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Therapists are under strain in COVID-19 era, counseling clients on trauma they're also experiencing themselves

"I can't be both a really worried human and a good therapist at the same time."
Image: A silhouette of woman with her head bowed, inside her head is an emotional man sitting at a computer screen.
Some therapists are feeling stressed as the coronavirus pandemic increases demand for their services.Chelsea Stahl / NBC News; Getty Images

Yuki Yamazaki makes sure her space is clean before a session, devoid of too many personal touches, as she begins virtual calls with her clients in her small one-bedroom apartment in Brooklyn, New York.

To accommodate the need for Yamazaki to create a private and confidential space for her clients in a space-limited apartment, Yamazaki's fiancé relocates to the bathroom to work, wearing noise-canceling headphones and using the toilet as a chair and a hamper as a desk.

Yamazaki, a psychotherapist and student, is one of thousands of mental health professionals adjusting to a new normal while demand for their services has increased during the coronavirus pandemic.

"It's really hard to maintain just work boundaries, because there's such a need and you feel like you want to give where you can," Yamazaki said.

With nearly 40 million Americans unemployed and more than 115,000 dead because of the virus, some therapists are feeling the pressure to take on more because they know the need for mental health care is more widespread than ever.

Vibrant Emotional Health, the company that administers the National Suicide Prevention Lifeline, also runs a Disaster Distress Helpline. The company said calls to the hotline increased by 338 percent in March as states began issuing isolation guidelines and the pandemic became a national emergency.

But mental health professionals aren't immune to the disruption caused by the pandemic. Therapists and counselors are facing the same anxiety, uncertainty and financial stress that are troubling those who seek their services.

Yamazaki, 29, a child of immigrants, went into the profession because she wanted to help people and work with communities of color where there may be disparities in access to care. She works in private practice three days a week and has a second job in executive function coaching while pursuing her Ph.D. And on top of that, she volunteers for New York's mental health hotline 12 hours a week.

She sees clients for about four to six hours during her private practice days, half in the afternoon and half after 5 p.m. and into the evening. Some clients have even asked to start having two sessions a week.

The world is experiencing a "unifying trauma" of loss and uncertainty, and mental health workers aren't exempt, Yamazaki said.

"Although for our clients it might be the first time they're really voicing and vocalizing this stuff, it's one of seven or eight times your therapist is hearing this, plus their own internal monologue of how they're doing," Yamazaki said. "And we don't have the same ways of breaking up the day that I think a lot of therapists do to maintain that sense of self to remain attentive or as attentive for each person."

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The coronavirus has been on Yamazaki's mind for what feels like forever, because her father is from Japan and she has family in Malaysia. But recently she has had to do her best to disengage from the news and her own worries on days she has clients.

"I can't be both a really worried human and a good therapist at the same time," Yamazaki said. "I have to kind of pick and choose."

Worries and personal anxieties take a back seat on days punctuated by appointments, the gaps filled in with paperwork, balanced with the work she needs to complete to present her dissertation this month. But Yamazaki does have very real personal concerns, about how the mental health industry will provide support for therapists and how practices will be able to keep the lights on as clients who need care the most begin to face financial distress.

Four of Yamazaki's clients who pay out of pocket for sessions have lost their jobs since the pandemic started. One of them has already had to stop sessions.

It is the never-ending cycle of wanting to help people while trying to figure out who will pay for it, she said.

"I think that's the last piece that's more relevant to me and my personal burnout, which is I'm a woman of color. I didn't come from a lot. I had to create a lot and take out a lot of money to be able to do the things I want to do and champion the things I want to do in mental health," Yamazaki said. "And that's really exhausting, because there's not a lot of money there. I have a lot of student loan debt and a lot of stress from my own life that this virus has impacted me as a human and therefore me as a therapist."

Yamazaki isn't alone in her concerns about how the industry will maintain the demand, Lisa Henderson, Southern region chair of the American Counseling Association, told NBC News. Mental health professionals all over are trying to balance the demand with a loss of income, she said.

"Just how do I take on more patients, fill that gap?" she said. "But then I can't abandon the people who've been with me just because they can't afford it anymore. That calculation is happening every day, I guess, in the terms of, you know, long term."

