Lockdown and adolescent mental health: reflections from a child and adolescent psychotherapist [version 1; peer review: 2 approved]

The author, a child and adolescent psychoanalytic psychotherapist working in the UK NHS, ponders the varied impacts of ‘lockdown’ on adolescents, their parents and the psychotherapists who work with them, during the COVID-19 pandemic. She asks, particularly, how psychological therapies are positioned during such a crisis, and whether the pressures of triage and emergency can leave time and space for sustained emotional and psychological care. She wonders how psychoanalytic time with its sustaining rhythm can be held onto in the face of the need for triage on the one hand and the flight to online and telephone delivery on the other. Above all, the author questions how the apparent suspension of time during lockdown is belied by the onward pressure of adolescent time, and how this can be understood by, and alongside, troubled adolescents.


Introduction
The time of the COVID-19 virus brings a strange shifting of priorities to my professional life as a child and adolescent psychoanalytic psychotherapist working in a Child and Adolescent Mental Health Service (CAMHS). COVID-19: the name itself encapsulates delay (Flexer, 2020, Waiting in Pandemic Times). Building into the term the origins of the virus in 2019, it provides a stark reminder that, having ignored warnings from the medical world and then the evidence before our eyes, we are now always already trying to catch up (Horton, 2020).
The world is in crisis, but it is hard to position the acute and chronic crises of mental health work in the NHS against the unfolding crisis we see on our screens. Are we high priority or low? Frontline or routine? Do we, like primary care staff, rush to 'man the barricades' (Davies, 2020, Waiting in Pandemic Times) -anxiety about the possibility of redeployment is spreading among mental health staff even where they are entirely untrained for physical health care -or do we hunker down at home to conduct therapy online for the foreseeable future? (What is foreseeable about the future, now, for the young patients, depressed, anxious or enduring the turbulence of adolescence, for whom the future was only hazily in view in the first place?) Mental health has traditionally been lamented as the poor relation within the National Health Service (NHS), with psychiatry under-valued and repeated cries to achieve parity between mental and physical health ignored. How, then, are we to consider the seriousness of psychological and emotional labour conducted in services such as CAMHS during a national crisis? Talking to young people and children about their anxieties, or even their considerable distress, appears low priority when compared to doctors and nurses battling COVID; yet an adolescent death by suicide remains one of the most catastrophic events imaginable, for family, friends and professionals alike. In the time of the virus, we are thus adrift in the prevailing geo-spatial metaphors of the age: nowhere near the 'front line', we may find ourselves thrust suddenly towards it if a teenager attempts to harm him-or herself.

Adolescent time
The world gives the impression of having halted adolescent time. Exams are cancelled; school is out, or virtual; universities have sent their students home. For those in their teens, the COVID-19 pandemic arrives at a crucial time in development, as they transition from childhood to adulthood. Yet the time of adolescence itself often feels both chronic and acute, its difficulties regarded as perennial, even predictable, yet often plunging the young into crisis. Disturbed adolescents may try to arrest a march of time that feels relentless by retreating into depression, or into their bedrooms: to halt their progress towards a future that is perceived as bleak, or simply unimaginable.
What can we learn about time -now, in the time of COVID-19 -from this sudden suspension of time which is not actually a suspension at all? This questioning of the future which is, curiously, so familiar to many of the young people whose mental health elicits our care?
The decision to award GCSE and A level results, rather than postpone the exams, could be seen as a shocking pronouncement: that time waits for no one, that adolescent progress cannot, must not, be halted -even if, for those awarded a grade less than that which they might have achieved, progress is thwarted. Like their younger counterparts at the top of primary school, they must, even from their bedrooms, be ushered forwards to the brink at which they bid their school lives farewell. Those struggling with the pressure of work and exams may be relieved, but their world has also crashed down upon them and many are disappointed. Some lament a lack of control: the final academic effort, for which they were preparing, is denied them, and teachers, or government, will decide upon their grades. Yet for some, for whom the pressure of external life has been unbearable, perhaps there is the possibility of respite, and the lockdown may provide them with much-needed time for recovery. Adolescent development 'runs unevenly' (Waddell, 2018, p. 26): how the time of COVID-19 intersects into each individual trajectory will vary hugely. While the media portray the young as oblivious -gathering in parks, spitting defiantly in the faces of police or the elderly -we hear our young patients report their varying responses, almost always ambivalent, anxious. For those with depression, existential despair, sometimes born of inter-generational trauma and loss, is known to dominate (Catty ed., 2016): how are they to believe that the future holds any promise when it appears to have been cancelled, or at least indefinitely postponed? For some, this will confirm a pre-existing belief, a bleakness. Meanwhile, they worry about grandparents, parents and, increasingly, each other.
There is an idea that psychoanalytic work with adults involves the recollection and processing of remembered trauma -that it is, as Wordsworth wrote of poetry, 'emotion recollected in tranquillity' (1805/1987, p. 42) -while therapy with children and adolescents is conducted during and alongside the unfolding of their key emotional dramas. Theory and clinical practice afford many contradictions of this dichotomy; yet it remains meaningful to conceptualise adolescent therapy as a 'being alongside' a teenager as they live through their most turbulent of times. How does lockdown impact on this sense of immediacy? During lockdown, young people are suffering a crisis that we appear to share with them, at least in this basic way: we too sit in our homes as we engage them in their therapy. Keeping a focus on the particularity of their experience -the extent to which the national crisis may or may not be impacting on their internal dramas -will need close attention. Yet perhaps they have something to tell us about uncertainty -about the future, about the passing of time -that they have long feared we did not understand. For some, we have finally entered into their world. There are implications here, too, for our work with their parents, now that we feel ourselves to share their most immediate circumstances: we are all in lockdown; we are all worried about our ageing parents; we are all, increasingly, worried about the young.

