Table 3.

Quotations

1. Lost in space, lost in time
1.1 Lived space	Q1, P2: The first thing I did when I learned about lockdown was to go back to the hospital to back up to my files… they said, “from tomorrow, you should not come, because the hospital is closed” Q2, P10: I only work from home and it’s very difficult. My husband is also working from home and now, we don't have the person who usually comes to take care of our baby Q3, P28: (every day, it’s going to be where you are right now, on this chair, on this computer?) Yeah, on this chair, on this computer, on this butt Q4, P5: They told us, “from now on you are hospitalizing patients at their home”… patients stay at home and we contact them remotely every day Q5, P32: We would still have our 8:30 in the morning meeting, but we had to split into two different groups… And we had, on the different chairs, we had a marking of where you could sit on the floor Q6, P14: I also have to go to the COVID area, because in our hospital we divided the department space to a COVID area and a non-COVID area. So, the child psychiatry [department] also had to provide surface to the COVID area… We have to wear the full level-three PPE. It's tiring, very tiring because it's very hot… At the beginning, I was a bit reluctant to do that
1.2 Lived time	Q7, P3: Before, my schedule was well defined and I have to admit that currently my days are more chaotic… I mix private and public practice on the same day and sometimes I get completely lost Q8, P20: Many times the parents (of teenagers followed in psychotherapy) want to see you, and then you have to inform the parents, and you lose time Q9, P14: Now in Corona conditions, our government and our hospital limit the working time… So I work in alternate days. If I work today, then tomorrow I get a holiday, then the next day I have to go to the hospital Q10, P34: We don’t know how long we will have to continue like this… one year, two years, nobody can tell. So we are here, working like this and waiting, and waiting… It’s a never-ending story Q11, P2: We were just told that the hospital is going to close, and that they would let us know how to take things further. Only emergency services would be available,… everything was canceled… We had a long waiting list, so we had appointments scheduled until June or July, and we had to cancel everything from March, until now and maybe after, who knows?
2. The body—of CAPs and patients body
2.1 Sensory aspects   Touch	Q12, P28: There's some cases where I find it really difficult and particularly, again, when you're dealing with kids with neurodevelopmental disorders where I can't do physical exams…I like listening to somebody’s heart, I like feeling their pulse, I like doing a neurologic examination because I often find things that other people haven't found. I'll see patients referred to me by neurologists or pediatricians or others, and I find things that they didn't find. It's much harder to do that… there's fun in doing that too, by the way. But I can't Q13, P21: We could not do the physical work anymore, all the holding, all the care, the baby’s sight, seeing them together, breastfeeding, we need to support this, it's very important during the first weeks, I don't necessarily touch them directly but all of this from a distance is way more difficult, because during a teleconsultation or through whatsapp, you see them in a small square. It’s more delicate to give proper advice and to assess the situation Q14, P8: I fear that we somehow we're going to continue being afraid of contact with people… that's going to be an issue for me if everyone wants to keep a lot of distance and space in between Q15, P2: Because, generally in a child psychiatry clinic, we generally give a handshake, or we hug the child, or you pat the child on the back, and should we stop doing all that? We had all these kinds of practical discussions of how we're going to manage Q16, P9: I mean you're trying to keep it always as you can, but you know with the kids they just come and crawl on your lap and what can you do? You just go with the flow
Sight	Q17, P32: I was in the mask and the visor; that was particularly weird because I can see their face and they can't see me. So that felt deeply unsatisfying to me and il felt like a very, to be blunt, not the robust comprehensive assessment I would like, in terms of what I can give to my patient Q18, P01: With the distance, there was something emotional that could not go through. Even a patient told me “but if we speak on the phone, you won't see my emotions.” And even through video, I could see the face, but not perceive the emotions Q19, P20: Sometimes, the clue is in the face you know, the way they look when they tell you a joke or make an ironic comment. But 2 m plus the mask, you miss it, you don't spot it… and you end up looking like a fool ‘cause you did not get it was a joke Q20, P06: my gut feeling was, we do our work with some automatism, the analysis of the information, the semiology, the nonverbal communication… And you become aware of all of this only when precisely you can't do it, you can't have access to that Q21, P28: I can't look for dysmorphology and just sometimes putting your hands on somebody tell you something very different about tone and spasticity and things like that, that you just can't see. You can see a head and shoulder tic, but you may not be able to see their hands or their legs or… and even then, you might see only one part of it, or they… so, some of those things it's much, much more difficult to assess on Zoom or whatever platform you use. Well, it's incomplete and uncomfortable because we can't do it… Q22, P30: I prefer using the phone with my patients. At least they don't expect me to read their facial expression to understand what they really mean. Sometimes the image can freeze or, because of a bad connection, there is a gap between image and sound… It's not reliable enough Q23, P06: It was not possible through video, because body image was precisely the clinical issue with my anorectic patients, I have two and doing video consultations was problematic so we did it over the phone
