IntroductionAlthough Pilonidal disease is rarely life-threatening, it is a painful and potentially embarrassing condition that if left untreated or treated poorly, can disrupt a patient’s ability to enjoy life, function at work, develop relationships, or attend school or the military. There are several different approaches to this problem which include non-surgical measures, minimally invasive surgery, excisional surgery, or flap surgery. This article relates the experience with a surgical practice that offers only the cleft lift procedure and describes the degree of patient satisfaction with the operation.Materials and MethodsSeven hundred and fifty-one patients were treated between 2011 and 2021. Surveys were sent out to these patients by email after at least eight weeks had elapsed from surgery. The study was closed once 500 responses were obtained. Statistical analysis was performed to determine if patients who had undergone previous pilonidal surgery  had different opinions than the patients who did not (primary group).ResultsOf the 500 respondents, 494 (98.8%) were “extremely satisfied” or “satisfied” with their procedure; 444 (88.8%) felt that the recovery process was “very easy” or “easy” and only 56 (11.2%) felt that it was “difficult but worth it” or “really hard”. Four hundred and one (80.2%) felt that the activity restrictions were “minimal, I was back to normal activity very quickly”; 438 (89.4%) felt that the scar looked “really good” or answered, “it’s fine, not an issue for me. I’m just glad to be done with this”. Whether the patients had previous failed surgery or not, the vast majority (78.2% and 79.6% respectively) felt that the cleft lift was an appropriate first operation for pilonidal disease; and statistical analysis failed to show any significant differences in opinions between the primary and salvage groups on any of the questions. The few patients who ultimately were dissatisfied with the procedure were unhappy with the cosmetic appearance of the scar and shape of the buttocks. By comparing the demographic characteristics of the respondents to the entire cohort, we found them to be similar groups, suggesting that the respondents were representative of the group as a whole.ConclusionA correctly performed cleft lift operation provides a solution that is very well accepted by patients, specifically in regard to recovery time, appearance, appropriateness, and overall satisfaction. In our pilonidal clinic, we strive to perform a cosmetically acceptable procedure that removes all active disease, prevents recurrence, and provides a solution with which the patient is satisfied. If the patient is not pleased with the cure, then the procedure was not a success for that individual. This paper is a report on patient satisfaction with the cleft lift operation over a 10-year period and includes survey responses from 500 patients.The cleft lift procedure was described by Dr. John Bascom in 1987. This was a modification of the Karydakis procedure, which is an off-midline closure operation, described by Dr. George Karydakis in 1973. The cleft lift operation has been found to be effective in treating pilonidal disease as both a primary procedure and as a salvage operation in patients who have failed other operations [With the advent of internet-based surveying techniques and the prevalence of email communication the ability to get patient’s opinions on their surgery and recovery has been enhanced. We began this survey process in 2011 using a Survey Monkey survey which was sent to all patients approximately two to three months after their operation. Surveying patients within this time frame would allow their recovery issues to be fresh in their memories, but not so soon that primary healing had not occurred. This is not a study of complications or recurrences, but rather the patient’s subjective opinion regarding the procedure. The wording of the questions and proposed answers was specifically structured to use only a small number of questions in non-clinical language, and include “other” fields for patients to elaborate on their answers and mention issues that the questions might not address. The patients in this cohort consisted of patients who chose the cleft lift as their first excisional procedure after diagnosis with pilonidal disease (primary group); and also patients who had one or more previous excisional procedures including minimally invasive procedures, open and closed excisions, and flap procedures . Incision and drainage operations for pilonidal abscesses were not considered excisional procedures.All of the patients in this cohort had the cleft lift operation done by the author. The key factors in performing this procedure are to flatten the entire gluteal cleft, remove all active pilonidal disease, and position the final incision well off the midline -3.The survey consisted of fourteen questions, nine of which were non-clinical and consisted of: how they found our clinic, how easily they were able to have surgery scheduled, and what they thought of our follow-up process, and some demographic questions. The five clinical questions, which are the topic of this paper, are related to the patient’s satisfaction with how they felt about: the procedure overall, the recovery process, the post-op activity restrictions, the appearance of the scar, and the appropriateness of the cleft lift as the first operation for a patient with pilonidal disease. The question about appropriateness was posed differently to the primary vs. salvage groups because we felt that patients who had previously failed surgery  might have a different viewpoint than those for whom this was their first excisional operation (primary group). All questions were analyzed looking for differences between these two groups. The survey monkey data was entered onto a Microsoft Excel spreadsheet and chi-square tests were used to calculate p-values and statistical significance.The survey included one open-ended question asking for opinions about the care they received at our clinic and for “Any advice for us to serve you better, or advice for other patients?”. Narrative answers were reviewed and categorized as appropriate for the question being posed.We ended the study period once 500 surveys were returned. During the time frame of the study, this included 751 patients, of whom 500 (66.6%) responded. Not all patients completed all questions, but each of the five questions for this study had at least 490 answers. Sixty-eight patients were not comfortable providing their name along with the survey, even though the majority of the responses from these 68 patients were quite positive about their experience.Overall patient satisfaction with the procedureThere were 500 responses to this question. The wording of the question and choices is demonstrated in Figure We looked at the responses to this question as either positive or negative. The positive responses were “extremely satisfied” or “satisfied”, and 494 (98.8%) of the patients chose one of these. Only six (1.2%) answered that they were “not very happy with it, but it did heal” or “unsatisfied, I’m still having problems”.When divided into primary vs. salvage patients, 276 out of 277 (99.6%) of the primary patients gave a positive response, vs. 218 out of 223 (97.6%) of the salvage patients, the difference was not statistically significant (p = 0.09).Patients’ opinion of the difficulty with recoveryThere were also 500 responses to this question and the wording and graphical view of the data is seen in Figure For this question, we felt that the answers indicating that the recovery was “very easy”, “easy”, and “better than I expected” were all positive responses, and that “difficult but worth it” and “really hard” were considered negative Table .Overall, 444 (88.8%) respondents gave a positive response, and 56 (11.2%) gave a negative response. The positive response rate for primary vs. salvage patients were rates of 89.2% and 88.5% respectively, which were not statistically different (p > 0.05). There was the option to add comments to this question and 170 patients had more to say. We specifically searched these comments for any indication of chronic pain; only two patients said they had minor discomfort with sitting at two months post-op.Patients’ opinion of activity restrictions after surgeryWe attempted to minimize the restrictions placed on patients during the postoperative period. The main restrictions were to avoid contact sports, jogging, and biking for six weeks. Sitting, showering, and normal ambulatory activity was encouraged immediately after surgery. The survey responses can be seen in Figure Patients' opinions regarding the appropriateness of the cleft lift as a patient’s first operation for pilonidal diseaseOne of the most controversial topics regarding the cleft lift is its place within the treatment algorithm for pilonidal disease. At our clinic we recommend this for any patient with pilonidal disease who understands the operation, the post-operative restrictions, and the cosmetic consequences; we make sure our patients are well educated regarding the procedure and refer them to a comprehensive website created by the author which includes many post-operative photos . We posePrimary PatientsThese were the 221 patients who had not had previous excisional surgery. The exact question posed and possible answers are shown in Figure Salvage PatientsThere were 275 patients who had one or more previous operations before the cleft lift at our clinic. The question for these patients is seen in Figure Why is there controversy? I wasted $5,000 on surgery, gauze, gasoline, and eight months of my life taking showers twice a day, getting stung by silver-nitrate weekly, and also not sitting properly, only to have a second surgery all over again. The cleft-lift should be standard practice, especially considering it's almost 100% success rate.Patient’s opinion of the appearance of the buttocks and scarOnly 490 patients answered this question Figure . The oveOpen-ended narrative question about their experienceWhen asked about “any advice for us to serve you better, or advice for other patients?”, 339 patients chose to elaborate on their answers to this survey. These answers were categorized as positive, negative, or neutral. Neutral comments were either observations without praise or criticism, or combined the two, such as “The first few days were very painful, but after that everything went well and I’m very pleased”. There were 322 (95%) positive, 12 (4%) neutral, and one (0.3%) negative. The single negative comment had to do with the amount of preoperative information given. Notably, none of these comments indicated that patients were experiencing chronic pain at the site of the operation.There is much controversy about the optimal procedure for treating pilonidal disease  because As surgeons, most of the operations we perform have high success rates and the majority of patients are satisfied with the results. However, with pilonidal disease many of the operations require prolonged wound care, and recurrence rates have been reported up to 67.9% at 20 years [For the few patients who were ultimately unhappy with the cleft lift procedure, it was based on their experience regarding the change in the shape of the buttocks and the scar, and this is very understandable. However, it does not mean that they would have been happier with the results from any of the other operations for pilonidal disease, and more studies of patient satisfaction from other operations are needed to put this in context. Nonetheless, the vast majority of these patients gave either positive answers regarding the appearance; or had a mature outlook on the situation and indicated that it wasn't a significant issue for them, and they were just glad to be done with their battle with pilonidal disease. The few that were unhappy with the appearance had good results - but their subjective opinion of the appearance was negative; further supporting the concept that there can be a disparity between the surgeon’s and the patient’s idea of success, and further highlighting the importance of preoperative discussion.The most controversial questions in this study seek the patient’s opinion on whether, in retrospect, they agree that they chose the right operation for their problem and whether they feel that the cleft lift is a reasonable choice as a patient’s first operation for this disease. In our clinic, we take an extremely positive view regarding the broad application of the cleft lift procedure. If our surveyed patients disagreed with this concept, this would have required re-evaluation. If we combine the responses from both the primary and salvage groups for this question, 496 (93.8%) feel that this is a reasonable first choice for a patient with pilonidal disease. It was notable that although 7.2% of the Salvage patients felt that a patient should fail a simpler operation before having a cleft lift, none of the patients felt that “The cleft-lift should be a last resort, and only used when multiple other operations have failed”.There have been other studies of patient satisfaction after pilonidal operations. Gaiser et al., correlated satisfaction after wide excision to gender, pain killer intake, and smoking cessation, and reported a mean healing time of 20 months . Doll etA limitation of this study was the response rate of our patients, which was 66.6%. However, the demographics of the respondents matched the cohort as a whole, so we feel that this is a representative sample of patients. The lack of a universally accepted pilonidal classification system and a validated tool for assessing patient outcomes  hampers When performed in a high-volume pilonidal clinic, patients indicate a high satisfaction rate with the cleft lift procedure. The few instances of dissatisfaction are related to the patients' opinion of the buttocks and scar. Overall, patients feel that the recovery from surgery and the activity restrictions are quite manageable. They feel that it is an appropriate option as a primary procedure. The high satisfaction with the procedure, recovery, and appearance, was the same whether or not they had previously failed surgery.


