Art by Valerie Thai

Ashwin Mehra’s mother had COVID-19 in Mumbai. In Toronto, he wasn’t sleeping well.

Before the diagnosis, even the thought of Mehra’s parents falling sick in India with him stranded in Toronto would keep him up at night. If they died, he knew he wouldn’t be able to attend their funerals.

And so, when his sister called one September weekend and said that their mother had tested positive, his worries found something to cling to. He ran through all the possibilities of what could happen in his head, barely sleeping for two nights. He reached out to a friend who was a travel agent to see if he could fly into Mumbai or Delhi, but eventually decided against it: India’s COVID-19 cases were rising and there was no guarantee he wouldn’t catch the virus. Continents away, he realized there was no way that he could help.

In his counselling sessions that week, Mehra, a clinical psychologist who works for a private practice in Toronto, listened to his clients’ worries around COVID-19—such as their own aging parents falling sick—unknown to them that Mehra could relate to those worries so intimately. One minute he  was fine, and the next, he would be reminded of his mother—it was, for him, a week from hell.

To be a therapist, says Mehra, is to sit with people’s pain, to watch and listen while thoughts and emotions run their course. But in a global pandemic, while his own anxieties run rampant, that’s become harder to do.

On a May 2020 episode of The Social Work Podcast called “Shared Trauma in the COVID-19 Pandemic,” Carol Tosone, a therapist, says that on the morning of Sept. 11, 2001, she was in a session with a client named David. He was comparing a recent date to his overbearing mother when, at 8:46 a.m., a plane flew overhead their office in New York City, rattling the windows. It wasn’t until Tosone stepped outside that she realized the enormity of what had happened: her office was a mile away from the Twin Towers and she could see everything burning, a trail of grey ominous smoke billowing from the North Tower.

In the weeks that followed, Tosone found herself dreading her sessions with David, worrying that 9/11 might come up. Reflecting on her own experiences, she writes in a 2011 article in the journal Traumatology, “Was it his traumatic reaction
or mine that I was sensing?”

As a professor of social work at New York University, Tosone is one of few academics whose research has shaped understandings of shared trauma or shared traumatic reality. During times of war, natural disaster, or upheaval, therapists often live through the same traumas as their clients but put their own needs aside to help others. COVID-19 is no different, says Tosone, calling it “shared trauma on steroids.”

One of Mehra’s clients that week happened to mention India’s rising COVID-19 cases, which, at the time were peaking at 95,000 a day. His thoughts took him to his own mother, isolated in the COVID-19 ward of a Mumbai hospital. He didn’t say anything, and they carried on with the session—clients shouldn’t have to comfort their therapists.

Therapy has that visible but invisible nature to it, says Hillary McBride, an author and clinical counsellor based in Vancouver, B.C. Therapists are often discouraged from speaking about their personal experiences or worries, so they stay hidden from clients. And unlike medical care, the work that therapists do is largely hidden away from the public eye.

But, if there was ever a time when therapy was more needed, we’re living through it: a poll by the Angus Reid Institute found that 50 percent of Canadians reported a decrease in their mental health since the onset of the pandemic. Substance use is on the rise. People are lonely. Quarantining has been linked to anxiety and post-traumatic stress. Researchers have predicted that up to 2,114 suicides will have taken place in 2020 and 2021 across Canada, fueled by the pandemic’s mass layoffs.

As Suzanne Dennison, a psychotherapist, puts it, “the walking well are falling apart.”

Therapists contend with clients’ pain and trauma every day and, unsurprisingly, it can lead to burnout. Up to 67 percent of psychotherapists will experience severe burnout sometime in their career. But in a global pandemic, that stress is exacerbated, as therapists face their own worries and witness the toll that the virus has on everyday people. Lindsay Ross, a social worker with her own private practice in Toronto, has charted the pandemic’s progression through the eyes of her clients: when infection rates soared in the first wave, so did anxiety. As a mom of two, she’s felt that herself. She took a week off in May 2020 and then another in July to cope with the added stress and burnout, but says no therapist right now is completely free of it.

Once September hit and school started, it felt like she was throwing her kids into the dragon’s den.

Good therapy requires therapists to feel the grief, loneliness, and anxiety their clients carry, but still keep themselves separate from that pain. Connecting too deeply with clients, research has found, can lead to emotional exhaustion and added stress. Ross, too, struggles with this balancing act: her struggle is amplified by being a mother and a therapist, and balancing those roles. Ross emphasizes the importance of checking in with herself when it comes to absorbing her clients’ emotions.

“If you’re too empathetic, you’re sharing in an exorbitant amount of pain that these people you’re interacting with are going through,” says Steve Joordens, a psychology professor at the University of Toronto who has been studying anxiety during the COVID-19 pandemic and designed and teaches a course on how to manage anxiety during COVID-19. “And how to share it but not carry it is a difficult thing and not something most of us are wired to do.”

Before he became a therapist, Mehra was a management consultant in India in the early 2000s. While the job paid well and he was good at what he did, he couldn’t imagine doing it for the rest of his life. And so, he turned to Google for answers. The 50 vocational, aptitude, and personality tests he took pointed to more or less the same profession: counsellor, therapist, or psychotherapist.

