One of the many outcomes of the COVID pandemic to date has been an increase in the number of people coping with severe anxiety, stress, and depression. Psychiatrists and mental health professionals working around the clock to help these individuals are not immune to the uptick.

While struggling to support a growing caseload of patients – from relapses to first-time crises – clinicians are also trying to find ways to cope with unexpected personal challenges. Adhering to some of the advice often imparted to patients may be useful for these HCPs, but there’s more to it than that.

The unprecedented nature of the COVID pandemic has had a significant impact on the mental health community – both on patients and on providers. No matter their day job, Americans are grappling with lost resources, remote schooling, isolation, and overwhelming concerns about family members, friends, and themselves falling ill or dying. Not surprisingly, more and more people are presenting with mood disorders, anxiety disorders, and an increase in alcohol and drug use. A Kaiser Family Foundation poll conducted in July 2020 revealed that more than half of American adults feel the coronavirus has had a detrimental effect on their mental health.1

Compounding matters is that even before COVID hit the US, there was a shortage of psychiatrists. The US Department of Health and Human Services reported that 111 million Americans were living in areas with a shortage of mental health professionals before 2020, and the National Alliance on Mental Illness (NAMI) reported that only 43% of American adults with mental illness were treated in 2018.2 With growing demand for psychiatric and behavioral care, our mental healthcare system is more than just overtaxed; it is becoming a crisis of its own – with some specific impacts on professionals.

Coping with “Compassion Fatigue”

Many mental health professionals are experiencing “compassion fatigue,” according to Charles Figley, PhD, founder of the Traumatology Institute at Tulane University and a professor in the Tulane University School of Social Work, who was one of the first people in the field to use this phrase prior to COVID-19. “Compassionate fatigue is the inability to say ‘no’ to the needs of others,” Dr. Figley explains. He says that this can lead to burnout for behavioral health experts, and can cause some of them to leave their jobs – or the field entirely – if they don’t address it proactively. In the midst of COVID-19, this risk of clinician burnout is especially elevated, Dr. Figley points out – ironically, just when patients need mental health providers the most.

“Significantly more practitioners are working with clients/patients who are extremely afraid, and have greater needs for education and reassurance,” he says. When these practitioners find themselves in such high demand, they feel pressured to give more of their time and attention to the patients, leading them to work longer hours and put their own needs aside, in return for an outpouring of gratitude from the patients. While initially practitioners may feel good about their elevated and more appreciated role, without a regular break or making time for relaxation periodically, they may be unable to sustain the intensity of their new situation, he adds.

A New Kind of Work/Life Balance

In addition, clinicians are facing new demands on any prior attempts to balance their work with their home life. With teletherapy dominating the delivery of care, patients are essentially “in” the homes of providers at all hours of the day, making boundary-setting nearly impossible. In fact, since most patients can now “see” into providers’ homes via remote sessions, and providers’ family members and pets are often nearby, it can be harder for clinicians to protect their privacy and to compartmentalize their personal and professional lives. This can add yet another layer of stress for many practitioners and make their daily practice more complex.

Tess Brigham, MFT, BCC, a therapist who practices in the San Francisco area, agrees that work-life challenges have become more difficult to navigate on a daily basis. As a therapist, a wife, and a mother, she admits that it is challenging to master her roles simultaneously. With blurred boundaries, she is finding her day-to-day more stressful and often finds it hard to decompress.

“Being a therapist was already difficult before COVID-19, balancing work life and family. But now with everyone home [all of the time], it feels like I’m going from crisis to crisis with no downtime. I’ll meet with a few clients and then end a session to walk over to my son’s room to manage his meltdown over something that happened at school. I’ll then calm down barking dogs and listen to my husband complain about work,” Brigham says.

But she makes an effort to find her balance and tries to keep things in perspective. “These days, I take a step back and recognize my job isn’t to solve my patients’ problems or change their behavior; rather, it’s to help them gain more awareness of themselves and their thoughts and feelings and help them determine what they can do to manage their lives and work toward their goals,” she explains.

She adds that keeping her focus on supporting patients in this way has enabled her to stay strong as things are evolving.

We all have to remember that, “Therapists are human beings and, therefore, are experiencing the same stresses and fallout as their patients,” points out Gail Saltz, MD, a clinical associate professor of psychiatry at the NY Presbyterian Hospital Weill-Cornell School of Medicine and host of the “Personology” podcast broadcast by iHeart Media. Even though teletherapy has long been a mainstay for therapists, it can also be “more taxing, and less satisfying, than seeing patients in person, and this adds to work stress,” Dr. Saltz says.

