For a better world to emerge after this pandemic, we must embrace and nourish the feelings of humility and solidarity engendered by the current moment.- Orhan Pamuk [1]
What if 2020 isn’t cancelled? / What if 2020 is the year we’ve been waiting for? / A year so uncomfortable, so painful, so scary, so raw – / That it finally forces us to grow. //2020 isn’t cancelled, but rather / the most important year of them all.- Leslie Dwight [2]
Background
Methods
Design
Participants and ethics approval
Data collection
We invite you to share with us images that represent your work during the pandemic. Specifically, we are looking for images that encapsulate the interface between your inner/personal and outer/professional lives. Our specific ask is to consider sharing two things: an image (or more), and a written or voice memo reflection of your thoughts related to the image(s). The reflection does not need to be polished—indeed, we encourage you to be spontaneous and not self-censored. We enclose examples from our respective work in order to give you an idea of what we have in mind.
Data analysis
Results
Sample description
Thematic analysis
Domain 1. Place (Table 1)
Theme | Sample quotes (source country) |
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1.1 Adjusting to emptiness and stillness | The most striking thing about these walks, apart from the beauty of the view, was the lack of airplanes in the sky. Our airport is usually very busy and although it was nice to feel so calm, no aircraft made everything seem eerie, a bit like an apocalypse movie. (Switzerland) “What’s happening?”, “Where are all the patients?”, “How does it come to be so?”, “Why does the hospital look like a ghost town?”—many questions emerged. However, there was only one answer fitting all these concerns: the reason is COVID-19, the consequence is doctors without patients. (Vietnam) |
1.2 Shifting timeframes | I had seldom, if ever, felt so disconnected and disoriented—not only from important people in my life but also from the rhythms that had been familiar and recognizable to me as my life. (USA) |
1.3 Blending of spaces: inside and out, personal and professional | Our provincial government had ordered all public parks, playgrounds, and trails closed. Officials had taped off entrances to facilities, basketball hoops and, in this case, an urban playground…I was focused on the abundance of tape, and the rattling metaphor that it conveyed about what this pandemic would mean to the concepts of childhood, parenting, and fun. (Canada) Maybe it was OK to show that I was in my apartment, that behind me was my messy and unruly kitchen. I don't know. I felt maybe too exposed…I saw this kind of tension between being open, accepting to share a little bit more than usual with my patients, while keeping a sense of privacy. (France) |
1.1 Adjusting to emptiness and stillness
We have been living in a dystopic reality for the past four months, since schools, universities and all non-essential businesses are closed. In the first days, I remember looking out of the window to a usually very busy avenue on Monday mornings: I could not see cars or persons for a few minutes, which was very disturbing in a city that never sleeps. (Brazil).
I decided to look out from my rooftop garden and it occurred to me that I might be living in an ivory tower that does not allow me to see what is happening on the ground every day, all the time. (Singapore).
Patients disappeared from all clinics, not only from ours. Community services rapidly adapted to the new reality, but also few patients appeared. By mid-June, patients started to come back, worsened. (Brazil).No patients, no appointments for a normal working day. We call this: “a unique event in a unique time.” (Vietnam).
When every city in the world became a Hopper painting, with no people and no life, it was hard for me to paint empty streets any longer. (Spain).
Avoiding the fellow humans responsible for this glorious noise and color has been a bizarre and dreadful adjustment. But I have adjusted. (USA).
This kind of visceral, full body experience, when you know something is not right. I grew up in an area of the country where tornados were not unusual. Everything gets very still. All of a sudden, the sky is this weird shade of green. Before you describe it, you feel it in your stomach. (USA).
1.2 Shifting timeframes
It is hard not to see an abandoned hospital as an 8,000-square-foot memento mori. I am seeking out a series of liminal spaces during a societal period of liminality…Timelines have collapsed. (USA).
