What It’s Like to Provide Mental Health Services During a Pandemic

In our series What It’s Like, we speak with people from a wide range of backgrounds about how their lives have changed as a result of the COVID-19 pandemic. For our latest installment, I spoke with Jessica Brown, L.I.C.S.W., a mental health professional in Washington, D.C., about what it’s like to provide mental health services during a pandemic.

On top of her work in private practice providing therapy for people, Brown works at a hospital emergency room admitting psychiatric crisis cases. She also works as a program manager interfacing with multiple mental health and child welfare systems. Between these three roles, she’s seeing firsthand many micro and macro impacts COVID-19 is already having on the mental health workforce. Here are some of the trends she’s noticing—and how she’s dealing herself. (The below exchange details Brown’s personal experience and perspective providing mental health services. She is not speaking on behalf of any of the organizations she works for. Her responses have been edited and condensed for clarity.)

SELF: Let’s start with your emergency room experience. What does your role typically entail?

J.B.: I work in the emergency room setting of a local county hospital where we have patients that come in expressing suicidal ideation, homicidal ideation, forms of psychosis, and more. In those cases we’re required as the counselors to do evaluations and assess the medical necessity for inpatient admission. In a lot of ways, my role has stayed the same. Non-coronavirus emergencies are still happening.

How has the day-to-day changed?

The first challenge that we’ve seen a lot is, of course, the shortage of personal protective equipment. Eventually we were required to get fit-tested for an N95 mask, and since then we’ve been required to utilize the same mask every single day, every shift. We’re required to take it home, sanitize it, and bring it back. Of course, I can only speak from a counseling perspective. I don’t know if that’s the same expectation for the doctors and nurses.

Are you seeing any trends in why people are coming into the emergency room?

I’m definitely seeing a spike in suicidal ideation. I haven’t had a lot of experiences of clients saying explicitly they’re in crisis because of everything going on, but I can see a shift. A lot of these patients already have existing mental health conditions and have experienced suicidal ideation for years, and now suddenly they’re put in a situation where they have to isolate, they don’t have access to resources, they don’t have support networks, they feel alone and hopeless. That’s how suicidal ideation becomes exacerbated.

How worried are you about coming in contact with people who have COVID-19 in your role?

I think the doctors try to do their best to inform the rest of the staff of who might be under investigation and who has tested positive. But sometimes those things just slip through the cracks. There’s also not enough equipment to test people who are asymptomatic, so I just have to go in there and do assessments. You don’t know who has it and who doesn’t, so how can you really feel safe?

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I think that ties into my therapy practice too. Some of my clients are experiencing potential COVID-19 symptoms, but they’re scared to go to the hospital because they don’t want to put themselves at risk by even being there. As a therapist, I’m trying to talk my clients down from their anxieties and be that support for them, but I have the same fears. It’s challenging trying to feel like an expert or a professional when you’re kind of on an equal level.

Speaking of your therapy practice, what does your new normal look like?

We fully transitioned to tele-health about four weeks ago. We took early precautions because we see a lot of university students and a lot of families, so we wanted to eliminate any chance of spread. The transition has been hard for our clients. I’ve had a few clients who don’t want to do tele-health, so I lost a few clients and have put others on pause for now.

What challenges does tele-health pose?

I think the biggest challenge of tele-health is that you’re taking people out of a safe space. We create therapy offices to be a safe space for our clients. It gives them 50 minutes of respite from the real world. Whether they’re mothers, fathers, spouses, students, what have you, when they walk through that threshold, this is like their oasis where they can just decompress and relax. And because they don’t have that at this moment, you can see the shift. They can’t relax as much because now they’re at home, where maybe their kids are hiding in the other room while they’re doing their session or they’re taking their session in the car because that’s the only place they can get privacy. It’s an unfortunate transition.

There’s a lot that’s lost through a computer screen. Body language can tell you a lot, and you don’t see that. You’ll also hear a lot of therapists say that we sit in the silence, especially when our clients are recounting things that might be traumatic or emotional. We always allow space for them to process in silence, but it feels different when you are in a room with somebody. You usually have that physical connection of “I’m still here and I’m with you, but I’m allowing you to process this.” It doesn’t feel the same through a computer screen, because on their end they’re processing alone in their environment.

Transition to teletherapy aside, what other challenges are coming up?

I have fewer answers. A lot of times with anxiety, we can always tell our clients, “The situation you’re anxious about happened or it’s going to pass.” There’s usually an end goal we can work toward together. But right now we’re in a situation where we don’t know when it’s going to end or what the world will look like when it does. The coping skills that I usually recommend don’t apply. For example, I’ve recommended guided meditation apps like Insight Timer or Calm or Headspace to a lot of clients, and that worked for them for, like, the first two weeks of sheltering in place. But now we’re over a month in, and it’s not working anymore. So we’re constantly evolving and trying new things to see what’s going to work, because sometimes that one coping skill is not enough.

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How has this all impacted your own mental health?

Working through a pandemic has been a challenge for my personal mental health. I am experiencing many of the same feelings of anxiety, frustration, and helplessness as my clients. Helping them to navigate through those feelings has felt like a struggle as I am trying to process my own feelings around living through this pandemic as just a human and not a therapist. It almost feels hypocritical when you’re advising people how to get through this. Our own mental health goes onto the back burner. I’m not implementing those same things I’m advising my clients to do.

Boundaries are also blurring more. When I’m in my office, I’m a therapist, and when I go home for the night, I can take off that hat and hang it up—I’m in Jessica mode and I feel like I can breathe again and just focus on myself. But when you’re working from home, everything seems blurred. It almost feels like you’re welcoming your client into your home and vice versa. Usually, that’s something that would never happen. It’s hard to keep it all separate.

How are you adapting your practice to adjust to these challenges?

I find myself being more transparent with my clients and just saying things like, “I’m completely with you. I understand what you’re going through.” Typically, therapists try to shy away from self-disclosure, but I find myself being more open with my clients. Like, “This is what my husband and I are doing. This is what’s working for us. Maybe you can try that too.” I’m trying to roll with the punches and allow my clients to acknowledge that I am also human. I’ve never portrayed myself to be all-knowing with my clients, but more than ever I’m very transparent that I’m on my own journey just as much as they are. I’m right here with them in the trenches trying to figure this out.

What concerns do you have as a therapist about the mental health consequences of this pandemic?

COVID-19 is already having an impact on local community-based organizations and mental health treatment centers. Many organizations are having challenges adapting to a fully integrated tele-health model as it can be very costly to ensure proper HIPAA compliance and encryptions. Some agencies are simply not able to accommodate the needs of their clients, causing gaps in services or treatment. Also, some organizations have already been forced to permanently close as a result of economic hardship from COVID-19, creating challenges for families to access or maintain necessary services.

This situation is constantly evolving, which unfortunately creates significant challenges in identifying some sense of stability.

How are you staying optimistic through all of this?

Despite the challenge, I am constantly trying to find the bits of joy in everyday life, whether that’s enjoying the sunshine or the rain, finding gratitude for things like remaining employed, dedicating time to learning new skills, or even just spending much-needed time with my husband.

The pandemic has afforded us the opportunity to learn more about ourselves and how we manage an ever-changing world. It forces us to explore and process our thoughts and feelings more deeply, and allows us time and space to learn or unlearn behaviors. There is so much beauty in seeing quieter streets, clearer skies, and the generosity of neighbors or people you’ve never met. I think overall the pandemic has shown us that we really do rely on one another and taught so many of us how to be human again.