For Brigham, it isn’t just the logistics, though, that can be challenging. She points out that she and many of her colleagues also feel overwhelmed by having to find ways to genuinely help their clients with the current restrictions in place. “Many of my clients are experiencing symptoms of depression and anxiety, yet many of the recommendations I make for someone who is depressed are no longer viable. You can’t tell your clients who are isolating themselves, ‘You need to interact with people more,’ or ‘Let’s talk about who you can reach out to, to grab dinner.’ This is what is so hard about this pandemic – the things we need to do to improve our mental health are no longer available to us,” Brigham stresses.

 

HCP Burnout By the Numbers

The WHO has defined burnout as an occupational phenomenon caused by “chronic workplace stress that has not been successfully managed.”1 Symptoms include:

  • emotional exhaustion.
  • a lack of engagement with and/or negative feelings about one’s job.
  • a decline in work performance, efficacy, and/or sense of professional accomplishment.

Burnout is associated with increased risk of physical and mental health problems,2 and while it affects just over 28% of all workers,3 prevalence is significantly higher among healthcare professionals.4-11 For instance, an estimated 42% of physicians reported being burned out, according to a survey conducted in early 2020 (ie, before the pandemic).12

While problems such as insufficient staffing13and underfunding14 are familiar to most HCPs, psychiatrists and mental health professionals also regularly work with patient populations that may be more likely to resist treatment,15,16 or behave violently toward themselves or others – pushing their stress and/or anxiety levels even higher.17,18 In fact, it was psychologist and psychotherapist Herbert Freudenberger who first described burnout in the scientific literature in the 1970s after realizing he and his colleagues had experienced the condition.19



Here are a few recent stats across the field:

        • 78% of the more than 2,000 psychiatrists surveyed on the “state of our profession” and published in the American Journal of Psychiatry scored 35 or higher out of a possible 64 on the Oldenburg Burnout Inventory (OLBI), indicating “a positive screen for burnout.”20 The mean score was 40.4.
        • More than half of 9,000 psychotherapists reported “moderate-high levels of stress and burnout.” In a 2018 review of the literature on risk factors associated with burnout.21
        • Between 21% and 67% of mental health workers are likely experiencing high levels of burnout. 22,23
        • Nearly three-quarters of psychiatry residents reported either moderate or high levels of burnout on the OLBI in 2019.24 (See how two residents are managing right now in our Resident’s Corner column.)
        • 47% of social workers say they have experienced significant job stress and emotional exhaustion, compared to just 17% of the general population.25
        • Almost 35% of psychologists reported emotional exhaustion in a 2018 review – exhaustion is the most commonly cited component of burnout.26

    Notably, all of these studies were conducted prior to the onset of the Covid-19 pandemic, which has only increased the strains on healthcare workers,27,28 including mental health professionals and their risks of developing burnout.20,29


     

    –Sidebar reported by Elizabeth Michaelson Monaghan

    …..

    Finding Addiction Issues At Work – and At Home

    When it comes to self-care for providers, making smart choices for yourself should be on the list of effective strategies. Ned Presnall, LCSW, owner/director of Plan Your Recovery, an outpatient counseling center in Saint Louis, Missouri, and a professor at Washington University, says that patients and mental health providers who are grappling with addictions can be especially vulnerable right now and need to take steps to protect themselves. “As we’ve all become more isolated in the days of COVID-19, people in recovery who rely on their social connections to help prevent relapse are at risk for returning to addictive substance use and addictive behaviors,” he says. This can be stressful for both the person in recovery and also for the therapist or counselor who treats them, too.

    With common coping mechanisms like exercise and social connection severely limited or even non-existent right now, more people (not only those with addictions) are “at risk for seeking out escapism through substances to temporarily leave this feeling behind,” Presnall says.

    A Recovery Village survey of 1,000 US adults just two months after the pandemic hit the country, showed higher rates of drug and alcohol abuse, including 18% reporting a significant increase in alcohol consumption, and 36% in increased illicit drug use. Reasons given for the increased use: 53% said stress, 39% said to relieve boredom, and 32% said they were trying to cope with mental health symptoms, such as anxiety or depression.3

    Mental health providers can also get caught up in escapism. “They tend to be people who empathize deeply with the people who they work with. So they take on their own problems, plus those of their clients and patients,” explains Presnall. This means that some providers can be at high risk for relying on substances to cope, in some cases fueling their own addictions. Recognizing the danger can be an important step in prevention.

    What Other Therapists are Doing to Avoid Burnout

    These clinical challenges, coupled with trying to be a person outside of work, can magnify providers’ risk of experiencing emotional and occupational exhaustion (ie, burnout). This makes it important to include opportunities for self-care on your daily schedule and – just as your tell your patients – to ask for help when you need it.

