’re a long way off, unfortunately, from getting there to ensuring sustained coverage,” she said. “Insurance companies right now are, for the most part, allowing telehealth. Some of that is based on federal regulation. Some of that is based on state regulations, which can vary. Unfortunately, what we see as a general trend, though, is that insurance companies have not quite caught up with the push for flexibility to use telehealth as a site of service permanently, not just during the pandemic.”

Peter Economou, an associate professor of psychology at Rutgers University, thinks insurance companies will have no choice but to bend to the demand of telehealth.

“I’m hoping that we’ve shed enough light on the need for this, that legislation will prevent [insurance companies] from being able to [end telehealth],” said Economou, a sports psychologist who also has a private practice. “I’m hopeful that insurance companies are dissuaded from regulating or preventing telehealth because it is a 21st-century mechanism.”

George James, of the Council for Relationships, said that while the pandemic and the increased demand for services has led to burnout among some mental health professionals, this past year has also been very rewarding.

“Knowing that as a clinician, I can be there for people during a really tough time and support them and be there for them, laugh with them … It also felt really good that this is what I was born to do, this is a part of my purpose,” he said.

He’s hoping others will be inspired to become mental health professionals as the discourse around the importance of mental health increases. That too will help meet the demand, he said.

“For a long time, people have minimized the importance of mental health. And we’re seeing across the board … that mental health is important. So I’m hoping that the conversation will be there. I’m hoping that more people will enter the field,” James said. “I think it starts with being able to say that mental health is important … more people from different backgrounds, different class levels, not only go to therapy, but have access to therapy. That continues to let people know that this is a job and a career that is not going anywhere.”

It’s OK to not be OK

Thomas recommends that professionals who are experiencing burnout seek support from friends and family. She said people should lend their support to others as well.

“I’m seeing it in international students, and especially those of Asian backgrounds who are experiencing heightened levels of fear and stress around the acts of violence towards Asian folks in our communities, Black and brown people who are feeling retriggered and retraumatized by the start of the [Derek Chauvin] trial. All of that is occurring within the context of an ongoing pandemic. Children are lying on the ground at the border,” she said.

“Everything is just kind of in flux and emotionally intense. And as a result, I think the only responsible thing to do as a professional is to make sure that you are taken care of, so that you can continue to show up the next day and the day after that to do your work, to have a long career and to really affect lives and support others.”

Peggy Rothbaum advised that anyone who is experiencing burnout — or any type of stress  — fall back on what has helped them cope through hard times in the past. She also suggested connecting with others, taking online classes, doing yoga, exercising, or gardening. If people still feel overwhelmed, they should seek professional help, Rothbaum said.

The American Psychological Association has a provider database. Some organizations, like the International OCD Foundation and the Anxiety and Depression Association of America, have databases for specialties. Local psychologists associations, like the Delaware Psychological Association, the Pennsylvania Psychological Association, and the New Jersey Psychological Association, also have provider databases.

People also can receive recommendations from friends or referrals from their physicians. Therapists said it’s important that people research the provider, and choose one with whom they have a strong connection.

Eileen Kennedy-Moore, who practices in Princeton, said it’s important that people understand that it’s OK to not be OK.

“There is that kind of an idea out there that we should be grateful. It’s like, ‘I’m not allowed to feel bad because at least I have a job and at least I’m healthy.’ This has been a huge strain on everybody, and the losses, big and small, that we’ve all had to endure are hard. I think it’s OK to acknowledge that, rather than think that, ‘Oh, I must be positive at all times.’ I think that that’s not fair, and it’s not kind to put that kind of pressure on yourself,” she said.

“Psychologists’ favorite word is ‘and.’ We can be grateful that maybe we have a job and we’re healthy right now, and, at the same time, be really fed up with all the restrictions that we’re having to live with, and sad that we don’t get to see our grandparents the way that we would like to. And I think that’s a lot kinder to ourselves than to put this pressure of, ‘Oh, my gosh, I have to be positive, and I have to be grateful and I have to be resilient.’”

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If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255. The hotline is staffed 24/7 by trained counselors who can offer free, confidential support. Spanish speakers can call 1-888-628-9454.