Open Access funding enabled and organized by Projekt DEAL.The article “Intragenus F1‑hybrids of African weakly electric fish (Mormyridae: Campylomormyrus tamandua ♂ × C. compressirostris ♀) are fertile”, written by Yevheniia Korniienko, Linh Nguyen, Stephanie Baumgartner, Marianne Vater, Ralph Tiedemann and Frank Kirschbaum, was originally published Online First without Open Access. After publication in volume 206, issue 4, page 571–585 the author decided to opt for Open Choice and to make the article an Open Access publication. Therefore, the copyright of the article has been changed to © The Author(s) 2021 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The original article has been corrected.


This paper uses secondary analysis to understand how COVID-19 shaped people’s experiences with psychosocial support services in Australia. Data are drawn from questionnaires (n = 66) and semi-structured interviews (n = 62), conducted for a national service evaluation, with 121 people living with enduring mental health conditions and using psychosocial support services. Data relating to COVID-19 were inductively coded and analysed using constant comparative analysis. Most people’s experiences included tele-support. While some people described minimal disruption to their support, many reported reduced engagement. People’s wellbeing and engagement were influenced by: their location, living situation and pre-COVID lifestyles; physical health conditions; access to, comfort with, and support worker facilitation of technology; pre-COVID relationships with support workers; and communication from the organisation. The findings can help services prepare for future pandemics, adjust their services for a ‘COVID-normal’ world, and consider how learnings from COVID-19 could be incorporated into a flexible suite of service delivery options. This study examines the impact of COVID-19 on people’s experiences of psychosocial support services. Psychosocial support refers to non-clinical services that assist people with enduring mental health conditions (EMHCs) to build skills to manage their mental health conditions, improve their relationships, and increase social and economic participation . Governments have provided additional funding to support tele-support expansion to ensure continued access  prepare for future waves and pandemics; b) adjust their services to an ever-changing ‘COVID-normal’ world; and c) consider how the adaptations necessitated by COVID-19 could be incorporated into a flexible suite of person-centred service delivery options in an ongoing way. A useful way of exploring the interaction between COVID-19 and psychosocial support is through direct lived experience insights from people who are living with EMHCs and using psychosocial support services. Service users’ subjective experiences are increasingly being recognised as critical to developing and delivering person-centred services .Data were collected for this evaluation in Australia between June and October 2020. During this period and in the preceding four months COVID-19 was having a profound effect on the lives of Australians  and Continuity of Support (CoS). Questionnaires and Participant Information Sheets were distributed by all willing service providers of NPSM and CoS services across the country (n = 105) to all current and former program participants who they could contact. A total of 500 people completed the questionnaire. Participants for qualitative interviews were recruited via a final questionnaire item, which asked respondents if they were willing to discuss their experiences in an interview. A total of 349 people agreed and provided contact details. Maximum variation sampling , or over the phone with one of the researchers. Questionnaire data were collected via REDCap, an online secure data capture tool with survey function. Where participants responded via paper questionnaires or telephone, responses were entered into REDCap by the researchers. Questionnaires included demographic items and questions about service involvement and satisfaction. They also included 3 open ended questions asking about “the best or most helpful thing” about the service, the “worst or least helpful thing”, and for any additional comments. While questionnaires did not specifically ask about COVID-19, it was often discussed in response to these open-ended questions.In-depth, semi-structured interviews were conducted for a deeper and more detailed exploration of people’s experiences and perspectives  described negative impacts. These related to the perception of risk of catching the virus, the impact of social distancing restrictions on their activities, uncertainty around the wider and future impact of the pandemic, and reduced access to formal and informal supports. For example, i22 explained that “all my health services stopped, so it was quite hard”, while i19 reported that “after a while, just sitting here day in and day out, I was feeling a bit not so good”. Others talked about feeling frustrated, sad, worried or anxious.There was considerable variation amongst participants in terms of whether and how their engagement changed during the COVID-19 restrictions. Some reported that psychosocial support services had become more important and necessary than at other times or that their services had continued to support them. Other participants, however, reported reduced engagement. Most discussed how the mode of service delivery had changed.q77: The contact - during COVID-19 it has been imperative to my mental health that I had contact from an external organisation to help me feel 'connected' to the outside world and to have someone to speak to about how I was feeling and what I was going through. Their contact has been so important and helpful to people in isolation and that having someone on the other end of the phone has made such a difference between coping and not coping.Due to the impact of COVID-19 on their lives, several people stated that their need for psychosocial support services had increased . For example, q77 stated that the most helpful aspect of the service was:i22:That was their strong point… the agency tried really hard to make sure that people didn’t get isolated or didn’t lose their support.Eleven participants , including 6 for whom engagement had become more important, reported that the psychosocial support service had helped them get through these difficult times, particularly by things like providing “a general catch up about how things are going” (q371) and letting people “know that there is someone looking out for me” (q366). Ten additional participants (10i) reported that the service had adapted well to the crisis, continuing to support them at similar levels throughout lockdown.For more people, however, engagement with the service was reduced due to closure of groups and activities, the inability to pursue goals that involved community participation, and reduced or delayed provision of individual supports.Thirty-two participants  described their engagement with services decreasing because COVID-19 restrictions meant that group activities, such as support groups, outings and social gatherings could no longer happen and people could not attend the service in-person. This was a great loss to many participants, even though they understood that it was necessary. i13 explained: “it was more socially with clients or with staff, there was none of that for a whole two months and I just, it got to me.” q430 summed up the feeling by stating “I can’t wait for the lockdown to end and for all the other activities to start”. Once group activities restarted, access was often less than it had been previously because of limited group numbers .i20: One of my goals was to—like I really was wanting to get involved in like some group stuff, so outside of the house. That was all …it's been put on hold.Eleven participants  talked about how some of their goals for their work with the service had to be put ‘on hold’ because they involved interacting with other people in the community in a way that, during lockdown, was either impossible due to community venue closures or seen as too risky. Getting involved in community activities and making friends were the most common goals affected.Other goals also stalled. For example, i21’s progress toward cleaning up her unit “just stopped” because her support worker could not be physically present, second-hand shops had stopped accepting donations and she could not find “a person who could take the rubbish away”.Twenty-seven participants  reported other delays, disruptions, and lack of support which they attributed to COVID-19. For example, for q107, the ‘worst or least helpful’ aspect of the service was “COVID-19 restrictions preventing people to get help”, while for q191 it was “not enough support due to COVID”. Interview participants provided more detail, with some reporting that their contact with the services became less frequent or regular, reducing their access to social and emotional support. i17, for example, reported that, “a couple of times I got a couple of text messages from some of the staff. That probably only went for a couple of weeks and then they just became distant.” i42 shared a similar experience, saying that “when things were normal, I always had a regular day or time to see [my support worker], and then when COVID came, things became different.”i8: [I would like] more social visits, I live alone so, I went to church yesterday and asked the pastor how many people he [can have] at his church worship and he can have to fifty. So, if you can have up to fifty, surely [my support worker] can come to my unit, just one-on-one.A couple of participants described promised support that had not gone forward even after restrictions were lifted and three participants (3i) expressed the opinion that services were maintaining stricter precautions than necessary, delaying getting back to pre-COVID support.Seventy-five participants  reported their psychosocial support service replacing at least some of their face-to-face sessions with telephone or internet-based communication. This involved: phone calls ; one-to-one videoconferencing ; and group videoconferencing , with some people describing services using multiple methods.i18: I'm occasionally not okay with face-to-face stuff. So it's been good for me to be having the video there because - I'm still seeing and being seen but it feels like it's one removed, so I'm not as intimidated.While four people  simply mentioned the change to tele-support without expressing an opinion, most told us how they experienced tele-support. Five participants  reported finding advantages of tele-support over face-to-face sessions. Some found it convenient: “It's been really helpful that I don't have to leave my house and organise transport and stuff” (i24). For others it was a less threatening alternative.Twenty more people (20i) indicated that they felt positive or neutral overall about having their interactions via tele-support, seeing it as a good replacement, or not making much difference to their experience. They said things like “I felt like the phone contact didn't take that much away from me” (i04) and “it’s like you’re there in real life” (i10).However, 47 people  indicated that the move to tele-support was negative for them. Eighteen questionnaire respondents answered the question about least helpful aspects of the service with comments like “no face-to-face contact during COVID-19” (q147). This was one of the most common “least helpful things” mentioned in questionnaires. Many interview participants also expressed a general preference for face-to-face interactions, stating that phone calls or teleconference “just hasn’t been the same”(i21) and “I prefer face-to-face, obviously” (i31). However, 21 people  provided more detail about problems they encountered.i60:[My support worker] can seem to instinctively be able to find out what's going on with me. Just one look at me. You can't do that over the phone. I could tell you the walls are pink here and you wouldn't know whether they're pink or blue or what.Some stated that the physical presence of another person was important to them, especially in isolating times. i35 explained how tele-support “was a bit difficult for me. I found I wasn't as into it. I don't know why, but I just prefer the person-to-person contact… and just the physical connection”. With phone calls in particular, people missed being able to see the support worker and read their body language. Similarly, the support worker was thought to be less able to be sensitive to how the person was going.q36: Communication from others in the group was stilted. The group participants were difficult to see and sometimes hard to hear…The online group was nothing like the cohesive and worthwhile groups I have