Hearing	Q24, P15: With some adolescent patients who did not want to show their faces on the camera, it was difficult, especially with one of them who rejected categorically telepsychiatry principles. At the end, I could only speak with his mother and did not even hear the sound of his voice Q25, P01: Some teens refused to speak to us, we knew why… Because their parents were standing next to them. There's not the separation we used to have…
2.2 A non-embodied encounter	Q26, P4: Of course, there are some things that you need to do in person… Surely there are some things that we can't do, like a physical exam or… But 98% of what we do you can do like this. Is it different? Yes, it's different but we need to adapt Q27, P20: I don't’ like it, I feel I can't really contain their anguish by just appearing on their phone Q28, P3: I had a case last week and they, the parents and the patient, didn't do anything that I recommended. I guess I'm less convincing on ZOOM than on reality Q29, P3: Now I have a safety net now, I always ask for a parent to be around when I do a consultation via ZOOM Q30, P9: It's meeting via screen; it's lacking the essence of the meeting… face to face… all the bodily work that we do when we meet our patients or with the family, containing the emotions or feeling the energy, the atmosphere… and assessing or finding things between the words or outside the words. So, that of course, is missing Q31, P24: When someone is someone is psychotic, you feel it, you smell it when he gets into the room. You feel it in your body, like, “Ah, something's not okay.” And it's kind of hard long-distance. And what I haven't done, but I think it would be really hard, but I haven't, is autistic disorders. I haven't had that in this quarantine, but that might be difficult I'm thinking Q32, P34: all of our training programs have transitioned to remote learning, remote teaching completely. We don't have any in person outpatient care in child psychiatry… I think some trainees are a little concerned about the quality of their education, how they're going to be impacted if they're not going to see these kids
3. CAPs’ emotions
	Q33, P17: I saw an opportunity for the families to find resources. I was quite calm about it and, with the exception of one family, all the others did pretty well. Family competency is confirmed! Q34, P25: Because of the family crisis causing effects on the patients, if there’ a family crisis, not only have they been through depression problems with some of the family but it is also being exacerbated by economic issues, which are not federal in Mexico in these days. Jobs have been lost. Most of them are middle class employees and they have therefore affected many of our patients now. It's very sad Q35, P01: and also the effects of this peculiar period, we thought we would see a lot of patients with OCD and anxiety. A lot of teenagers, because teenagers would be stuck at home with their parents. Not an obvious situation, we all know that. That was our fear
3.1 Angst	Q36, P05: I was highly anxious myself at this moment… the first 15 days, it was really general anxiety. I was like: what is happening? Are we in danger? Those first 15 days it was more handling my own anxiety Q37, P22: They were, but I had a pool of patients, let's say there were about two handfuls of patients, these were the patients that I was worried about because these were depressed patients… there’s also the adolescent patients that I was worried about. That day some of them had ADHD, some of them ADHD and depression, so I was worried about how they were going to cope Q38, P5: This kid did not have access to technical means to…, not everyone has internet you know, or a computer at home… and it was very difficult to reach her on the phone. We tried but no one was answering. When it is discontinuous like that, there is less presence, It does not make sense for them I think. And physical presence, I mean when you are not well, it is not about what you say or do, but it is about being here. And this is a big part, even the main part, of our job: be there, at the end doesn't matter what you say as long as you are here for them, even in silence. There is this need for physical presence, to really see them Q39, P1: For instance, kids with anxiety, with school refusal issues, what we used to call school phobia… the fact that they are doing well during this crisis, I think we need to think more about it Q40, P9: More self-disclosure because some parents and even some kids allow themselves to ask about how I am doing, for example, when ending the session, they could say that they hope my family stays healthy. Or be safe. Or “be safe you and your family”, so stuff like that that they wouldn't normally do Q41, P20: Honestly, I don't know if you I call it “therapeutic consultation” when all what we can do is to chat on the phone and send the prescription by mail. I mean, of course it must have had a therapeutic effect, but definitely, it was not the same… I wouldn't say that I continue to “treat” them during the lockdown, what I did was keeping in touch… at the end of the day, it’s not much Q42, P3: No, I didn’t make them pay… I would not feel comfortable with this
3.2 Loneliness	Q43, P6: It was empty, a phantom-like ambiance… we felt very isolated since all the meetings were postponed, canceled, or transformed into ZOOM meetings. All the training part was canceled