Urgency and delay
Crisis time in adolescent mental health services relies on a redamber-green system of case-flagging. Now only the reddest of the red cases can be seen in person, anxiously diverted from Accident and Emergency departments to the community clinic to avoid contamination. While those on duty manage these most critical of crises in person, the rest of the team connect to their patients via telephone and video-conferencing. Fears that mental health work will be deemed such low priority as to justify sending therapists into the medical settings for which they would be entirely, shockingly, unprepared, seem to abate as authorities determine that mental health emergencies are themselves 'priority'. At the same time, the urgency of attending to an unfolding mental health crisis is becoming clearer: articulated in a recent 'call for action' to include data collection on the psychological, social and neuroscientific effects of the pandemic on both the general population, vulnerable groups and those with the virus (Holmes et al., 2020).
What, then, are the implications of mental health triage in this new world? In the early weeks of the lockdown, we wonder whether to activate a crisis response by focusing only on emergencies, keeping in touch with our regular patients for more frequent, but briefer, telephone updates. Implicitly, we are invoking ideas of triage (focusing only on emergencies in any detail or depth) and support (finding out how our patients are managing, rather than working with them). Yet it is clear that such a model will not serve us well in the longer-term: if nearly the whole CAMHS population is provided with brief, intermittent support rather than treatment, logic dictates that their mental health will deteriorate. Yet does such a distinction between support and treatment hold in a time of crisis? It is a distinction that has always been uncomfortable where it privileges the activity of psychological therapists over other mental health specialisms, such as nursing, occupational therapy or social work (deemed to be providing 'support' or 'risk management'); yet it has enabled us to retain an emphasis on the 'work' that is involved in psychological treatment and the process that unfolds between the participants in psychotherapy, patient and therapist. What the nature of such work may be during lockdown remains to be seen.
Meanwhile, mental health emergencies among the teenage population seem to have plummeted: we wonder, where are they? Have they too been suspended? There is anxiety about when the dam may break; an increase in anxiety, depression and self-harm are expected in the population as a whole (Holmes et al., 2020) 1 . For those that come in, we find ourselves contorting the familiar NHS language of 'risk': do we mean suicide risk or COVID-19 risk? Where is 'safe' for a 16 year-old determined to kill herself, or a 13 year-old who has taken an overdose? A mother asks whether, were her teenage son to harm himself, she would be allowed to be with him in hospital; we cannot advise her. The focused maternal care that a teenager may specifically crave in such desperate moments becomes the one thing he would deprive himself of; the choices facing those with suicidal thoughts become starker now. We ask ourselves, can we provide a reassuring presence dressed in protective mask and goggles? Or should we retreat behind a computer or smartphone screen, through which we can, at least, be seen as ourselves?