done in person.For these reasons, a couple of people expressed a preference for videoconferencing over phone calls. However, videoconferencing had its own issues, with a couple of people reporting difficulty connecting, interruptions, and a reduction in meaningful interaction.Some reported that using phone or videoconferencing: made it more difficult to develop trust and rapport with their support worker, reduced their ability to concentrate, and made them feel less relaxed and comfortable, impacting on the therapeutic value of the interaction. For example, i40 said that “it sort of almost feels like you're talking to a machine”, while i32 described becoming bored quickly when interacting through the computer and that “a lot of times I just want to hang up.”Most people accepted tele-support as being necessary, even if not ideal. For example, i5 explained that “for me it's just another challenge… something I've got to get through until we're back on our feet and mobile again”. Four participants, however,  reported having reduced their engagement with the services because of the perceived insufficiency and difficulty of tele-support. i19 explained that, because the group was online “I didn't want to do all that, so I just left it.”i36:[My support worker] was well aware of the fact that meeting her in person, like physically seeing someone and being around other people once a week was very important to my mental health… we'd go and sit down at a park and just sit apart from each other and talk.Twenty participants (20i) reported that they had continued to have at least some face-to-face interactions with their support worker during the COVID lockdown. People described modifications, such as sitting in the back of the car, wearing a mask, answering questions beforehand about any symptoms, and interacting outdoors at a distance. People tended to appreciate this continued face-to-face support.People described several factors that they felt influenced the impact of COVID-19 on their wellbeing and their engagement with services. These included: their location, living situation and pre-COVID lifestyles; any physical health conditions; their access to and comfort with technology; how the support worker facilitated technology use; their pre-COVID relationship with the support worker; and communication from the organisation.Where people lived affected the level and duration of restrictions and the perceived risk of COVID. For example, those living in Victoria were experiencing a second extended lockdown, while in other states, severe restrictions had been relatively short-lived. Several people (n = 6i) mentioned that living alone had heightened the impact of the restrictions. For example, i13 explained that “it was hard, all you'd do is go to work, come home—it really hurts your life”. A couple of people were grateful to have a flatmate, caring neighbour or a pet to provide contact during lockdown. For some, particular features of their situations, such as living in a remote area, having few social contacts, or having family members in different states increased their feelings of isolation. This sometimes made psychosocial support more important. However, others (n = 6i) noted that the impact of COVID-19 on them was not as severe because “I’m not a very social person” (i7), or “I was isolating way before COVID came in so nothing's really changed in my life in that respect” (i41). People felt the effects of COVID on services more if they were previously involved with and highly valued the group activities offered, which were no longer available.i33: I try to be really careful and I guess that’s stressful in itself. Then when you go out, there’s all the stuff you’ve got to remember and things you can do and you can’t do, and meant to do, and yeah, so it has put an extra bit of stress on.Participants who had a physical condition that increased vulnerability to COVID-19 or who cared for someone who did (n = 5i) reported increased restrictions and worry, as exemplified by i33, who had a chronic health condition.Comfort and familiarity with using technology was very important for people engaging with tele-support. For example, i31 explained how “I've done work with psychologists and psychiatrists and stuff through Zoom, so I'm pretty used to it now”. On the other hand, i38 stated that “I’m not very comfortable at all online with anything.” People also needed to have the right equipment and services. Some people who did not have a computer, for example, or who had poor internet reception, felt more isolated or that they faced additional barriers to a smooth and positive experience of tele-support.i18: We can type down little notes of things that we're interested in and we can both see them and talk about them… then at the end of the call we both get a copy of that.How the technology was used and facilitated by the service providers was also important. While two participants mentioned that staff needed more training, time and funding to transition to online service delivery, others talked about how teleconferencing was “made user-friendly by the staff” (i9) or how staff persevered in helping them to learn the technology. One participant was impressed with the support worker’s use of videoconferencing features.Six people  mentioned that their comfort in engaging with their support worker remotely was influenced by their existing relationship. Five had not previously met their support worker face-to-face or had only met once, and they found this difficult. For example, q451 said she could not trust her support worker because they had never met face-to-face. On the other hand, i56 described how “I have already met with them on face-to-face meetings so changing to telephone conversation did not make any significant change.”i40: They made it very clear. It was very obvious what was happening, but they explained it to me that ‘your program – it's just been delayed, it hasn't stopped, you haven't missed out, but because of COVID and the COVID rules and lockdown’.Eight people  indicated that their experience was influenced by the communication between themselves and the service, which determined their knowledge and understanding of what was going on and what to expect. For example, q265 said that they were “not really getting much contact lately, and not knowing what's going on with it.” i40, on the other hand, felt that the communication had been good.i17: Through this Coronavirus, it's been a really bad time, my support worker has contacted me consistently and if she isn't there she will get someone else to contact me.Twenty-four participants  described support workers proactively engaging with them throughout COVID, by making contact and checking in with them, for example, through increased text messaging. This was generally appreciated.Five participants felt reassured that they could call the service when they needed to, with i48 saying that she “always knew I had phone access to [my support worker] when I needed it.” On the other hand, i42 explained that, despite needing support during lockdown, she had not phoned her support worker because “I didn't realise that it's okay to.”Psychosocial support programs provide an essential service that addresses people’s basic needs to better manage their mental health, stay connected and actively work on their recovery goals. Physical distancing requirements associated with the COVID-19 pandemic have impacted psychosocial support service delivery (Productivity Commission, Our findings indicate that continued engagement with psychosocial support services is important to service users. Yet our participants were more than twice as likely to report reduced engagement than continued engagement at a similar level. While some activities, such as attending community events, may have needed to be put on hold, other delays and disruptions were not an inevitable consequence of social distancing. For example, some participants received socially distanced face-to-face services and others attended online groups, even involving practical activities like cooking. Reductions in individual contacts, an important source of social and emotional support, were likely due to upheavals caused by services being overwhelmed, which can largely be attributed to the speed at which they were required to adapt and change modes of service delivery in a COVID-19 environment. Our data suggests that a lack of familiarity with tele-support options amongst both service providers and users may also be important. This has highlighted both a need to prepare for a more agile service response in future situations and an opportunity to incorporate new modes and options into standard service provision.Using technology to deliver health services has, for many years, been advocated as a viable way of facilitating access for those who face barriers, particularly for those living in rural and remote areas (Dew et al., Encouragingly, in our study, around a third of participants who reported receiving some psychosocial tele-support services were positive or neutral in their perceptions of it as a replacement for face-to-face services. Attending to the barriers described by the other two thirds of participants will be critical to facilitating increased comfort and uptake of tele-support services, both in the event of further pandemic events and to increase flexibility and choice in normal service delivery.Issues with technology amongst people with EMHC are often cited as a barrier to telehealth. For example, the Productivity Commission  reportedOur study indicated that familiarity with technology and tele-support was important to people’s experiences. This is supported by research in allied health, which has suggested that the acceptability of telehealth services increases with experience and exposure (Hines et al., However, working with service users to facilitate access to and comfort with tele-support requires support workers to have positive attitudes and skills around tele-support. Health professionals’ attitudes have been identified in both mental health and allied health research as a barrier to telehealth implementation (Topooco et al., Specific skills and strategies are likely to be needed to optimise tele-support experiences for service users. For example, psychologists using technology for appointments during the pandemic reported that they learned strategies such as using words more to communicate empathy and ‘check in’ with clients, and using more exaggerated physical gestures (Downing & Harriott, Several limitations to this study should be noted. First, service users who had lost contact with services, whether due to negative experiences or other reasons, are not represented in this study. Second, the same ‘tools’ of engagement were used in interviews as in tele-support – telephone and video conferencing. It is likely, therefore, that those with the greatest barriers to tele-support options may not have participated in the interview component of this study. Lastly, as a secondary analysis, the impact of COVID-19 was not the primary focus of the study. There were no explicit questions in the questionnaire and only one in the interview guide about the impact of COVID-19 so the relevant data from each participant was limited. Further, sampling for the original study was not based on saturation of COVID-19 related categories. However, the spontaneous comments around COVID-19 throughout questionnaires and interviews indicate that it was an important issue, and the number of people’s perspectives represented in the analysis enabled coverage of a considerable range of issues.Psychosocial support services have been forced to engage with tele-support throughout COVID-19. While this has not always been a positive experience for service users, it has opened up possibilities for the future. Some people with EMHCs may never find tele-support practical or acceptable, and person-centred services need to acknowledge and respect that. However, our research shows that others are, or may well be open to tele-support if given the right resources and opportunities to learn and use it in positive circumstances. Given the potential benefits of tele-support and the learnings from COVID-19, rather than abandoning tele-support in a post-pandemic world, psychosocial support services, their staff and clients would benefit from additional investment in a planned and well thought out transition toward blended service delivery where this is compatible with person-centred practice. This requires research, evidence-based guidelines that are co-produced with people with EMHC around tele-support practice, and government support through ongoing funding and policies to move into this new era of healthcare service provision wherein tele-support is offered as part of a suite of service delivery options.