“I was like, what the hell is this?” he says, laughing.

A friend suggested he try counselling, so Mehra signed up to be a suicide helpline volunteer at a Mumbai-based helpline called the Samaritans. For seven months, between June and December 2006, Mehra spent his weekends in a sparse apartment turned makeshift office, sipping tea and eating Parle-G biscuits, listening to callers who struggled with depression, suicidal thoughts, and anxiety. Helping those in distress was the most emotionally and spiritually rewarding experience of his life, he says, challenging him in ways that consulting never did. He eventually quit his job to attend New York University for a PhD in psychology.

More than a decade later, Mehra still finds his work deeply spiritual. As a therapist, he witnesses the fragility of human life and the addictions, depressions, and anxieties that ravage people in waking nightmares. But he also sees the beauty of life in the strength and resilience that people show in overcoming their traumas. When someone chooses to get help, they become a better friend, spouse, and child, and those effects are felt for generations to come. There have been countless times, says Mehra, when clients thanked him for saving their life. “The way I look at it, we’re all in this together,” he says. “I’m doing my part so there is less tragedy and unhappiness in the world.”

In her research, Tosone found that what buoyed therapists counselling during times of shared trauma was their sense of purpose. No one goes into therapy for money or prestige, says Kathy Offet-Gartner, a registered psychologist based in Calgary, Alberta, and the incoming president of the Canadian Counselling and Psychotherapy Association. “We do it because it’s a calling,” she says. “We do it because we genuinely care.” She’s been seeing clients for the past 38 years and says she’ll provide therapy until she doesn’t “have a brain cell left.”

“I will go to my grave with millions of secrets—not hundreds, not thousands, but millions,” she says. “And I hold each one of them as a treasure and as a gift. So, to stay well and to stay healthy is my responsibility.” She knows her work is
still needed.

At a memorial ground in Washington, D.C., there are over 200,000 small white flags planted in never-ending rows, printed with names of those who have died from COVID-19. Long after the pandemic stops taking lives, therapists will remain on the frontlines. The mental health effects of the pandemic are a tsunami we’ve barely seen the tip of, says
Offet-Gartner, and it touches everyone in some way. “I don’t have enough hours in the day to see people,” she said.
But as public health officials preach to mask, sanitize, and distance, it can be easy to assume that COVID-19 only affects our physical bodies. “This false dichotomy of separating mental health from physical health is an insane perspective,” says Offet-Gartner. “It’s the same damn coin. Why are we only flipping it always to be on one side, not the other?”

Beyond anecdotal evidence, there is virtually no research on the burnout or mental health effects faced by therapists counselling during COVID-19 or during the SARS epidemic in the early 2000s. What does exist, is ample research looking at the burnout faced by medical frontline responders. During SARS, nurses and physicians in Toronto, which had the largest outbreak outside of Asia, reported increased levels of burnout, psychological distress and post-traumatic stress disorder. Anna Banerji, an infectious disease specialist who worked during the tail end of SARS in Toronto in July 2003, said that most medical professionals were working 15-hour days and were traumatized: “Every time they had a kid with a fever, they assumed it was SARS.” While literature on COVID-19 is new, studies on burnout that have been done largely focus on physicians and nurses. One study looking at 1,257 medical healthcare workers across hospitals in China, for example, found that they were more likely to report anxiety, insomnia, and depression.

The lack of research on therapists’ mental health is symptomatic of a wider problem, says Abi Sriharan, an assistant professor at the University of Toronto’s Institute of Health Policy, Management and Evaluation. When we medicalize epidemics, we only see doctors and nurses as frontline responders, when, in reality, “healthcare is a team sport,” she says. Sriharan is researching the burnout and stress faced by healthcare providers—therapists included—during the pandemic.

In a culture that praises the everyday heroes on the frontlines, one is either a healthcare provider or someone needing help. Therapists are often seen by clients as being psychologically perfect, somehow immune to the stresses and anxieties that plague their clients, which can make it harder to seek help. It’s an ideal that clients like to uphold themselves: if therapists don’t have it all figured out, what hope do the rest of us have?

“For those who have ever looked at their therapists and wondered how they were so high functioning, I’ll let you in on a secret: we are not,” writes Brittany Wade, a psychotherapist based in New England, in a psychiatry journal. “So here I sit, at my little ramshackle home desk, in complete discomfort, reflecting on the irony that the very illness, anxiety, isolation, and loss that erode the mental health of my patients are now the main characters on my emotional stage.” In other words, it is impossible to exist without emotion or worry or stress, especially in a global pandemic.

Within a week, Mehra’s mother had turned around for the better. It was painful knowing that he couldn’t see her. He had to resign himself to updates on the WhatsApp family group chat and conversations with his mother, who offered frequent updates on the food served in the hospital ward that day. Though he felt the added strain in each of his sessions that week, providing therapy also helped him cope—he couldn’t help his mother, but he could help the person in front of him.

It’s frontline responders like therapists that play the invaluable role of healing the broken and will continue to long after we’re all vaccinated. But they are only human, and these days, that means burnout can come with the job.