Why is it that I think back to that terrible day so many years ago? It may be that as we live through this pandemic, this tragedy of a very different kind, one that we cannot see, one that is not circumscribed and finite, and one whose repercussions are likely to stretch for months and years, if not indefinitely, I think back to those terrible few hours. Where will we be as many years from now? What will be the repercussions of the invisible scourge we are living through? I do not know, but on this day, with blue skies, fair weather and the ability to go out and celebrate life on my bike, I think not of the tragedy that we lived through back then, or of the one we are living through these days, but of the gifts of endurance, of perseverance, of life and love. Final score for the day: life one, death zero. (USA).
1.3 Blending of spaces: inside and out, personal and professional
We who were born here still remember very well an iron curtain that did not allow us to travel abroad. We all have an inborn fear that this could happen again, but that the borders could be closed from the outside was simply unimaginable. (Russia).
That very insular community in large part threw caution to the wind and maintained prayer and learning centers open, crowded tight as always. The percentage of COVID-19 positive cases in that community were staggering. Literally overnight, we had to open two full corona wards, including a large corona ICU unit. (Israel).
various struggles that have come about now that all of my roles actively need me. Normally if work is demanding, my family life is stable, etc. But now, every single identity/role needs something from me. (USA)
Domain 2: Person (Table 2)
Theme | Sample quotes (source country) |
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2.1 Disruption to life rhythms, family impact | Children can’t go out and enjoy the summer, can’t see their grandparents, some are dead, some are too afraid of getting the virus, they can’t see their teachers or school friends. Driving through the city, our children asked, “Wait, STOP, our school is there!, can you stop a moment so we can see it?” (Spain) The visitor restrictions have been among the most challenging pieces of this puzzle. Knowing that family is so important and necessary for the children, for them to not feel abandoned, for them to know that they're supported, has been one of my main goals throughout this pandemic. It's very difficult to explain to them the necessity of social distancing, why we're wearing masks, why they are wearing masks. (USA) |
2.2 Emotional toll, loss and death | In a matter of days we’ve gone through all the stages of grief and loss, from initial denial and isolation (“it will not happen here; it is a China and Italy problem, our health system is the best in the world”), to anger (“who’s fault is it?…human’s best friend is not the dog, it’s the scapegoat”). Then bargaining (“it is bad only if you are very old or already ill”) and then you see young healthy people dying, or having amputations due to thrombosis, or pulmonary embolisms. Then depression (“my God, it IS here, and there is nothing or little I can do”), and finally acceptance…I am not quite there yet. This reality is difficult to accept. (Spain) This situation has in some subtle way robbed us from the absolutism of daily life. The things we took for granted are now no longer reliable. The belief that we had in the world: that optimism, that naiveté, have been taken away. And we are terrified. Death was a distant and abstract entity. The COVID pandemic in no time has collectively given us a reality check and here we are, perplexed…Truth came very abruptly: the truth of our mortality, our vulnerability, our feeble existence in the face of this adversity. It reminds me of something I read years ago: “Just when I have all the right cards, everyone else stars playing chess”. We thought we had figured it all out. (Pakistan) |
2.3 Positives of the pandemic | Family, family, family. Every cloud has a silver lining. (Brazil) It may be self-indulgent to say so, but when again will I have all this time to make productive use of? It Is remarkable how much time I’ve reclaimed just by not having to run around from one physical location to another. (Israel) |
2.1 Disruption to life rhythms, family impact
We could never have anticipated that I would be delivering our first child in the midst of a pandemic. We had planned meticulously: our parents and siblings were going to visit in turns to help us with the baby. And here we were, discharged less than 24 h after birth (to minimize risk of infection) holding our child tightly, and grateful to be together in our isolation. As we gradually sank into the deep and mellow gratitude of our new normal, I could not shake off the feeling that many people had been without any support during childbirth. Still others were dying alone in hospitals from the virus (USA).
Culturally our practice of hongi, the sacred sharing of each other’s breath through touching noses, was not allowed. I was in grief at this sudden loss. One of our leaders came up with a greeting that had first been used in the time of the Spanish flu. This was resurrected as hā mamao, literally, breath from a distance. This became our new salutation. (New Zealand).
