Mental Health of Social Workers in Pandemic
by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field
(Editor’s Note: This article is a follow-up to What About Us? The Mental Health of Social Workers.)
When I first wrote about the mental health of social workers a year ago, I had no idea where we would be today. Of course, none of us did. But social workers were attuned to a certain impending doom, and we were right. We are typically the canaries in a coal mine. I just don’t know that we even knew what we were singing out about.
Because of that, let me start out by clearly naming what we are working with right now: a worldwide pandemic, a governmental attack on scientific principles, a democracy that is fully hanging by a thread (insofar as it existed at all), a widening understanding of the violent and homicidal impact of bias in law enforcement, a rupturing economy with no safety net, and millions losing employment and (therefore) health insurance.
I am stating the outline of these earthquakes clearly, because we really can’t move forward without having some sort of shared understanding of what is happening. This is what is happening.
As for social workers, here are some specific ways in which we are suffering collectively and that we can hopefully find some connection.
1. We need advocacy on a national level.
Not a day goes by when I am not worried about my license and that I am doing something in violation of the daily iterations around the current regulations. I know there is the Code of Ethics that mandates that we don’t abandon our clients. I also know that several of my clients needed to immediately locate across state lines when the pandemic started. State-by-state reciprocity was and is being declared on an emergency basis, if it is declared at all. It quickly became clear that it was the responsibility of each individual practitioner to determine what is and is not “legal.” There were posts on the listservs that I follow daily, loaded with panic and fear. And today, nearly six months later, clarity on this is still opaque; at best.
This is no way to function. It is impossible to be practicing at this time, with the complex level of content that is being directed toward us, while also feeling scared that we are in violation of either our licensing responsibilities or our ethical responsibilities. As we try every day to get things “right,” we need some sort of nationwide advocacy that guarantees that we are safe to do our work and maintain our licenses as we make decisions in accordance with the ethical principles that guide us all.
2. We can’t trust that insurance companies won’t put us in harm’s way.
Just as the local and state regulatory bodies are slowly moving toward any type of guidelines, the same is true for insurance companies. What is and is not considered HIPAA compliant is totally confusing. We don’t know if Zoom is truly safe, and when an insurance company says that it covers telehealth, we don’t know if this is video or tele or if we are doing something wrong, again. We don’t know whose co-pays are being covered by emergency declarations and when that expires. Oftentimes, telehealth is being extended for months at a time the day before it is set to expire.
This lack of unification and coordination is a parallel process to how COVID-19 has been handled by the country as a whole. Everything has fallen on the shoulders of miniscule localities with no national guidance or coherent policy. It is hard enough to practice as it is, let alone with the looming bureaucratic nightmare that is facing each of us individually without any support to clearly navigate all of this evolving policy.
3. There is a pervasive increase in mental health acuity.
Outside of the logistics and systems around us that permit and reimburse us for our work, there is the work itself. And it’s the hardest it’s ever been. The overall baseline has lowered for many of our clients, as isolation has increased and instability pervades many of the environments that we are in. If we are lucky, those around us are wearing masks. This can increase feelings of safety, yes. But we are losing huge amounts of social data that we used to rely on to feel connected to each other.
We are trained in nuance and subtlety. We weren’t trained to live in a masked world. We also weren’t trained to practice over Zoom or any other virtual platform, for that matter. We literally learned nothing about any of this. And now we are supposed to be holding together clients who are struggling with increased symptomology from the privacy of our homes, home offices, remote offices, or across a room with obscured access to facial gestures. I know this is what we have to do to stay safe. I am not complaining about that. I am, instead, naming the persistent feelings of incompetence that are likely haunting many of us as we wade through this work.
4. We have to trust some authority but there is so much to be skeptical about.
I don’t know any two social workers whose work has been impacted in the same exact way. Some school social workers are practicing from home and attempting to build rapport via Zoom with kids who are jumping out of their skin. Others are in school buildings, watching safety procedures and protocols evolve on a minute-to-minute basis. We don’t really know what is influencing the decision-making of those above us and if it is our health and well-being that is being centered or being seriously considered.
Everyone is suffering from decision-making fatigue around each move we make. That might mean where we decide to buy groceries or if we can resume that exercise that we used to do. But we are also fatigued by trying to assess the credibility of the decisions that are being made for us. Are we all mandated to come back to the office? Is air really being properly ventilated? What is ventilated air? Who says we need to come back? Is it because there is a lease and someone is paying rent on it? Is it because Aetna is about to stop covering telehealth? Is it because the needs of our clients just can’t be served virtually now, but could be last March or April?
There is so little we know and so much at stake, which typically could be somewhat soothed by high levels of transparency. That type of transparency is rarely available and is decreasing all the time.
5. We need to establish some sort of shared reality.
There are states where people are going to bars, unmasked, daily. There are states where indoor dining was just re-instated. There are places where kids go to school and places where they don’t. These policies are ideally being informed by public health decisions and the local incidence rate of COVID-19. In reality, they are being informed by the political orientation and the need to sustain capitalism as it currently exists. With a backdrop that is so variable, unpredictable, and shaky, we are having a hard time stabilizing and orienting our clients to what is “real.”
There is, in fact, a true lack of reality and shared perception right now. We don’t even know if there is adequate or precise testing for upcoming COVID outbreaks. What we do know is that there is a false binary between public physical health and intrapsychic mental health, and we are operating at the intersection of the collapse of both.
On some level, the best intervention we have to offer is to keep saying that, to keep observing and labeling truth and how legitimate the experience of being totally confused is right now. We need to admit what we don’t know and tolerate that not-knowing, while easing our clients into the ability to do the same. This is tricky stuff. When you can’t perform a sound mental status exam on the country you live in, it becomes much harder to expect your clients to have some sort of even level of orientation amidst everything that is going on. The shared reality right now is the agreeance on the fact that one is absent right now and that it is excruciating and exhausting to live through.
6. We are all flying technique-free.
I don’t know how you were trained or what theory you gravitate toward. I just know that theory is not what is grounding us right now. Does CBT work on Zoom? Can I mention transference in group therapy that is a group of 10 boxes of faces on a screen, many of whom are muted? Is someone being muted symbolic of something? Is it normal? What is the most sensical way to understand the different ways we are attempting to communicate with each other and the limitations of those ways? Should we start to bend the frames we have relied on to decrease the feeling of distance created by virtual realities? Is it time to start texting our clients and to let them text us? How about if they wake up from a bad dream, should they let us know immediately?
The fact is that we don’t know what the boundaries are here. The frame has shifted, our cats and dogs are in the room. We used to spend weeks deliberating about whether or not to disclose that we even have pets. We don’t know what does and doesn’t work. In the absence of technique, we have gut instincts—the instincts that brought us into this field and will help our clients navigate their ways through this de-construction of norms.
7. This is so sad. Have some tenderness and grace around your own humanity.
Everyone I know thinks they are doing this wrong. They are worried they are not holding their clients and the boundaries around this work responsibly. Our jobs changed dramatically from one day to the next, regardless of where in this field you are located. There was no real preparation for this change and no time to truly adapt to the gravity of it. Yet, here we are.
The most essential thing we can offer ourselves is a high level of tolerance for our own humanity, imperfection, and discomfort. We are all living with elevated levels of grief that are making cognition, deliberation, and intention harder to access. This is a trauma state. Let yourselves know that, let your client know that, and sleep as much as you need to in order to let your whole system keep metabolizing all of this as it unfolds.
Dr. Danna Bodenheimer, LCSW, is the founder of Walnut Psychotherapy Center, and the executive director of the Walnut Wellness Fund. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field (The New Social Worker Press).