Lorsque l’enfant paraît, she responded to thousands of letters sent in by listeners requesting help with parenting problems and personal questions of a psychological nature. The article explores Dolto’s cultural position as a child psychoanalyst – understood in the 1960s and 1970s as a radical profession – but from a conservative, Catholic background. It then examines a sample of the letters sent in to her show, analysing the demographics of the correspondents and highlighting their most common concerns. Finally the article studies the relationship between psychoanalysis and trauma. It indicates the anxiety that a psychoanalytic understanding can cause, by reinforcing parents’ fears that childhood traumas are common, can be created unwittingly by parents, and lead to major psychological consequences in later life.Françoise Dolto (1908-88) was a prominent French cultural figure thanks to her practice of dispensing psychoanalytically-informed child-rearing advice via the radio. From 1976 to 1978, on her show  SOS Psychanalyste! The exclamation mark revealed the ambiguity of the show’s intent. Listeners were offered the opportunity to discuss an ‘emergency’ personal problem with a qualified professional, but the show was also a form of entertainment. Dolto’s participation – soon identified despite hiding her identity behind the label ‘Docteur X’ – attracted criticism from the French psychoanalytic and psychotherapeutic community. How could one claim to dispense psychoanalysis, a treatment requiring a long-term commitment to understanding the deepest workings of the unconscious mind, in five minutes to a disembodied stranger? The concept was seen as bringing psychotherapeutic medicine into disrepute; Dolto was threatened with suspension from the Ordre des Médecins . The show was cancelled after one season.In 1968-9, the French psychoanalyst Françoise Dolto hosted a radio phone-in show on the commercial radio station Europe 1 entitled Memoirs of a Dutiful Daughter, she had numerous connections to the French media and political establishment before 1960 . Her brother, Jacques Marette, had been Minister for the Post and Telecommunications under Charles de Gaulle, while her son, Carlos, a friend and sometime driver to Johnny Halliday, had won fame as a radio entertainer and pop star. Popular engagement had been a theme of Dolto’s career since the Second World War. As early as 1946, she had a column in the popular magazine, Femmes françaises. She wrote for various psychological and Catholic publications, such as Psyché, run by the Catholic writer Maryse Choisy; Études carmélitaines, founded in 1949 by a liberal-minded priest; and the journal of the École des parents, an association – also of Catholic inspiration – with the aim of diffusing practical parenting knowledge and methods. She occasionally spoke on the radio in the guise of a child psychology expert, for example in 1950 to argue in favour of sex education. She took advantage of her brother’s ministerial position to commence what became an annual tradition in France, ‘la réponse du père noël’ – a friendly, generic reply, sent at state expense, to children’s Christmas lists.However, Dolto did not permanently renounce the idea of finding ways to bring psychoanalysis to a popular audience. Born in 1908 to a wealthy Catholic family in Paris’ prim 16th arrondissement, in which she experienced a cloistered childhood not dissimilar to that described by Simone de Beauvoir in les années ‘68 in reference to the role of the student and worker demonstrations of May 1968 as a trigger for the transformations in question . These changes included the growth of feminist, homosexual, and immigrant consciousness; a shift in the place of youth in society; and changes in educational philosophy. In addition, the 1970s were the culmination of a longer period of economic and social transformation that had begun after the Second World War. French economic growth in the 1960s was the fastest in Europe and second worldwide only to Japan. Cities and suburbs grew rapidly through internal and external immigration, life expectancy increased by some 8-10 years, and a new consumer and leisure-oriented society took shape – indicated by the growth in TV ownership from 9% of households in 1958 to 80% in 1974 .In the years following 1968, France was undergoing a series of significant cultural changes, often collectively referred to as les années ‘68 was that of religion. Regular church attendance dropped precipitately, from 30% of the population in 1961 to 14% in 1975, with most of the decline happening after 1969 . The number of ordinations into the clergy fell sharply.Above all, May 1968 embodied the weakening or discrediting of various forms of authority: that of De Gaulle and his government; the authority of the police, tainted by association with colonial and Vichy repression; the authority of the trade union Left, perceived as too embedded in the system and as having vacated the terrain of resistance and radicalism; and that of Marxist political analysis, discredited by the repression of the Prague Spring rather than events in Paris. For historian Rod Kedward, this period witnessed ‘final disintegration of the archaic ideological opposition to social change which had limped on in the ranks of the political right throughout the 1950s and had sheltered behind the authoritarian rule and nationalism of de Gaulle in the 1960s’ . A further authority that declined significantly in Following the 1968 events there was thus a strong appetite for new ideas and radical theories. Maoism was one of these, attracting intellectuals such as the philosopher Alain Badiou and the writer Philippe Sollers. Psychoanalysis was another. As a discipline it had had a relatively slow start in France; the Société Psychanalytique de Paris, the institution set up in 1926 to organise and promote it, had only 24 full members in 1939 (Roudinesco 1990). However after the Second World War it had prospered and established a significant foothold within the state medical system, such that by 1967, young medical graduates entering the psychiatric service felt under pressure to undertake a personal analysis . The movement was however fragmenting, with splits in 1953 and 1964 over how far psychoanalysis should be treated as a purely medical as opposed to a philosophical discipline, whether it should be practised by people without a medical degree, and increasingly, over the authority of Jacques Lacan. Lacan’s seminars, delivered at the École Normale Supérieure (at the invitation of Marxist philosopher Louis Althusser) from 1964, drew a wide audience from well beyond medicine and psychiatry, and appeared to announce the arrival of psychoanalysis as a central discipline in French intellectual culture. His theoretical radicalism and disregard for the norms of psychiatric and psychoanalytic practice  chimed with the predominant mood of questioning of authority.Écrits, first published in 1966, were re-printed in a popular two-volume edition in 1969. A number of younger psychoanalysts, such as André Green, Didier Anzieu, and Daniel Sibony, published their first books in this period, works which were not orthodox medical studies but instead pushed psychoanalysis into new areas of cultural and literary criticism. Another sign of the times was the creation of a Department of Psychoanalysis at the University of Paris VIII, under the control of the Lacanian disciple Serge Leclaire. By 1972, the increased cultural presence of Freudian thinking was producing its own radical backlash, for example in Gilles Deleuze and Félix Guattari’s Anti-Oedipus, and among some feminist campaigners.Public interest in psychoanalysis spiked after 1968, and publishers soon sought to capitalise. Lacan’s Psychoanalysis and Paediatrics, completed in 1939. In 1971 she was approached by an editor at the prestigious Éditions du Seuil who offered to re-publish that work, plus a book-length psychoanalytic case-study, Le cas Dominique. Both were reprinted as mass-market paperbacks a few years later, achieving solid sales and positive press coverage. And in 1976, a producer at the state broadcaster, Radio France, invited her to make another attempt at an audience-participation radio show.Françoise Dolto – who remained aligned with Lacan throughout the splits in the psychoanalytic movement – was a direct beneficiary of the growing prominence of psychoanalysis. Despite her regular writings in journals and magazines, she had not published a book-length work since her doctoral thesis, Dolto was an attractive choice for Radio France not only because she was a respected psychoanalyst with experience of broadcasting, but also because her position with regard to the radical legacy of May ‘68 was ambivalent. In effect, if many people were looking for change and novelty after 1968, there were also large groups of French people who felt disconcerted by the sense of a world being uprooted, and seeking reassurance and continuity. The massive pro-Gaullist demonstration of 30 May, eclipsing the mobilisations of the students and workers, and the large majority won by the centre-right in the elections of June 1968, were one manifestation of this. More broadly, the decline of France’s traditional rural economy and its attendant behaviours and attitudes (such as religious observance), and the growth of a technocratic, bureaucratic society in its place, made it seem to some as if a whole way of life was disappearing. This gave rise to nostalgia for a lost or fading artisanal world associated with authenticity and freedom from bureaucratic restraint, expressed in literature and popular culture and in the writings of thinkers such as the Jesuit intellectual Michel de Certeau.As a Christian who was old enough to remember both World Wars, who had grown up under the influence of conservative and even far-right thinking in the 1920s and 1930s  Dolto was well placed to appeal also to this second current. Her claim to expert authority was based in large part on her length of experience: she had qualified as a doctor and psychoanalyst in 1939 and had been a paediatric consultant at a Parisian hospital since 1940. She freely admitted that her advice drew on grandmotherly wisdom as often as it did on Freudian theory. She did not identify with feminism, and defended conservative positions on subjects such as abortion and gay rights. Her work tended to stress the importance of the classic nuclear family and the active presence of two heterosexual parents, which drew her a degree of criticism from feminists and homosexual rights activists, including for example Luce Irigaray .les années ‘68 in ways that would reassure a more conservative audience.Dolto in 1976 was thus in the unusual position of being able to speak to both aspects of the cultural climate of the time. She gained a certain progressive cachet from her association with psychoanalysis. She was becoming known as a liberal voice on some issues, notably sex education and educational reform, where she argued for school environments designed to foster children’s autonomy and creativity and criticized the obedience and rigidity that she argued had historically characterized France’s state education system. Yet in other ways she appeared to be out of step with the radical spirit of SOS Psychanalyste!, Dolto was initially reluctant to make another venture into radio, but eventually agreed. This time, however, there would be a crucial difference – instead of phone calls, listeners would send in their psychological dilemmas via letter, in response to broad themes suggested by Dolto.It would appear to have been this unusual balance which encouraged Radio France to hire her. Mindful of the failure of Lorsque l’enfant