Families are left breathless by the new demands of our shelter-in-place life: trying to feed, homeschool, entertain and soothe all of their children, while not missing a beat of their employer’s ceaseless drum…I find myself saying again and again: “You’re right, there aren’t enough hours in the day. There simply are not.” There aren’t in my home either: we try to keep up with the flurry of emails from our child’s school about virtual assignments and school portals, each, of course, with its own login system and password, overtaxing our neurons to the point where they begin to fray. (USA).
I think of the brave parents who have to make the difficult decision of sending their children to an inpatient setting for safety in the midst of this. During my last on-call duty, the mother of a COVID-positive adolescent expressed how helpless she felt between getting the care her child so desperately needed and leaving him in isolation as she took care of the rest of her family. These are the difficult situations many parents and guardians have had to face (USA).
2.2 Emotional toll, loss, and death
“Unprecedented,” “uncertain,” “once-in-a-lifetime,” “unparalleled” are some of the words being used to describe this global event. It is hard to write a coherent reflection about something that continues to elicit a cacophony of reactions. (USA).Our language becomes casually, but consistently the language of war: “First line,” “losses,” “additions,” “reserves,” “casualties.” How will this “battle” end? Unfortunately, everything seems to indicate that it will be a long positional “engagement.” (Poland).
the coronavirus pandemic brought back personal and difficult memories of growing up at a time of civil war, when we were sequestered in our homes for extended period of time with rationing of food supplies and outdoor curfews. (Cyprus).
I talked to people I hadn’t spoken to before. There was an opening up of social interactions, a sense of license to converse, albeit at a distance. A drive to try to connect, to maintain some human bonds, to share the uncertainty and fear (New Zealand).
one of the paradoxes of this time was maintaining and even strengthening connection and community, given the massive reconfigurations of social space in which everyday gestures of care and concern had seemingly been disrupted. (France).
Mark Epstein lays it out very beautifully in The Trauma of Everyday Life [33]. He talks about how this human attribute of relating to each other is assumed to be one’s birthright. If we look at the current pandemic situation, does it mean that COVID-19 has robbed us of our birthright? (Pakistan).
I spent more than a week at the hospital. My son had been hospitalized five days before me with an acute respiratory distress presentation. His situation was so frightening, and my desperation so profound, that my stress-weakened immune system could not fend off the virus. In the hospital, I faced a cytokine storm that could barely be slowed down by a combination of anti-IL6 medication, an antiviral, and convalescent plasma. After a few hours, the storm and my fever were over. I embraced the treatments, even as there was little evidence for their use. I also experienced corona hepatitis, a syndrome first described just a week before I had it. Due to the seriousness of my son's and my own condition, I had been in a dark mood and was just getting into a relatively reasonable state of mind, less fearful. However, news of the death of the physician with whom I had been admitted to the COVID floor reactivated my feelings and thoughts from the time of hospitalization—along with feeling guilty about having survived while others fell. My son and I have fully recovered. We now look for what we can do to stay human, to move forward and repurpose our lives and professions (Turkey).
So many people dead, so fast, that funeral homes, crematoria and undertakers can’t keep up. They had to store corpses in an ice-skating stadium known as “The Ice Palace.” A painfully ironic name for these poor people who died alone, most having never been to a palace before (Spain).
Some of us, myself included, experienced the grief of losing friends who passed away because of COVID-19. And that's a very hard thing to deal with, to bring that fear every day to work. But we simply had to keep moving on (Brazil).
2.3 Positives of the pandemic
We may think that as child psychiatrists we know a whole lot about childhood, but it is children themselves who are our best teachers…reminding us of where ingenuity, breakthroughs and true hope will always stem from (USA).
One of the positives of the lockdown is having more time on hand for activities and hobbies that are often sidelined. So I have been able to get on with painting the portraits of our eight grandchildren as young children, having started years ago with the eldest who is now 18 years and at University. I recently completed grandchild number 6, as shown in the picture, and am about to embark jointly on the last two – 8-year-old twins. I’m not sure what I will do if I run out of grandchildren before the pandemic ends (South Africa).
