In a pandemic, people might know they need food or housing. But how do you help them realize they also need therapy?

As the pandemic wore on, Kayode Martin felt stuck.

He'd graduated virtually, a high school senior when COVID-19 arrived in Chicago. A year later, in 2021, he was working at a store but struggling to find a routine that felt on good footing.

When his grandfather told him about a construction training program at the Inner-City Muslim Action Network, he applied. During the intake process, a social worker there also suggested counseling, and the 19-year-old was connected with therapy. A year later, he looks forward to the weekly Monday morning appointments.

"I actually never really thought about going to a therapist," he said. "I kept a lot of my emotions bottled up inside." Now, he said, "I feel more relaxed. I feel more in touch with myself."

Martin is one of the Illinois residents who reached out for help during the pandemic with an immediate need—housing help, groceries—and were also connected with a therapist. During the pandemic, many Chicago organizations began rethinking how to provide mental health help as the virus swept into the city and many were left for the first time feeling in need amid the psychological rubble of upended lives.

"We've seen a lot of people seeming overwhelmed," said Jennie Hull, chief program officer for Lakeview Pantry services such as food distribution and mental health programs. "Especially if you're going through that for the first time—I don't even know where to turn, what services are available to me?"

People seek help for many reasons. A single mom goes to a food pantry for groceries but might need counseling after domestic violence. A single 30-something who recently lost his job and part of his identity, reaches out for employment assistance. A family seeks a child care subsidy and while in line, the children hit each other. All these are examples of people with an immediate need who may also need mental health support.

And many might not even realize these needs.

The pandemic created a mental health crisis in the U.S. By fall 2020, the Centers for Disease Control and Prevention had released findings showing Americans were facing increased symptoms of anxiety and depression; nearly half reported at least one adverse mental or behavioral health condition. Already destroying normalcy everywhere—schools, child care, travel, family reunions—COVID-19 added excruciating hardships, shuttering businesses and heightening unemployment. In December, Surgeon General Vivek Murthy said young people were facing "devastating" mental health challenges; the Centers for Disease Control and Prevention tracked and offered tips on stress and coping regarding COVID-19.

People who are in crisis might know they need food, or housing—tangible needs—but not realize they are also struggling mentally. This posed a challenge for agencies that try to help them. When people are in crisis, how do you carve out space for them to evaluate and address their well being?

During the fiscal year ending March 31, , Lakeview Pantry served 8,742 people new to the organization. As the group received people for short-term needs such as groceries, employees ramped up efforts to connect people to longer-term needs such as counseling. Similarly, other organizations offering temporary housing, rent relief and food assistance began rethinking how to reach and help people during the pandemic.

How do you assess mental health?

One main question is how to assess if someone needs mental support. This can be a delicate process, involving sensitive questions or careful conversations. Different groups approach this in different ways.

"The majority of people aren't coming in asking for counseling," said Joan Liautaud, chief clinical officer at Heartland Alliance Health.

Instead, people arrive for immediate needs such as housing, or workers encounter them at places such as homeless encampments. Initial conversations deal with basic needs, but Liautaud said they assume everyone they encounter has some level of trauma.

"If you live outside you're more likely to be exposed to violence, a victim of violence, probably using substances to cope, exposed to the elements, loss of family, loss of home, loss of identity," she said, "all that sort of stuff which we know causes trauma."

Heartland and other groups have extensive intake processes, often done by social workers, including questions such as asking about poor appetite, or thoughts they would be better off dead. They also employ people from the community with experiences that reflect those of the people they'll be reaching out to.

"When you meet someone who's more like you, and they've walked this road of recovery, it also communicates hope," Liautaud said. "It's personification of hope that this person's done it. This person's real. I can do it too."

At the YWCA Metropolitan Chicago, people arrive for multiple reasons, from programs to child care subsidy. Because of this, said Peggy McGuire, director of child and family development, the staffers are cognizant of translating both various needs and meeting them beyond what they arrived for.

"When you're in chaos or crisis, you don't see everything around you, you only see, 'I need food today,' " McGuire said.

Recently a mom called the YWCA, worried about her daughter smoking marijuana. The mother was connected with a parent-mentor specialist in Bensenville, and they were able to also refer the family to mental health services after hearing more about their situation.