paraît (‘When the child appears’). It would focus on helping parents understanding the psychology of their children and dealing with problems with a psychological component – bed-wetting being a frequent example. It went out on weekdays at 3 p.m. and each episode lasted just fifteen minutes. Despite this apparently unpromising slot, the programme was an enormous success. It made Dolto into a household name in France, leading to three spin-off books that sold hundreds of thousands of copies (Dolto 1977-79). Transcripts from the earlier show S.O.S. Psychanalyste! were also published (Dolto 1976). By 1978 Dolto felt that she could no longer take on new clients to her psychoanalytic practice, because her degree of fame was such that she could no longer be a neutral presence.The new programme would be called The archive of letters sent to the programme was preserved initially by Radio France and subsequently by the Archives Françoise Dolto, which were in turn transferred to the Archives Nationales in 2015. It totals around 6,000 letters, offering an insight into the psychological concerns and anxieties of a cross-section of French society of the 1970s. For the purposes of this article, I examined a randomly-selected sample of 266 of these letters.To begin with, the show received modest volume of correspondence – around 40-60 letters per week for the first two months. Early letters mainly came from mothers and were concerned with direct questions of child-rearing, such as toilet training, sibling rivalry, breastfeeding, or how to tackle subjects such as sex or death with children. As the show progressed, the number of letters received rose to between 100 and 150 per week, and the average length of the letters also increased. Letters began to come in from adults and adolescents regarding their own psychological problems (as opposed to those of their children), and doctors, teachers and nurses wrote in offering their own perspectives. Dolto received numerous requests for book suggestions, for the names and addresses of recommended psychotherapists  or invitations to participate in lectures, conferences, governmental consultations, and various other events.Around three-quarters of the letter-writers were female. This gender imbalance disguises an even greater one when it came to parenting, for many of the letters from men were written in a professional capacity  or were penned by general listeners without a direct personal issue to raise. Of the 266 letters in the sample, 107 were written by mothers raising issues regarding their children, compared to only nine from fathers (despite repeated requests from Dolto for more fathers to write in) and five from both parents jointly. Nine letters came from grandmothers, and only one from a grandfather. A further six were from pregnant women.Letters came in from all parts of France and sometimes beyond – around 7% of the letters were sent from abroad, mostly from Germany, Belgium and Switzerland. The number of letters received from each French region was mostly in proportion to its population, but with some exceptions. Letters were disproportionately likely to come from wealthier regions such as those around Paris and Lyon, and the Pays de la Loire, Midi-Pyrénées and Auvergne. Disproportionately few letters were received from poorer regions such as Lorraine, Burgundy, Picardy and Languedoc. This pattern was repeated in the letters from within Paris. Most Parisian correspondents lived in the wealthy districts of western Paris, not the working-class areas of the north and east. This may simply demonstrate the truism that wealthier people have more time and inclination to write letters in to radio shows, but it may also say something about the social conservatism of Dolto’s core audience. For the most part, the letters are carefully written, without major errors of spelling or grammar, and most writers appear as to have, at least, a reasonable level of secondary education.sortent marqués à jamais) by the experience.1 Other representative examples include a letter from a 23-year old secretary in Chantilly, who wrote to Dolto of her difficulty in dealing with the crying of her 8-month old baby. Sometimes it all became too much and she resorted to giving the baby a smack on the bottom (fessée) to silence him. She asked Dolto to tell her ‘if this will have traumatised him and whether it will have psychological after-effects (des séquelles)’? . One mother wrote of her concern about children being traumatised by finding out about the realities of human sexuality too early, or in the wrong way; another asked whether allowing children as old as five or six to sleep in the same room as their parents would have long-term psychological repercussions . A further correspondent worried about the negative consequences for her child of a difficult weaning . One listener even wondered about the possibility of pre-natal trauma, wanting to know ‘how the psychical and nervous balance of a pregnant woman can be experienced by the child she is carrying’ . The language of error accompanies that of trauma; the mothers who wrote to Dolto were frequently afraid of making mistakes. ‘I’m afraid that it’s too late, I’m realising that I’ve committed major errors,’ wrote one mother of three children, aged between nine and twelve .The subject of trauma and associated lexical fields are a recurring theme in the correspondence. It is striking, however, that in most cases the trauma in question is one that is feared or hypothetical rather than one that has definitely occurred. Mothers write of their fear that a particular event or set of circumstances will traumatise their child or leave behind negative ‘traces’ or ‘consequences’ for their child, or to ask Dolto’s opinion as to whether or not a certain experience could be traumatic for a child. The very first letter received by the show, in September 1976, asked whether children who are obliged to repeat a year of schooling would be forever scarred  of the social effects of Dolto’s advice. Most correspondents praised Dolto for her reassurance and enlightenment that she brought to her audience, like the 63-year old woman from south-western France who wrote of her ‘enormous regret that there was nothing similar to help me avoid several major errors that I committed with my own children’ . But some correspondents expressed objections to pieces of advice that Dolto dispensed, again frequently expressed in terms of trauma. When Dolto made an on-air comment about masturbation in pre-pubescent girls – her position was that there was nothing to be ashamed of, but that one probably shouldn’t do it in public – she attracted a number of outraged letters. ‘Such ideas may be in fashion,’ wrote one woman from the Vendée, ‘but you have serious responsibilities […] masturbation is a grave disorder, which seriously perturbs the potential for future sexual development.’ Another argued that ‘you do not have the right to traumatise people in this way […] what you said was disgusting, scandalous and DANGEROUS’ – and suggested that the girl in question would do better to seek advice from her local priest . On the other hand, Dolto, a firm believer in the power of the Oedipus complex, was herself accused by other listeners of provoking needless anxiety when she argued that it was ‘dangerous’ for young children to see their parents naked. One wrote that when her children were young she had not made a point of keeping the bathroom door closed, and her children were not obviously traumatised by the experience. Another wrote that ‘there is nothing immoral in nudity […] [but] adults can pervert their children through such taboos of the body’ .chagrin) to someone, and my parents and my teachers are too stupid and foolish’ wrote one 18-year old .The second type of letter that becomes more noticeable is that in which correspondents discussed their own personal issues at length, seeing Dolto as someone who would understand their problems and perhaps offer support. ‘I think you are the only person who could help me,’ wrote a 17-year old girl suffering with severe depression and alcoholism. ‘Talking to friends does nothing and it is very difficult to ask people for such profound assistance’ . Several such correspondents were not interested or keen on having their case discussed on the radio, but hoped for a written response from Dolto. For some the act of writing was in itself enough: ‘I’m not expecting you to respond to a question because I’m not asking you any, but I had to confide my suffering .These letters frequently manifest a different level of intensity to the rest of the correspondence, and a large proportion of them came from adolescents or young adults. Some speak of the commonplace sufferings of adolescence, such as loneliness, parental incomprehension, yearning for love. ‘I can no longer work at college, I don’t care about the Future, I think only of being Loved, loved truly and profoundly…’ wrote one correspondent . Others raise more profound problems, such as eating disorders, alcoholism and unexpected/unwanted pregnancies. A recurrent theme is the social aspect of distress: these correspondents write to Dolto because they are ill at ease in the world, have no one to confide in, or because their social setting is compounding a previous difficult or traumatic experience. A 15-year-old girl wrote about having been raped the previous year; her current problem, however, was that her parents, shaken by having been unable to protect her, were now no longer willing to let her out of the house. ‘They shout at me and make me work harder than my brothers and sisters. I almost have the impression that they no longer love me’ . One 16-year old described the health problems he had suffered throughout his childhood, as a result of which he now appeared younger and more feminine than his male classmates, who bullied him ceaselessly. ‘For the last seven years my life has been a nightmare […] am I a social misfit [un inadapté], or am I traumatised by the disease that’s blighted me?’ he asked . A 25-year-old alcoholic from Rennes wrote of his difficult childhood in a rural family and his mother’s early death from lung cancer. But above all, ‘I am gay, a homo [* * * * *Two brief points by way of conclusion. First, although only a small minority of the letters indicate that the writer (or their children) is suffering symptoms of post-traumatic stress, the concept and the language of trauma pervades this correspondence. This shows the extent to which psychological and especially Freudian thinking had entered into popular consciousness: Dolto’s audience understood that neuroses resulted from childhood trauma, and the idea made them anxious about the effects of their parental behaviour. The co-occurrence of the language of trauma with the language of error in the letters, however, suggests that something else may also be at work here, namely Catholic ideas of guilt and original sin. In a rapidly secularising age, Dolto’s correspondents were seeking new sources of guidance and reassurance. In the French context at least, Dolto was a pioneer of using a mass media platform to bring psychoanalytic thinking to a popular audience in search of these qualities .les années ‘68, played an important role in her therapeutic effectiveness.The second point concerns the power of letter-writing as a form, which performed a cathartic or therapeutic function for at least some writers, in a way that Dolto’s earlier phone-in show could not. Through stimulating the production of thousands of such letters, as much as through any responses that she gave, Dolto helped many people to take a step towards resolving their mental health difficulties. Central to this was Dolto’s status as a trusted interlocutor, someone who would understand. In this sense, Dolto’s position as someone in step with her times and able to bridge the key cultural divide of