Domain 3: Profession (Table 3)
Theme | Sample quotes (source country) |
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3.1 Changing practices | I was part a group of physicians from different specialties who volunteered to cover the newly established COVID-19 call center to handle calls from patients, families, other physicians and healthcare staff working in remote areas. This was a brand new experience for all this group, most of whom had never handled this type of patient before but now had to deal with a flood of calls, to make quick decisions, to handle cases as best we could while working in crisis mode. (UAE) And it has become more evident than ever to me that, the precious moments that you get to spend in a patient's room, they mean more than ever before. I know that we're supposed to be in the room of a COVID-positive patient as little as possible. And we're totally geared up, we have our masks, face shields, and gowns –and our patients can't really see our faces. But, it's hopefully through our eyes and the inflection of our voice that we are bringing hope and encouragement and trying to get these patients home as quickly as possible, as safely as possible. (Redeployed psychiatric nurse, USA) I called a family from far away, abroad. Mom and the adolescent girl came to the camera, and the grandparents also sat down in front of the computer to "see" the psychiatric visit—forget confidentiality and HIPAA violations: this is war. Probably they had nothing better to do that to see a live child psychiatric evaluation unfolding, no Netflix required. (Uruguay) |
3.2 Outreach efforts | After the lifting of the lockdown I went out to distribute facemasks to traders at the market. The majority of them are uneducated and untrusting; they don’t see the need to buy or use facemasks. Most are of the opinion that since the government is enforcing it, they should have given out the facemasks freely to all citizens. (Nigeria) |
3.3 Guild pride—and guilt | Despite a medical condition placing her at risk, [the nurse] didn’t bat an eye as she told me "I am here. This is my work. This is what I do. I will take extra and additional precautions in doing what I do, but I need to be here for the kids and it's a privilege to serve." And I sit in awe. In awe of what everybody is doing this day. I have fallen yet again back in love with medicine, with child psychiatry and with the wonderful, selfless people I get to work with each day. (USA) The stress we absorbed is starting to surface only now. The disconnect was difficult for me when hearing from some people how lockdown had been "a holiday". I found this tough to reconcile with my experiences of families struggling with intergenerational mental illness, substance abuse, violence, food insecurity, loss of work, loss of a future. The stark reminders of the ‘haves’ and ‘have-nots’ in our little corner of the world. (New Zealand) |
3.1 Changing practices
We had to remain psychiatrists (still and first of all), but also to become pulmonologists, reanimation-ologists, radiologists (“doc, I’m sure I swallowed it [the virus], could you please take a look?”), laboratory doctors, parents, and so much more. By the end of my shift in the hospital I hardly remembered what I wanted to say to this child in the morning (Russia).
For hours we analyze the paths we should take to and from patients infected with COVID-19 so that the paths of those who enter and leave patients do not intersect. We learn how to don (important) and how to doff (crucial) our PPE: barrier aprons, masks, goggles, helmets, protective scarves, shoe protectors. (Poland)About 20% of our overall workforce across the hospital got sick, but slightly more than that got sick in our department –maybe from this sniffling, fever-spiking, runny-nosed kid, or perhaps more likely from their asymptomatic coevals– so we were constantly adjusting schedules, with new testing algorithms, new plans, new schedules, new PPE regulations (USA).
how you're the patients’ only lifeline, the only person going into the room, the only person they get to physically see or touch – through a glove (USA).
we rely so heavily on the use of nonverbal communication. That has definitely challenged me to adapt the way I practice. More than once I've had to tell a child, "I'm smiling underneath my mask. Although you may not be able to tell right now.” (USA)
One common refrain I hear from those who continue to see me is that they are not used to the new location and they're not used to the room that I'm now in. But they have found comfort and familiarity in the therapy tools that I have always used in a room that they have come to know and cherish. It is only when they see these and they see me that they realize that the room may have changed, the circumstances of our meeting are different, but the therapeutic relationship remains the same. In this time of uncertainty, the work we do together is a comforting constant. There is still what we have between us that remains unchanging. A bulwark against the unknown. For that one hour, we get stronger, together (Singapore).
In alliance with the mental health service of our practice, we created online support groups aimed at different care providers and open to any region of the country (UAE).
we were able to follow families more closely, and that eliminated the difficulty in getting a suitable time to meet, to park, to balance so many other things that had affected the frequency of family meetings before the pandemic (Israel).