    “Therapists sometimes need mental health care just like everyone else, and during this time I do think more therapists are finding themselves in need, just like many other healthcare providers who are being overstressed, burnt out, in fear, and anxious about the uncertainty of the future,” Dr. Saltz says.

    But she admits that asking for help can be difficult for healthcare providers – and especially for mental health practitioners, who are conditioned to be there for others.

    “One’s own judgment is affected by anxiety and depression, and you need an objective outside professional to help you. Therapists also often enough don’t follow the very self-care they prescribe. So in this sense, following your own advice for what to do at home is important,” Dr. Saltz says.

    Jaren Doby, MSW, LCSW, with Novant Health in Charlotte, NC, agrees that “practicing what you preach” can help therapists. Just as Dr. Saltz noted, it all boils down to integrating a consistent self-care regimen – which Doby has applied to his routine and found to be very beneficial.

    “Exercising and being physically active have remained huge coping skills for me. I also engage in healthy conversations with my friends and peers regarding an array of topics. I find it motivating and encouraging to talk about the issues that are going on in the world right now,” Doby says.

    Such conversations help him to express his feelings and gain a broader perspective. “It is through coming together and having a conversation regardless of view to promote positive approaches and change as an advocate that keeps me strong,” he says.

    Doby also points out that self-care can’t be a one-size-fits-all approach. Just as you may see in practice, what may work for one person does not always work for another person. Focus less on what you do and more on the doing. “Take time to explore what helps boost your mood in a positive way and what helps you to relax. I encourage everyone to identify the supports that are in their lives as well…family, friends, and colleagues,” he adds. “As providers of any kind, we are in the business of helping others, so please make sure that you are helping yourself as well. If a self-care routine is absent in your life, I encourage you to take the time to create and implement one.”

    More Self-Care Strategies to Cultivate COVID Resilience

    Research shows that psychiatric and mental health professionals can build their resilience to meet the challenges that currently exist by engaging in some strategic steps, says Diana Concannon, PsyD, dean of the California School of Forensic Studies at Alliant International University. She offers the following tips – which you may wish to share with your patients as well:

        1. Adopt a positive mindset toward stress: Studies on stress show that those who chose to view stressful situations as motivating experience less depression and anxiety, higher energy levels, better professional performance, and greater life satisfaction. Choosing to view a busy day as a challenge in which we “get to engage,” for example, rather than “have to get through” transforms our experience for the better, and bolsters both well-being and resilience. You might try mindfulness as well.
        2. Tap into compassion satisfaction: It’s important to connect with the meaning and purpose behind acts of compassion. This can be facilitated by setting aside even just 20 minutes per week to write or remember the number of times you received positive feedback during the week — words of gratitude, a smile, an expression of relief, or comfort as a result of your intervention. These moments are fortifying and will remind you of the reasons you entered the mental health profession in the first place.
        3. Engage in self-support activities: This includes connecting with family and friends, eating a balanced diet, exercising regularly, and getting enough sleep. During this time, it is also important to have flexibility and gentleness around these routines so that they remain a kind source of self-support and not a source of stress or a burden.
        4. Start or join a peer-support group for some like-minded support: See how fellow psychiatrist Peng Pang, MD, director of child and adolescent psychiatry and assistant professor at Hofstra University’s Northwell School of Medicine in New York, started peer support groups when COVID hit her practice head-on.

    Always Seek the Silver Lining

    Many mental health professionals also agree that it’s important to look for the good among all of the stress and sorrow that has come with COVID-19; for many providers, identifying the silver lining can help them stay grounded.

    Says Doby, “Being a mental health expert at this time is an important undertaking given the array of things that are happening in the world. Personally, I have taken it as an honor and a privilege to be in a position to help those in need in any way that I can… It continues to be important to be able to remain ready to address the needs of those we serve.”

    In the same vein, Brigham says that when things feel overwhelming, it can be helpful to revisit why you got into this field, to find your passion for helping others, and to validate your own feelings, so you will be able to care for your patients’ needs.

    “Continue to focus on what is within your control and remember that, just like for our clients, this ‘crisis’ is here to teach us something about ourselves and about the world. We’re at a point in our history when big things can happen, and while it’s hard to see everything out in the open, it needs to happen to get us to a better place – so what’s your ‘better place’? What do you want for yourself personally, for the people around you, and the world you live in?,” asks Brigham.

    If you can answer this question, she believes it may help you find the resilience you – and your patients – need.

References
Last Updated: Nov 17, 2020