We examined the personal and professional impacts of the COVID-19 pandemic on the development, practice, and shifting values of child and adolescent psychiatrists (CAP), in order to inform how the field may move forward post-pandemic.We conducted individual semi-structured interviews of child and adolescent psychiatrists (n = 24) practicing in the United States. Participants were selected as a diverse purposive sample of active members of the American Academy of Child and Adolescent Psychiatry (AACAP). We analyzed anonymized transcripts through iterative coding using thematic analysis aided by NVivo software.Unsettling, or “who have we been?” ; (2) Adaptation, or “who are we now?” ; and (3) Reimagination, or “who will we become?” (renewing a commitment to psychiatry as advocacy). Even as we identified a collective agreement toward the need for implementing change, just what needs to change, and how that change will be realized, remain contested.We identified three main thematic domains within participants’ response to the pandemic, which have engendered a reevaluation of and a recommitment to the aims of each clinician and the field of CAP more broadly. These domains, paired with representative questions, include: (1) These three thematic domains, augmented by a national confrontation with race and equity, have engendered a field-wide reckoning with known inequities. They have reinvigorated collective responses and calls to action. The divergent mindsets to change and leadership have provided an aperture for what values and practices the field might instill in its next generation of practitioners.The online version contains supplementary material available at 10.1186/s13034-021-00382-6. Don’t panic. Pivot.– Cheryl AmyxWith the COVID-19 pandemic’s arrival in the United States in early 2020 –6. SourcFrontline healthcare providers are not the only ones who experienced the negative mental health consequences of the pandemic. As medicine moved quickly to address the infectious disease crisis, a slower-burning but increasingly urgent mental health toll began mounting for the general public. By mid-2020, American adults reported increased levels of depression, anxiety, substance use, and suicidal ideation , alongsiChild and adolescent psychiatrists (CAPs) occupy a unique role in managing the psychosocial consequences of the pandemic and in shaping the country’s emergence from crisis. As healthcare providers themselves, many CAPs are at risk for the same COVID-19 stressors plaguing providers across medicine. Simultaneously, they shoulder the responsibility of supporting the increased psychiatric needs of children and adolescents amidst an ongoing national crisis. With the arrival of new COVID-19 strains and the shaky rollout of the US vaccination protocol , 18, theYet the COVID-19 pandemic is not the only crisis confronting leaders in CAP and medicine more broadly. As the virus was taking hold of the country, the United States began to grapple with a renewed confrontation with systemic racism. By April 2020, data emerged illustrating the disproportionate racial impact of COVID-19 on Black Americans . In respBalancing the competing urgencies of COVID-19 and systemic racism in medicine requires effective adaptation and leadership, reflecting a necessary shift of existing energies toward new or renewed priorities. In an essay on the transition to remote research mentorship during COVID-19, Pfund et al. raise the concept of pivoting during times of change, engaging in reflective practice to “reassess, realign, and reimagine” one’s values and work . They diIn a recent paper from our group, Herrington et al.  exploredWhereas Herrington et al. provided the “camera” to take time capsule “snapshots” through photo-elicitation methods, in this study we aim to “develop” the photographs: to bring specific dynamics into focus, to explore the apertures for and exposures of certain viewpoints, and to highlight the process of change in order to visualize a narrative arc of how the field of CAP can effectively move forward. To that end, we used individual, in-depth, semi-structured interviews, in which each participant offered the concept of “pivot points”: the shifting of existing momentum in a new direction. The field currently juggles the energies of competing crises, and how and where the field chooses to pivot dictates where future momentum is directed. By exploring the early shifts and pivots of CAPs in the context of the US, we aim to apply lessons learned about change, leadership, and development within CAP to identify the field’s next steps in service of more equitable child and adolescent mental health.We conducted individual, semi-structured interviews, complemented by a small photo-elicitation component, in which participants submitted a set of photographs representing their life and practice during COVID-19 along with a reflective exercise around a prepared list of sensitizing questions . In recruiting participants, we were attentive to include varied representation across gender, career stage, geographic region, racial identity, ethnicity, and professional practice setting , with the option of an additional written or voice-recorded reflection. We sent invitations via email from April to August of 2020, using the language below:Our invitation also included the list of sensitizing questions and a sample submission.Each interview was transcribed for analysis to create our final data set, with the participants’ photographs and written reflections serving as a reflective exercise rather than as analyzed data. All but four participants submitted images, with one of the four presenting a physical object during the interview in lieu of a photograph. Thirteen participants accompanied their photographs with written reflections. We uploaded transcripts into qualitative analysis software , adding each participant’s contributions throughout the interview months to ensure that analysis remained an iterative process.We coded the transcripts according to the principles of thematic analysis, a qualitative approach involving the active construction of overarching patterns and meaning across a dataset , 37. TheTwo authors  coded independently throughout the study span in an iterative manner, with coding and interviewing interdigitated to allow for the inductive approach to shape subsequent interviews. The authors combined codes and assessed the final codebook to eliminate redundancies, clarify domains, themes, and codes, and ensure theoretical sufficiency . Each fiwho have we been? Participants described exposures of the pandemic that served to “shine a light on” or “illuminate the underbelly” of three key areas of dissatisfaction: (1) daily workplace inefficiencies; (2) barriers to patient care; and (3) intraprofessional devaluation, loss of trust, and moral condemnation . Others reflected on psychiatry’s failures in social justice, limited training perspectives, shifting work values of trainees , and the manner of compensation that hampers effective collaboration. This discontent diminished some participants’ enjoyment of their careers and even triggered a reevaluation of one’s place in the field entirely, with one participant “questioning whether even my involvement in [professional organizations] is the best way to be using my resources.” Some identified this disenchantment as a pre-COVID-19 phenomenon, stating that “we've clearly been requiring a revolution in terms of psychiatry for a long time… and that has nothing to do with COVID-19 in my view.”who are we now?, and answered in three themes: (1) operational adjustments; (2) the affordances and limitations of virtual work; and (3) the evolution of professional and personal identity  created a new operational challenge. Participants reflected on the “occupational-residential merge,” manifested as converted office bedrooms or living among stacks of patient files, as well as the challenge of balancing a professional home workspace with family needs: spouses also working from home, students completing online school, and young children requiring supervision. Those who previously maintained stricter work-home boundaries depicted their divides as increasingly “permeable” and “frayed at the edges.” Some leaned into the dissolution of boundaries by being more available to patients after hours or emailing late into the night, while others sought to underline the end of the workday: keeping the laptop shut, creating an end-of-day dog-walking routine, or using a downtime app to limit evening phone use.Regardless of their in-person or virtual status, most participants reported grappling with novel demands: “It turns out COVID-19 didn’t take away any of my responsibilities…it just added a couple jobs on top.” Directors navigated pay cuts, safety planning, and newly-limited inpatient capacity to prevent infectious spread. Virtual meetings were scheduled for early mornings, late nights, and weekends. Collaborations evolved both within the profession, such as increased participation in professional listservs or international projects, and across specialties, such as improved ER virtual consults. Participants also adapted to new educational demands. Across multiple institutions, training directors altered orientation, team-building, and graduation exercises to meet the needs of their now-virtual cohorts, incorporating breakout rooms for presentations and virtual diploma hand-offs; and medical school deans became “Grand Central Station for questions” for anxious medical students worrying about how their education could adapt to a pandemic.Despite these increased educational demands, multiple training directors and educators savored the new opportunities for connection with trainees. In tele-adapted events, online platforms provided different yet equally meaningful ways to engage personally. One participant celebrated the new ability to engage more members of the trainee’s world, citing a mixed in-person/online graduation ceremony in which a small group of trainees and family members enjoyed an in-person celebration, followed by food delivered to each family’s location for a socially distanced meal and a “big Zoom graduation with 80 or 90 people from around the world that happened a couple of hours later.” Echoing the unexpected joy of a more intimate ceremony, another participant described how their Zoom graduation allowed the space for family members to share stories about their graduates during the ceremony, making the event “one of the most meaningful graduations I have ever been a part of.”Beyond requiring adaptations to virtual workdays and training, telehealth afforded alternative avenues for communication and care. Virtual visits increased accessibility and decreased no-show rates, with one participant celebrating the marked decline in no-shows for mothers with post-partum depression given the lower activation energy necessary for session attendance: “Before… they just couldn’t get it together to come.” Participants also reported increased family member engagement and valuable insights into the patient’s home environment. Video backgrounds offered a novel source of contextual information, such as pets or artwork, which provided “meaningful connections to who they are as a person, which may not have come out in an in-person visit.” As for participants’ own backgrounds, most maintained firm boundaries with patients: “It's clear that it's my home…but I have really tried to maintain that it's not overly personal.”The affordances of increased connectivity, however, became a double-edged sword. Participants