Dominique Moore, 25, came to the YWCA after hearing about the job-training programs. It was May 2020, and she was feeling shaken by seeing jobs evaporate.

"I felt very hopeless when the pandemic started, because I had seen a decrease in employment," she said.

Moore was also pregnant and through the job-training program she was connected to a program for new moms. While there, after several conversations included the possibility of therapists, she began seeing one. But it took multiple instances of someone she knew bringing it up.

"If you don't have trust, you don't have anything," Moore said. "I said, 'OK yes, I'm going to do it.' Sometimes people need to be at their own pace." Now, she finds the weekly therapy sessions "so wholesome, and so healing." The program she's in offers seven free sessions.

Challenges are often interconnected. A lack of safe and affordable housing can be a barrier to substance abuse recovery, for example, or someone seeking work experiences anxiety. "How do you manage your stress and anxiety while you're looking for work, while you're feeling like, I have to get this job?" Hull said.

In fall 2020, Lakeview Pantry received a city health department grant to hire more full-time therapists. The $240,000 they receive each year for three years goes to pay the salaries of three full-time therapists and part of two other salaries for employees who offer counseling. The grants are part of the city's Building a Network of Trauma-Informed Centers of Care project, which was launched in October 2020 and funded 32 community-based mental health organizations to expand services regardless of people's ability to pay.

Employees know to look for signs of mental distress.

"Someone might start talking to a case manager and say, 'I'm really stressed about my relationship,' or, 'I have trouble sleeping,'" Hull said. "Or they may even come out and say, 'I need a therapist. I'm depressed.' "

Illinois faces 'crisis' in shortage of behavioral health workers

But even if people want to help, they can't always help immediately.

Illinois is facing a shortage of behavioral care workers that even before the pandemic, legislators were trying to address.

In a December 2019 report, the Illinois Behavioral Health Workforce Education Center noted Kaiser Family Foundation data showing only 23% of Illinoisans' mental health needs could be met with the workforce in place at that time; wait times were as long as six months. It cited accounts from Illinois counseling centers having trouble finding applicants or filling vacancies.

The Illinois Department of Human Services calls the shortage a "crisis." Although the Kaiser Family Foundation data remains similar, showing 24% of mental health needs can be met, advocates and officials say the pandemic made it more difficult for people to access therapy because of shortages and by adding pressure to safety net services.

"We are losing staff and people are fried. We can refer to systems all day long, but if there's nobody working there, it's all just a pipe dream," McGuire said. "I have never seen a disappearance of people in the helping profession like we do now."

Advocates note that communities of color are disproportionately affected by both COVID-19 and the mental impact of events such as the George Floyd protests.

"It's kind of like all the issues we saw before, but on steroids," Hull said. "If you had anxiety before, your anxiety's worse. If you had depression before, your depression's worse. Relationship issues, you're stuck at home with your partner."

Although the state requires Medicaid to pay for mental health services, people who have private insurance or the ability to pay out of pocket have an easier time accessing help. This might leave people with the option of waiting months or seeking help in extreme cases such as hospitalization. People who do not have Medicaid, or do not have availability to meet a counselor when one is available, face much longer waits.

A bill in the state legislature would increase payments to mental health providers, which its supporters say would help with retention. Advocates say that if the state reimbursed providers more under Medicaid than they do now, it would help retain more therapists, reduce turnover and offer incentive for more behavioral health providers to see more clients.

Emily Moen, vice president for marketing at Thresholds, which offers substance abuse treatment and youth services, said community providers have sliding scales available, for example for those who are in the country illegally or don't meet income requirements for Medicaid. "The real problem is staffing shortages and inadequate rates that mean expanding services is almost impossible to meet demand," she said.

To assess the workforce issues, the Illinois Department of Human Services announced a student loan repayment program with applications opening in summer for community-based mental health services—including psychiatrists, psychologists, social workers and professional counselors—in rural and underserved areas. The department and the Illinois Board of Higher Education are also investing $6 million to develop an Illinois Behavioral Health Workforce Center, which will be housed at the Southern Illinois University School of Medicine and the University of Illinois at Chicago to research shortages and boosting the workforce.

Getting innovative about meeting people where they are

In the meantime, groups are getting creative about how to help people.