The financial concerns are just one part of a constantly turning wheel of what therapists and counselors are working with as they try to maintain the same standard of care while adapting to a new normal. It has been a significant challenge to navigate self-care while helping others, Henderson said.

"The other side of that question, though, of not taking into account that we have our own fears and our own pressures and those sorts of things, I think that's been sort of absent from the conversation, really," Henderson said.

Matthew Poon started his own private practice in New York City about a month ago, specializing in young professionals and marginalized communities, after eight years of working with young people in universities. The "hustle" of starting a small business amid a pandemic is twice as hard, Poon said.

"I know therapists are kind of seen as folks who can hold a lot of space and contain lots of other people's feelings, and I think that's completely true," Poon said. "I also think that we are experiencing the same levels of helplessness, the same feelings of anxiety and doubt and fear, and on top of that are holding spaces for other people. And so I think it's a tough job, too."

In normal circumstances, Poon would be able to rely on referrals to bolster his new practice, but it seems financial strains have limited those who might seek out therapy or have pushed therapists to do everything to hold on to their own clients, he said. Poon has been trying to reach out to potential clients in new ways, testing how young people engage with mental health tips over social media, in addition to holding his normal sessions through telehealth platforms.

He tries to practice what he preaches to clients, to check in with himself and create routines that ground him in the present, he said. But he also has found it helpful to redefine some of the normal boundaries between himself and patients by sharing some of his own feelings and concerns.

Poon, who describes himself as a "recovering optimist," wouldn't describe himself as burnt-out just yet, but he's certainly finding the job exhausting in a new way.

"It kind of feels like you're being asked to move a hundred miles an hour but you're also running through, like, molasses," Poon said.

Working through the anxieties and fears of other people means mental health professionals are consistently being exposed to the collective trauma of the pandemic, said Munib Raad, founder of Grounded Talk Therapy in New York City.

Raad said he tries hard to do more physically grounding activities, like YouTube workouts or taking his rescue dogs for a walk. He often feels like there's pressure to talk about the latest events with his husband, who is a physician, but he tries to create space away from the stress of the day as much as possible.

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But after a few sessions in a day, Raad said, he is "pretty beat."

"I noticed that bringing that into the room and saying, 'Hey, you know, this is hard for me, too,'" Raad said. "I do know that there is a shared experience and a universality there that you want to be accepted and acknowledged, even if it's painful."

Although his practice takes health insurance, Raad understands that there's a disparity in mental health care for people who need it most because it's often treated as a luxury for those who can afford to pay for what insurance won't cover. Since the pandemic began, about 30 percent of his clients have lost their jobs. He's lost some of his clients who pay out of pocket.

And yet Raad has still increased his sessions from five to six per day, which he said has been exhausting.

There's a certain pressure that comes when people are seeking care during a crisis, because the need for consistent mental health care to build coping mechanisms is rarely acknowledged during normal times, Raad said.

"Mental health is not some sort of a magic solution," Raad said. "It's actually sort of learning a new skill set and practicing it. You know, sometimes I think they expect mental health workers to miraculously cure something."

The pressure on mental health professionals during times of collective distress, such as the coronavirus, is especially troubling, therapist and author Lori Gottlieb said. The expectations are particularly difficult as therapists are often focused on the needs of other people without considering the need to take care of themselves, said Gottlieb, author of "Maybe You Should Talk to Someone."

Sometimes people feel guilt for even the smallest aspects of joy during times of great adversity, Gottlieb said, but it's important to create space for balance. Therapists in particular have to prioritize self-care and avoid running themselves ragged so they can be fully present for other people, even if that means making the unpopular choice to say no to taking on extra sessions.

"They don't realize that we therapists very much are on the emotional front lines right now," Gottlieb said. "And it is a crisis, and we are trying to treat it as much as possible."

Society needs a cultural shift to understand that just because therapists aren't in hazmat suits in hospitals or exposing themselves to cashiers at grocery stores, that doesn't make them any less essential in this pandemic, Gottlieb said.

"This is life or death for a lot of people," Gottlieb said. "People having suicidal ideation, people feeling desperate, people unable to function, getting very emotionally ill with anxiety, with loss and grief and depression, feeling like their whole lives have been turned upside down."