reported fatigue from back-to-back meetings, the intense focus of videoconferencing, and the constant flood of emails encouraged by a nonstop virtual workday. Put simply, “there was no turning off.” Participants also worried about the privacy afforded and the suspicion aroused by virtual backgrounds, along with the implications of pet or family member interruptions for professionalism, and the need for new boundary-setting with patients given the visibility of clinician homes or the settings of virtual care . Some participants opted to continue going into the office for virtual visits to address these concerns. Increased visibility also necessitated a “different set of parameters” for acute intervention in the event of visible emergencies on camera, and the benefits of telehealth only extended to families with adequate internet connectivity and access to private spaces. Some mused about the long-term efficacy of telehealth, noting missing “emotional engagement” with some patients and not wanting to “settle” for a lower level of care in the future: “Tele is not a substitute for in-person visits. It’s an alternate treatment modality, but where exactly does it fit?”The substance of each session adjusted to pandemic life, in both content and modality, depending on age group: “Early childhood mental health is a very physical kind of sport, and those tools are all out the window with Zoom.” Participants reported increased reliance on parental involvement for younger children: requesting pre-session email updates, focusing on the dyad, or leaning on virtual play and parental coaching. Discussions with older children highlighted struggles like concern for loved ones, others’ failure to social distance, and social development, including confusion about quarantine friendship protocols: “Are you on the level where you can FaceTime? Do you have those privileges?”Most benefits of virtual care did not extend to virtual school collaborations in this study. Apart from one district that reworked an existing mental health curriculum for COVID-19 and grief coping, the closure of schools and school-based care hindered –and in some cases eliminated– child mental health care. Participants reported decreased interaction with teachers, perhaps due to reduced behaviors due to the different environment or increased direct communication with parents (“I cannot remember having spoken to any teacher since COVID-19 happened”) and a loss of special education services. Adherence to Individualized Education Programs (IEPs) suffered, given the difficulties of virtual school, and students who are nonverbal or with significant developmental disabilities were left without the specialists or much-needed services that special education programs provide. For all children, the attentional demands of virtual school were an unavoidable challenge: “It’s torture for an adult; just imagine for a kid.”In metabolizing the pandemic, participants reflected on their personal histories as part of a broader reflection on their identities and roles. Many contextualized the COVID-19 pandemic and social justice activism within prior experiences, “like another verse of a song that I’d experienced or heard before,” citing the AIDS epidemic, Hurricane Katrina, or Pearl Harbor as guiding analogies. Participants also connected community responses and activism to events familiar to their families or communities: local school shootings, community suicide clusters, regular hurricane seasons, and activist spirit passed down through generations. These histories encouraged reflection on one’s roles and identities, since, as one participant stated, crises make you “revisit or rethink your priorities and your values; who we are now.”One such revisitation included the ethical charge of physicians and the role of that identity for each participant: What does it mean to be a doctor during a pandemic? We identified a strong sense of duty and responsibility to the public, despite personal risk, as strongly tied to a physician’s job description: “I was surprised by how quickly people shed their identity as a physician, to hunker down and worry only about themselves and their family. This is a national crisis, you're a physician, you're expected to play a role in helping people.” Participants also underscored the importance of “going in,” continuing to work in the hospital despite infection risk and advances in telehealth: “You just can’t be a doctor taking care of patients in this setting without coming in.” Despite this commitment to physician duty, participants overwhelmingly refused to claim the “healthcare hero” narrative, with one stating that “I've been careful not to lump myself in with that group because I just haven't taken those same risks.” Many attributed this difference to working in pediatrics and behavioral health, stating that “as psychiatrists, we are not true COVID-19 front-liners,” downplaying their own contributions in relation to other specialties like emergency medicine, where physically examining patients presenting with unknown ailments increases the COVID-19 infection risk compared to socially distanced, tele-mental-health visits afforded in psychiatry. Ironically, the conceptualization of physician identity through duty and sacrifice, along with the moral condemnation of failing to fulfill those values, may represent a sort of savior behavior aligned with the very “healthcare hero” narrative participants were reluctant to accept.The question of physician identity seemed a particularly provocative one for psychiatrists, who felt that initially, “our nation had called us to do something very, very different, which we hadn’t been trained for,” alluding to the specter of being drafted as reserve physicians to intubate COVID patients, or the expectation of infectious disease expertise beyond one’s specialized training. Participants felt capable of answering the psychological demands of the pandemic, but some felt helpless in the face of an infectious disease crisis, noting how in the early days, “the psychological impact hadn’t fully hit yet. We didn’t have a major role then,” reflecting the distance many participants felt from the intensive care unit (ICU) environment emphasized during COVID-19 hospital narratives. Some expressed a particular sensitivity to this worry, given the stereotype of psychiatrists as too far removed from the rest of medicine: “We have worked hard to be seen as physicians, … [to have] a bidirectional sense of mutual respect,” worrying that psychiatrists’ lack of routine practice with ventilators or intubations might diminish their perceived value as “real” physicians. Yet as the pandemic progressed and the mental health toll of the pandemic became apparent and more urgent, participants emphasized that psychiatrists are “uniquely trained for this COVID-19 moment,” becoming frontrunners in telehealth adoption and tending to the psychosocial impacts of the national crisis. One training director told new trainees, “You are all physicians. You know how trauma and distress impact human functioning. You have the perfect training.”Alongside a meditation on one’s duty as a physician, participants considered how much of their own identity was ascribed to that role: “How much of you as a person or identity is being a doctor… and how much are you allowed, as a human being, to take care of yourself, separate from being a doctor?” In reconsidering their roles, participants sought a sense of balance amidst competing priorities, be they professional, personal, or institutional. One participant found themselves longing to prioritize the personal over the professional, noting that after two weeks of telemedicine, “I was just like, ‘I just want to do my laundry. I don’t want to be a psychiatrist today.’” Others questioned the balance of their competing work roles: Given the shortage of CAP providers, one participant touched on the difficult decision of taking non-clinical roles given potential “obligations… of being available to people.” Another participant, seeking a reconciliation of their simultaneous professional duties, countered, “I’m not naïve. I don’t think that the best use of [my] 40 h a week is seeing patient after patient” at the expense of other roles in research, education, and leadership.Within meditations on work-life balance , multiple participants reflected on their family lives. In light of the uncertainties and revelations of the pandemic, one early career participant reconsidered their past decision to postpone having a child due to the demands of work; now, they have decided to try to start a family. For others, increased time at home with kids completing online school offered new perspectives, such as one participant struck by the image of their son, home from college, in the backyard: “He used to play in that yard, and I used to look from that window… and here it was, he was home again under very different circumstances.” Moments of novel, unexpected visibility into a new phase of their children’s lives were at times bittersweet, but also motivating and humbling. One participant discovered their son manufacturing plastic face shields for essential workers in the basement, sparking the reflection that “among these unsung heroes… are the kids, who are going to be leading us, not the other way around.” Participants also led as 'ersatz clinicians' by supporting family members virtually, such as siblings, parents, and grandparents, through safety concerns and isolation, as well as navigating losses and illnesses from afar.The sense of urgency from both the COVID-19 pandemic and the summer of protests reoriented participants toward their core motivations, allowing a pivot toward practices better aligned with their re-identified sense of purpose in the field. For example, among the acute adaptations of roles and identities during the pandemic, several participants focused more intentionally on leadership roles to support colleagues and trainees. For many, shifts in leadership style were forged by the national confrontation with racism and the emotional conversations that followed, with participants adjusting their leadership style according to their own identity, as part of the personal reckoning driven by crisis. For example, one clinician of color reflected on assuming a facilitator-like leadership stance, acknowledging that “you have to take a different perspective, one that's more educational; and many times, not one that's necessarily sharing your own experiences.” The same clinician also noted the need to identify new leaders among colleagues to lead these psychologically heavy conversations about racism and bias in psychiatry, because “it’s so important that it cannot be the exclusive responsibility of every African-American person to do all the education,” reflecting a proposed redistribution of energies fueled by the “pivoting” mindset held by most participants.Participants also emphasized the role of supporting colleagues’ wellbeing, noting the importance of caring for the carers. Many participants created or volunteered for peer support systems, wellness programs, and mental health first-aid for their peers in and beyond psychiatry, providing the additional benefit of increasing gratitude. Regarding mental health care, several participants also noted their own involvement in therapy and the importance of taking time to process the psychological effects of the pandemic. As for social support, renewed investment in social strengthening soothed a “hunger for interactions,” including more frequent check-ins with friends and family, restructured e-meetings that replicated in-person small-talk, and a deeper level of intimacy in previously casual conversations. Some participants also spoke of missing