At the Inner-City Muslim Action Network, which offers health services, housing and job training, they started what director of behavioral health Natali Rehman calls "brief therapy"—a four-session series with the first as assessment and the next three to stabilize someone. The network also offers group therapy on topics such as grief or stress management for those unable to immediately connect with a therapist. The wait list is now at four months; it was nine months in previous months of the pandemic, Rehman said.

"We figured if you're having housing insecurity, I'm pretty sure there's other things you need assistance with," Rehman said. "You can imagine an individual who's on the verge of being evicted or on the verge of not being able to put food on the table, what does that do to your social, emotional well-being?"

Group therapy is something that many organizations are expanding. Before the pandemic, the YWCA offered about 15 workshops, now it has nearly 40. It's a way to reach more people at once, and may be a setting some people are more comfortable in.

"We have to be creative and innovative," Rehman added. "The need is just so high within the community that to just sit back and do nothing, it's a huge disservice."

During the pandemic, hearing about changing needs, the Inner-City Muslim Action Network created new programs —its Food and Wellness Center in Englewood offers essentials from food to face masks. All employees there are trained to look for signs of trauma; clinicians and interns are from diverse backgrounds and provide services in Spanish and Arabic. Signs of mental health challenges can include someone seeming down or hopeless, saying they've had trouble sleeping, that they've felt like a failure or have let themselves or their family down. All of these are things that could prompt someone to suggest meeting with a therapist. Many providers use a questionnaire that asks people to rank how often they may feel this way.

"We don't want to put a Band-Aid by saying, 'Here's a box of food and go about your way,' " Rehman said.

Martin is part of the Green ReEntry program, which helps people learn skills such as construction. Through this, he attends group sessions that approach topics, including substance abuse or how to handle difficult situations, in addition to his weekly meetings with a therapist.

"It's a blessing, it really is," he said. "A lot of people don't actually get therapy for free, and I get mine every Monday."

Martin and his therapist discuss school and emotions. "I was never really used to talking about how I felt, things of that nature," he said. "They really like cracked the shell."

At Turning Point, to provide an immediate place other than emergency rooms for adults in crisis, there is a Living Room and Resource Center, which offers in-person, walk-in and remote services. Last January, Turning Point expanded services to 365 days a year. Therapists are available from noon to 8 p.m. during the day and through the crisis team 24/7 at 847-933-0051.

The Living Room is staffed by therapists and peer counselors, called recovery support specialists, who complete Illinois Department of Human Services trainings.

"They're taught to look for different signs like depression, anxiety, things like loss of appetite," said Noy Frial-Lopez, chief clinical officer at Turning Point.

Heartland operates drop-in centers where people can come and grab a cup of coffee. With a sometimes transient population, Liautaud said they try to keep tabs on people as they wait, either visiting where they last were or getting in touch with people who may know them. She emphasized that however people are finding help, being open to it is in itself something to laud. It's brave to trust a stranger offering assistance, she said.

"I think the fact that people come through the door is amazing," Liautaud said.

Not everyone wants to meet with a counselor

Of course, not everyone says yes. For anyone, therapy can seem overwhelming. People feel intimidated by the thought of telling their life story to a stranger. What if they don't like the person? What if they can't spare the time to go? Telehealth offers flexibility, but many remain hesitant. For some, stigma remains; others are simply too overwhelmed to consider an appointment.

On the flip side, many said the pandemic has normalized mental health struggles.

"People feel like, yeah this is a really stressful time, it would make sense that I should talk to someone during this time," Hull said.

Word-of-mouth can sometimes be most effective.

During the pandemic, a 58-year-old Chicago woman who did not want her name used discussing previous trauma, told friends and even people she encountered on the CTA about Lakeview Pantry. Having gone there since a traumatic event affected her ability to work years ago, she often tells strangers about the groceries. She also posted messages in her neighborhood social media group about their free counseling.

Many she talked to said they weren't "bad enough off" to need any help, she said.

"People would have never thought they needed a food pantry," she said. "People say, 'Oh no, we don't need it that bad, we need to leave it for the other people who need it more than we do.' "

She tells people "it's self care, it's family care" to ask for help. And that goes for counseling too. She knew that for people like her, already experiencing things such as anxiety, the pandemic created extra grief and stress.

"It turns up the volume on whatever's already there," she said.

For Martin, several months of therapy helped him open up to others in his life, like his mother. He feels stable, not so stuck.

"I feel like I'm evolving now," he said.

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