Working alone, without colleagues	Q44, P16: It was the recommendation that people not stay at home so that all the staff of the polyclinics came to the polyclinic, but then we had to operate with the remote connections. So we really tried not to meet in the kitchen or in the cafeteria or in the relaxing room, but instead of that, we had coffee at our desk and all the meetings between the staff with remote connections via Zoom or Skype… Kind of only coming here to work and not to interact Q45, P34: I probably leave the house around 7:30, I get here around 8:00 AM… and I just have Zoom after Zoom. I have Zoom fatigue. I’m constantly like boom, boom, boom. Usually one meeting kind of bleeds into another… A full Zoom day Q46, P1: We work from a distance, and way less than usual. We went from full days of work to keeping few hours per days. And at home, it is more difficult to work. I remember when we did the first meeting online, I said I want everybody with the camera on, I don't want anyone in pajama, not shaved… I have this team responsibility and it was very important that the team feels the solidarity and the bond between us, not everyone in his little corner Q47, P15: I woke up, I was going to work for practical reasons, my partner was working from home and was always on the phone. It was not possible Q48, P18: I had a full agenda with a lot of meetings and contacts with colleagues between the meetings Q49, P28: I think the hard part is that there's no separation between work and the rest of your life… it's tiresome. You don't get up and walk around as much. There's not as much writing in your day and you miss direct contact with your colleagues. Although, we have meetings. We've written three grants in this time. You meet with your grant-writing team and all of that. In fact, I'm working on my fourth grant now. So, a grant a month, which is pretty good. But it's tiresome but it feels good to interact and work together on these projects Q50, P01: One interesting point, we could invite people from the all world to our meetings, as they were online Q51, P6: Some disappeared from our radars. Child protection services, they were only teleworking and only by phone. It was not organized at all and they completely stop the interventions. Some situations, without the support and intervention in the presence from child protection services, families don't show up Q52, P33: As I was saying, the day hospital is closed and we don't know yet when it will reopen… so the day hospital patients will be followed in the outpatient clinic, and for the ones that colleagues want to address for day-hospital, it is even impossible now to even put them on a waiting list
Working alone without the other childcare professionals	Q53, P6: I have one particular situation that worried me a lot. I had to hospitalize a patient… I had the feeling I was all alone, dealing with this situation, I tried to call everybody and no one was available, I mean no one was even answering the phones. Contacts were through mailing only except in some urgent situation it is not possible to do it through e-mails Q54, P27: We were concerned that the children were likely going to regress because they're supposed to continue or start therapy and all, but because we were not able to access, we were afraid that we are likely going to lose some milestones by the time they could benefit for specific care Q55, P32: I can see them, but they can't see me. So one of the things that I suggested to our nurses that need to make some badges, a big picture of what we look like without the PPE, to help our patients see us, see our face Q56, P8: Those kids, I'm still seeing them in person. I take them for walks… They are not allowed in the program. So I meet them outside the program in the street Q57, P6: With one patient for instance, we played chess together. We both had a chessboard and we played like that. Then he suggested we directly play online and it was easier
Resilence and creativity	Q58, P2: In fact, we actually thought families would have difficulty managing the change, taking care of them throughout the day because day care [centers] are closed, therapies are closed. They don't have… I mean, I predominantly see autism and developmental disorders in the hospital, so I actually expected a lot of things to go badly. But, we had many parent interviews, we had Webinars with parents, we had online meetings with parents, groups, asking how they're all doing. Surprisingly, most of them seem to be doing really well, probably because both parents are at home, there is a lot of family support, and now they're actually working almost as therapists, they're actually doing home-based intervention programs, they are the only therapists available Q59, P24: They're at home, so the mom said, “Why is she always goes to the bathroom after we eat or stuff like that?” The quarantine makes the parents more responsible and that they can spot more of the symptoms. That's clearly happening with eating disorders. They are getting aware, or they cannot minimize that a girl is jumping three hours at home. You can see it, it's not like sometimes they take them to the gym and say, “Okay, she stood at the gym, maybe she was with her friends.” And now no, now they are looking at them Q60, P9: It is going very well with the parents… We are completely on the same team, working together… Paradoxically, the pandemic is doing well for the alliance with the parents Q61, P12: I mean I always ask my patients what they prefer. If they want to have the session with their parents around, or if they want to talk to me alone. And I find that even a lot of the parents wants their teens to talk to you alone, and usually the kids end up going to their bedrooms with the phone or what-ever, or they go to the basement, go to kind of a quiet space for them. Yeah, but some still want to be around their parents