the “random” encounters of an in-person workplace and intentionally building back “incidental” work contacts, setting aside dedicated time to catch up with colleagues who were part of their daily work life despite not sharing any projects or teams.who will we become?, we organized their hopes and hesitations into two themes: (1) renewal and recommitment; and (2) psychiatry as advocacy  and utilizing technology to deepen connections . The aperture for creativity also opened a deeper concern, with some participants fearing the perilous potential for unregulated, for-profit telemedicine, or a potential to return to the status quo.Within reimagining, we identified a subtheme of recommitment to the profession and its purpose. Some participants reflected on their “origin story” in psychiatry, with several recalling their motivation as wanting to address disparities, to “make things better for people who have, for many reasons, limited access to the resources they need.” Consequently, some desired for CAPs to both serve as more prominent leaders and collaborators and to become liaisons not just for children’s health but for families’ well-being, “because we really have the capacity to understand how relationships build brains, how society and social determinants of health have such an enormous impact on human functioning.” Several participants also hoped to “banish the term ‘med check,’” finding it an insufficient descriptor of CAPs’ deeply interpersonal work: “The best kept secret is, we don't prescribe as bots…Your story matters to me.”Multiple participants identified the field as being at “a critical crossroads,” with COVID-19 and renewed confrontations with system racism as “accelerants,” as forces “pushing” the field to reckon with existing issues and adapt to necessary change. One such tension is balancing psychiatry’s complicity in and response to systemic racism, with the view of the field as a profession of advocacy. As participants looked toward the future of CAP, we identified conflicting assessments of the field’s ongoing social justice work, and divergent mindsets toward the hope for lasting change.“It was also important for people to say it because for the people who have been victims of these experiences for many years, the response has always been, ‘Well, why do you think it's racism? Or why do you assume that [racism] is what it is?’ And to have others recognize how horrible it was without having to be the only one to say it, I think was really important.”Increased recognition of the Black Lives Matter movement created space for renewed activism and dialogue between colleagues. One Black participant noted a slight shift in the burden of initiating emotionally heavy conversations about racism, remarking that the shared horrific experience of George Floyd’s death opened an overdue dialogue that more directly acknowledged racism:Multiple participants described workplace participation in White Coats for Black Lives demonstrations, formation of diversity, equity and inclusion (DEI) committees, and increased activity of identity-based caucuses. Several training directors emphasized the role of social justice education in their residency and fellowship curricula. Attitudes towards professional organizations’ responses differed, with some participants appreciating the immediate strong condemnation and others feeling dissatisfied by the lack of concrete action.Participants grappled with the call to action based on their own identities but overwhelmingly reflected a motivation for change. Several white leaders reflected on the complexity of supporting trainees, colleagues, and communities of color from a position of racial privilege, such as one respondent “trying to be a good leader in that area as a white man.” Another reflected on the existence of collected data on health disparities that had not been explored: “We should have been looking at this.” For multiple Black participants, the call to action was not a new one, but rather an amplification of the work they had engaged in for years: “I don't want to make it seem like they're just now noticing. People have been noticing, and people have been experiencing this for a long time.”then say, this is what we’re doing, versus ‘we stand behind diversity.’” Additionally, some participants expressed frustration over the necessity of such catalysts in the first place: “It’s also just a bit ridiculous, that it takes the murder of a man to be filmed for people to reckon with what we’ve known all along.” Consequently, although the pandemic and the simultaneous summer of increasingly visible activism figured as “pivot points” or “fulcrums” for growth, disappointment and frustration tempered optimism about the possibility of meaningful change and highlighted the significance of CAP’s follow-through. As one participant encapsulated the overall outlook, “it's a fertile time for progress in a positive direction; but like anything, only if we choose to do it as such.”Alongside this delayed collective acknowledgement of systemic racism, fear of institutional inertia and loss of focus also interfered with some participants’ hopes for lasting improvement to post-pandemic psychiatry’s role in social justice work, as well as generally. “Is it an opening?” asked one participant. “Sure. Are we going to take advantage of that opening? We'll see.” For many, faith in valuable change hinged on concrete action. “We don’t just want to make a statement,” said one Black participant of their institution’s response to the Black Lives Matter protests; “We want to do something and In seeking to understand the impact of the COVID-19 pandemic on child and adolescent psychiatry in the United States, we identified three domains of change across participants: unsettling, adaptation, and reimagination. Encapsulating these three domains, throughout the six-month study span, participants mulled over three implicit questions: who have we been? Who are we now? Who will we become? The third question became more poignant as the study drew to a close, as participants grappled with the tumultuous summer of protest and calls for change. Participants at every career stage identified discontents and started to draft a vision for an improved practice; and although mindsets to actualization of that vision diverged from skepticism to optimism that is bounded at best, no participant desired a return to the prior status quo. All viewed the pandemic as a reckoning that afforded an opportunity to reimagine a better future.We began our study with the concepts of aperture and exposure, identifying the COVID-19 pandemic as a catalyst that opened portals to new possibilities or re-illuminated that which had been taken for granted, following Arundhati Roy’s description of the “pandemic as portal” . In the syndemic, coined by American medical anthropologist Merrill Singer in his work on the AIDS epidemic [As participants began to include discussions of systemic racism and protest in their reflections or conversations, we identified a key subtheme of America’s struggle not just with a pandemic, but with a syndemic. The term epidemic , represeepidemic , 42. In posttraumatic growth in healthcare, seeking “positive psychological change experienced as a result of a struggle with highly challenging life circumstances” in a way that creates a “new normal” rather than seeking to return to the status quo [In response to a traumatic year, this momentum-oriented mindset represents an adaptive response that seems promising for the hope of a successful pivot. Olson et al. call for pandemic-driven atus quo . As one Any desire for change and growth, wrought by the unsettling of the pandemic, is not enough to actualize progress. Participants’ bounded optimism reflected fears of institutional inertia, red tape, and actual backwards movement, such as the planned reinstatement of insurance and licensure barriers that had been lifted to alleviate the immediate demands of the telehealth surge. Participants stressed the continual need to “propagate the opening” of the moment to work toward concrete change. That is, to move beyond COVID-19’s “ground zero empiricism” described by Lorraine Daston, American historian of science, in which “moments of radical novelty and the radical uncertainty novelty emits” lead society to observe a phenomenon for the first time . It is nOvercoming these barriers to change and actually propagating pandemic-driven posttraumatic growth will hinge on the ability of leadership in CAP to respond to discontents and hopes like the ones identified in this study. Leaders must demonstrate the flexibility to avoid the sunk-cost fallacy of sticking with the field’s long invested beliefs and practices in favor of pivoting towards reinvigorated priorities. When leadership is placed “on the edge” amid crises, their communities of practice require connection, communication, and collaboration , the lasMoreover, with the field of CAP facing a workforce shortage , leadersWe recognize several limitations in our sample and approach. First, although we included clinicians across the career development spectrum, our sample was weighted toward senior clinicians 20 or more years past CAP graduation. The resulting emphasis on the importance of leadership may therefore reflect the sample’s seniority and position, with half of the sample serving as either division chiefs or training program directors. Although participants from all levels of practice did give a comprehensive account of team dynamics and echoed the importance of refining values and priorities, our insights could be deepened further with future studies including a wider range of perspectives; in particular, those of trainees like residents, fellows, and perhaps medical students invested in CAP, as well as those of non-physician behavioral health professionals.Second, although this study aimed to “develop the film” of participants’ photo reflections, we recognize that this reflective exercise occurred in the midst of the pandemic, rather than serving as a retrospective analysis of completed events. In describing the opportunities for posttraumatic growth, Olson et al. caution against pressuring individuals to seek growth too soon after a traumatic event ends, let alone during a crisis . AlthougA third limitation leading to a potential follow-up study is the unexplored component of participant age, career stage, and family status as factors in one’s response to both the COVID-19 pandemic and the surge in social justice activism. Even as some participants did mention these factors briefly in their reflections (either directly or through reflections on career growth and leadership roles), the focus of our interviews, driven by participant photographs and written reflections as well as emerging commonalities, did not explore these dynamics in depth. Providing intentional time to dig deeper into the influence of participants’ life and career stage could provide valuable insights into career development considerations for future crises.A qualitative exploration of child and adolescent psychiatrists' responses to the COVID-19 pandemic revealed a tentative yet growth-oriented reimagining of the field in response to unearthed discontents, as well as a reappreciation of the field’s strengths and a recommitment to a profession of advocacy. In the throes of a pandemic, clinicians pondered several questions: Who have we been? Who are we now? Who will we become? Now, with the COVID-19 pandemic raging into its second year, a fourth question arises: How can we facilitate the passage from a time of crisis to a reimagined future?Additional file 1: Appendix S1. Sensitizing questions.Additional file 2: Appendix S2. Characteristics of study participants (n = 24).