I miss people, I look for reassurance in other people. Although I deeply appreciate contemporary technology, I love to feel people around me. A person needs a person, simply to come closer. It’s not just our thoughts and our words: there is also that live presence of ourselves and everything we carry with us. All those congresses that we were traveling to, it was not so much to hear, so much as to feel presence in the moment; to belong to something so important to us (Montenegro).
3.2 Outreach efforts
He provides once monthly pro-bono consultation to a province in that small island. He brings his car and gets a two-hour ride in a roll-on/roll-off (RORO) ship. Then he drives four hours to reach his destination. He is the only psychiatrist who visits this province monthly and continued to do this regularly during this pandemic. There, he sees adults and children (Philippines).
I experienced a different story, that of poor people’s hunger. It seemed a cruel joke to tell those far less privileged fellow citizens about our well-intended mental health tips, rather than providing them with money or food to survive (Bangladesh).
On our online CBT program for child, teen, and parent anxiety, I was shocked to see that in that one week, our registrations were four-fold higher than usual. Clearly, I wasn’t the only one struggling. Some of the comments left online by parents shocked me and I felt a deep sadness for those who were struggling so much. Parents reached out to me personally, sending me videos of their clearly distressed children and how they were attempting to manage their stress (Australia).
a presidential technical committee on mental health was created. It was an honor being asked to direct it. This action is unprecedented, and watching the President speaking about the importance of mental health to the population has been a hopeful sign (Chile).
3.3 Guild pride—and guilt
a heartening experience, for our team to have been given the priceless opportunity to support fellow medical colleagues as they helped one another and their patients, to ease their efforts as they made so many personal sacrifices (Singapore).
We showed up, we took the punches, we stayed open when people around us were closing up shop, we got sick, we got better, we looked after the vulnerable and marginalized kids we promised we’d always be here for, we didn’t just look after our own department and our own kids and families, we fanned out to wherever we were able to help in the hospital, we worked side by side with nursing, we cared for people who were dying, and we did it every single day and every single night (USA).
I was ashamed of myself. Ashamed that I had only started to care about COVID-19 when it impacted my personal life…I am still working on making peace with the shame I felt at my initial insensitivity to COVID-19 and its impacts (Pakistan).I have been forcefully disconnected from my patients and their families. I know that I am an important figure in their lives and feel guilty of abandoning them…as if it was my fault…I wonder how they are doing… (Spain).
My thoughts were around the word “hero,” and all the talk around heroics so pervasive in the air these days. The term is usually applied to healthcare and “essential” workers. In some ways, I am aware that my team, and even I, have been considered “heroic.” Yet, the term feels inappropriate and uncomfortable. Countless families have not been able to afford the steep price of social distancing. It is these parents, mostly mothers, I'd imagine, staying at home, trying to make a life of normalcy and safety for their children, the endless days under the pandemic. It is they who are the heroes. The breadwinners among them, going out, taking risks to scrap a living. It is they who are the heroes (USA).
We all sit comfortably in our homes at the end of the day. We have plenty of food, we have protective gear, we certainly have shelter. We have the internet. We complain of being for too long on Zoom calls. But what about the countless many who have limited or no connectivity? Zoom and the internet: such problems of affluence (USA).