Time and space
How do we keep time in such a crisis? There is a rhythm that psychotherapists and their patients come to live and breathe: the regular pulse of the psychoanalytic session, whether weekly or more frequent; the predictability of the starting time; the inevitability of the session end or the week's wait. This rhythm underpins the duration of a therapy as it unfolds in time and is the bedrock of the 'containment' (Bion, 1962) that psychoanalysis offers (Baraitser & Salisbury, 2020, Waiting in Pandemic Times). Can this rhythm, based on the fifty-minute hour, be maintained over the telephone or protected with the same boundaries as in the clinic?
In the rush of psychotherapists to online platforms and the telephone, can we maintain this steady pulse? For a teenage patient, does it still feel like his session time if he knows his therapist is going to ring? Will it still feel like time to stop if we are wrapped in the cocoon of sound provided by a telephone call in a quiet room; or if we have been trying to focus on each other's faces in a shaky video call? Despite the fact that most teenagers are more familiar with online discourse than we are, this shift raises issues of space too. Is it intrusive to conduct therapy online with an adolescent, looking into that most private of spaces, their bedroom? Alternatives are unlikely when families are crammed together conducting school and home lives under one roof. What is it like for a depressed adolescent to know that his therapist is telephoning from her own home? Or for a troubled teenage girl, reliant on self-harm to embody her misery, to bring her therapist into her home on a smartphone screen?
Decisions continue to need making: despite the impression that time has been suspended, in fact it waits for nobody. An offer of time-limited psychotherapy for a girl of seventeen-and-a-half is paused: can it still be done? The time-frame provided by the therapy model was to fit neatly into the time that remains for her as a CAMHS patient: upon her eighteenth birthday, she will be discharged. Despite the impression that the world has stopped turning, time is marching on.
Nothing sums up better the paradox of the crisis for adolescents or gives the lie more obviously to the notion of shutdown, suspension or postponement. Time is still passing.

Data availability
All data underlying the results are available as part of the article and no additional source data are required. 1 This paper was written in the first two weeks after lockdown, when emergency presentations nationally were hugely reduced (BMJ, 2020); by the time of publication, it could be anecdotally observed that emergency presentations of adolescents in a state of mental health crisis had increased.

Open Peer Review
The child and adolescent psychoanalytic psychotherapist, Jocelyn Catty reflects on how psychological therapies are positioned during a crisis such as the COVID-19 pandemic. The author questions how the psychoanalytic session is maintained over online platforms and telephone consultations. Furthermore, Catty addresses essential reflections of how the crisis leaves time for emotional and psychological care in a time characterized by the pressure of triage and emergency. The introduction outlines the immediate and dark consequences for young people, their school achievements, mental health, social development, and the opportunity to get adequate treatment. She points at the specific developmental challenges of COVID-19 putting young people at high risk for lagging behind in this important transitional phase into adulthood.
The manuscript is well-written and contains highly needed questions regarding adolescent mental health during a crisis as the pandemic. It emphasizes the uncertainness in therapy rooms and improvised therapy rooms at home worldwide. The paper raises the urgency for young people and the need for society to take their situation seriously. Jocelyn Catty fears that only mental health triage will be offered to young people and a generation will be deprived of the opportunity for treatment. The paper is formulated as a warning bringing into the discussion some problematic sides of video consultations.
The paper is submitted as a research article, however, we read it to be an opinion article. Thus, evaluation according to research standards is not applicable. The paper does not provide sufficient details of method and analysis to allow replication of others, neither are any conclusions drawn -as there are no results and the manuscript is lacking both qualitative and quantitative data. However, as an opinion article, the paper is a structured and well written, article.
However, the manuscript might be more useful to a broad clinical readership if the author moved beyond the rather pessimistic undertone regarding psychotherapy during a crisis and explored alternative perspectives. As there is evidence as well as clinical experiences during the ongoing pandemic that some young people in some periods of therapy might profit even more from video consultations. In addition, video consultations give the therapist an opportunity to follow the young person and offer treatment even when students according to change in school or study situation move to other places.
Some questions the author may consider: How does the therapists' attitude towards online therapy or telephone consulting affect the therapy delivered on these platforms? How is the therapist marked by the current crisis and shaped by being forced to deliver therapy on alternative platforms? Might it be that the physical distance to the therapist for some adolescents facilitates a greater emotional closeness to the psychotherapy -and therapist?
The manuscript ends rather abruptly with loads of important questions to reflect on without stating a clear take-home message.
Overall, this is a timely and much-needed essay. It is written nicely with rich metaphor and moving examples of how these last months has changed the entire field of psychotherapy -both for patients and most therapists. The paper might be improved by modifications addressing the detailed comments below and perhaps a mention of alternative perspectives to better recognizing the complexity of this important matter.

If applicable, is the statistical analysis and its interpretation appropriate? Not applicable
Are all the source data underlying the results available to ensure full reproducibility? No source data required Are the conclusions drawn adequately supported by the results? Partly