Domain 4: Purpose (Table 4)
And I submit that nothing will be done until people of goodwill put their bodies and their souls in motion. And it will be the kind of soul force brought into being as a result of this confrontation that I believe will make the difference.- Martin Luther King, Jr. [34]Table 4Purpose: themes and sample quotes
Theme Sample quotes (source country) 4.1 Moving from pandemic to syndemic The pandemic, if it is even imaginable, came to take a backrow seat to yet another crisis, a racial crisis long developing in this country. Four hundred years and more in the making. (USA) 4.2. From lamenting to embracing People panicked. Stores were emptied out, shelves left bare –the reality once again of the social disparities were evident– those who could afford it stocked up for a war, but those who relied on social grants and a weekly wage could do nothing but look on helplessly as they were unable to buy anything, let alone more than usual to stockpile. (South Africa)Psychiatrists, like all physicians, need more than ever to speak out to the public to amplify good science while refuting nonsense. If we don’t, there are countless others, most of whom have never done science or actually cared for a patient, who are more than happy to fill the void. (USA) 4.3 Planning toward a better tomorrow Following each forest fire, new green shoots emerge. COVID-19 has had the same effect, by providing us new opportunities that were not available to us before. (Singapore)
4.1 Moving from pandemic to syndemic
The daily news reported Asian-Americans spat on and attacked with racial slurs. The “model minority” had led us to believe that working hard and not complaining would lead to peaceful coexistence. But even as we have become physicians, lawyers, engineers, and entrepreneurs, we continue to be the target of bias, violence, and racism (USA).
The pandemic would redefine what it meant to have access to care, as telehealth required having access to stable internet, highlighting the staggering inequalities in health care access, with higher COVID-related mortality among minority populations. The pandemic forced a long overdue reckoning with racism (USA).The inexcusable overrepresentation of minorities, the indigent and the poor among the dead. And yes, an unacceptably high number of Blacks among the dead. This image reminds me of those in the shadows, those overlooked, those brown and Black faces that we have not served right (USA).I've fluctuated between gratitude for this time with my children and our safety, being able to have a job and work remotely, and a deep sadness and insecurity for all Americans of color…I have reticent gratitude that my kids live in safety, but deep rage and sadness that not all kids of color can (USA).
4.2 From lamenting to embracing
This public health crisis is exacerbating existing vulnerabilities, access to care services, and gross inequalities, particularly for young women and girls (Chile).With their daily hand-to-mouth sustenance, I wonder who is feeding their children and how many of them have gone to bed hungry for days. I think about the systemic racial inequities around me, the state-sanctioned murder of Black people, the Latinx children caged at the borders, the internment camps in China. And, all the while, the red death claims more victims. A storm ravaging a storm. And my heart is broken (USA).It seems that the “voice” of children is yet again drowning in the fear and priorities of adult society. Children are so easily forgotten (Poland).
stunned into silence when I learned that my 16-year-old son was part of a veritable underground army of formerly nerdy computer types, now become heroes of sorts by producing in countless basements throughout the nation what the country itself was not able to provide: PPE…The following day, he took a large box to the Veterans Hospital and donated equipment to its frontline staff. He was keen on having the equipment go to the “unsung heroes”: the cleaners, janitors, phone operators, nursing assistants, and countless others keeping the healthcare system ticking (USA).
He went with some of his friends to the remotest islands to distribute relief. Along with basic food items they distributed essential medicines, clothes and handwash. A surprise request from the locals was for mosquito nets to be used for protection against snakes while sleeping at night (India).
It is not clear where we will end up, it is not even clear where we are today, but the stirrings of social justice that have been so painfully and magnificently evident across the land do give me hope (USA).The black plague heralded the Renaissance; surely we are looking at another period of enlightenment ahead (Pakistan).
4.3 Planning toward a better tomorrow
the medical students that I am privileged to teach, still fierce and passionate, determined to leave the world better than they found it, and my friends and colleagues, still with the embers of hope that goodness and justice will prevail (USA).
the concept that life is with others –as our dear Professor Donald Cohen said in his eponymous book [38]– has become more meaningful and precious for me these days. I predict that enhanced connection, interdependence, and collaboration across near and far will be the positive corollary and lasting impact that the pandemic will have on children and on child and adolescent psychiatry (Spain).
Discussion
Encapsulating the pandemic
We write these “reflections” in the moment, as the impacts of the pandemic unfold around us daily. We are all living it right now. When it is over, we will look back and reflect upon it and with the benefit of hindsight, might make normative judgements regarding what we ought to have done and what might have been best at a certain time [42].
Global snapshots of an overstrained profession
Flickers of opportunity amidst an unfolding crisis
The interconnectedness of the world made society vulnerable to this infection, but it also provides the infrastructure to address previous system failings by disseminating good practices that can result in sustained, efficient, and equitable delivery of mental healthcare [54].