Letter from Barcelona: Child Psychotherapy in the Time of Covid

In the ending scene of the 2007 movie, Love in the Time of the Cholera, based on Gabriel Garcia Marquez's 1985 novel, an aging couple sails away from judgment and intrusion to be with each other, finally, after a lifetime of forbidden love. They do so on a ship with a flag signaling cholera onboard. Ironic, confusing, and slightly dangerous for this young reader's imagination to sense that a sign of death can signal freedom. As an adolescent, I loved this book as well as its author who often took me into surreal worlds where primitive aspects of human existence were explored in my cultural context. Through Marquez's 1967 novel, Cien años de soledad (One Hundred Years of Solitude), I found myself escaping into Macondo, the fictional Colombian town, and imagining myself as part of the mythical and daring scenes drawn with words by the author. Like my adolescent patients today who find solace in screens, I found safe refuge in the pages of these books.

Forward 34 years and I'm in front of a computer screen, in my home in Barcelona, my former office in New Haven, Connecticut, appears as my Zoom virtual background. I left the USA on March 16, 2020, in a transatlantic plane with only 25 passengers, and, since landing in Barcelona, I have been confined to my new dwellings for nearly three months due to the covid pandemic. Perhaps, the virtual background represents a brief denial of the changes in my life, rationalized as a way of offering a familiar electronic setting to my patients. However, reality quickly sets in as I see into the bedroom of my 18-year-old patient, a young woman I once saw in Connecticut in three-times-per-week psychoanalysis and whom I now see once a week on the screen, from Barcelona. By coincidence, we had decided to continue our therapeutic relationship online prior to my moving to Barcelona to start this new chapter in the book of my life.

As I sit in front of the computer for the fourth time today, I feel my eyes becoming tired and my body restless. I long for the presence of two people in a room and feel the confusion between mourning processes. After all, at this time, the whole world is in mourning. For Jenny (not my patient's real name), my 18-year-old patient, and me, though, this is about us. So, I am able to use my psychoanalytic mind to process, observe, and reflect on the myriad feelings that this surreal existence in front of a screen has brought. Tapas lunches al fresco and the company of new friends are delayed by covid, as well as the illusion of control that has contained my anxiety about my move all these months.

In the midst of a global pandemic and my ever-changing personal life, I think of the patients who have become the organizing thread of my professional life through the years. I reflect on how this situation might be affecting every one of them and acknowledge the multiple losses they might be facing as I process my own, some temporary, some more permanent. However, every night at 8:00 pm when we all come out to cheer the health workers in the trenches, my neighbors remind me some things are remembered and gained. A sense of community is always a good source of resilience in these situations. I am reminded of this too as I wait with anticipation for a Zoom meeting in two days where I will be able to see my colleagues from the Western New England Psychoanalytic Society.

I also recall patients I just left and imagine the impact of this crisis on them. Like Jenny, who is in her own words: “suddenly stuck at home with the one person I have worked so hard to liberate myself from.” I am thankful for the technology. Whereas in the past I have focused on screens as one of the culprits interfering with our capacity to play and connect interpersonally, these days it has become a lifeline, one that keeps me connected. I have days when time seems my friend and days when confusion and helplessness set in. Today, I am thankful to connect with Jenny (We are able to reflect together on the value of being able to continue our work under these circumstances. As we talk, her mother opens the door. A startled Jenny looks at me with a mixture of anger, surprise, and fear.

During these precious 50 minutes, I enter Jenny's world and she enters mine. Even though the pandemic means she's stuck inside, she no longer feels stuck, alone, with her mother's anger and cruelty. However, we don't inhabit the predictable space of my consulting room. I get to experience the sounds and the feeling of her bedroom and she gets to have a window into my life outside the consulting room. I have tried to create a consistent environment by using a virtual background at times and by creating a real background with carefully selected books and some familiar items from my old consulting room, but the reality of the outside remains with its current uncertainty and the primitive fears it feeds.

Like with Jenny, I had agreed with a number of my adolescent, young adult, and adult patients to continue long distance therapy until the summer 2020. However, as the Covid-19 pandemic makes transferring to new therapists difficult for many of my patients, I'm supporting many of my New Haven patients online. It's a different experience. I have worked online given my lecturing schedule for about five years now, but not with child patients on a regular basis. Arranging the frame of the session ahead of time with parents is helpful. Where in our separate houses do we sit? How do we maximize confidentiality? Do we include a parent? How long should the session be? However, nothing protects us 100 percent from what I call “the iPad roller-coaster effect” and the “house-tour syndrome.” The aim of our work becomes containment as we look for new ways to play and to coregulate. In this virtual territory, many of my child patients are digital natives who can be my best teachers. In return, their agility online can strengthen their egos and sense of agency.

Offering Support at a Distance

In my experience working from a psychoanalytic framework, saying goodbye is never final. My move to Barcelona came faster than anticipated due to the pandemic, so I wrote to former patients and families to tell them I had moved, precluding the possibility of an in-person farewell or catching up anytime soon. With the covid crisis, many of these families have returned for support, especially for parenting consultation. At times, this has exacerbated my geographical confusion both psychically and physically. As a result, I often find myself in a parallel process with the experience of my patients who now spend their lives at home while seeing co-workers and teachers and classmates online and struggling to find “a new normal.”

As part of my efforts to feel part of my new community, I have been able to offer voluntary consultation and support to local colleagues who work in the public sector with high risk communities. Many of them are psychodynamic in their thinking but face the limitations of public funds and the pressure to find “solutions.” Recently, during an online supervision of a team of 16, already overwhelmed clinicians spoke of the lack, two months into the pandemic, of an internet platform. They spoke of using their own resources to stay in touch and of the limitations of phone contact. Most of them have caseloads of 80 to 95 cases, so follow-up by phone or Zoom is daunting. Who to prioritize? How to intervene? And how to conduct intake interviews? The nature of the consultation is different under these circumstances. During these times of covid, questions about how to work with children under the age of five emerge for example. I fear all I have to offer these days is empathy, containment, curiosity, and, yes, a good old psychodynamic formulation that supports “good enough” delivery of services, with very different goals in mind. More than ever, supporting our colleagues and developing systems of support around the mental health worker is of the utmost importance.

When I was asked to write a letter from Barcelona – what it's been like being caught in the middle of my own personal and professional transition during the time of covid–my first association was: Love in the Time of the Cholera. The covid pandemic has taken me back to my adolescent surrealism, where time is different, sleep is often your friend and the characters who once inhabited my consulting room on Bradley Street in New Haven now appear once or twice per week on the screen. The love that one cultivates in a therapeutic relationship is a special one, the same as the hate and all other emotional experiences shared and survived in the psychoanalytic encounter.

Since stepping off the plane in my new Spanish home, I have found peace and a desire to keep going forward while enjoying my work on the screen with young and old. Surprisingly, it has brought a sense of continuity which might have been abruptly interrupted otherwise. So, as in my favorite adolescent book where the two lovers find ways of loving and enjoying life in the time of cholera, we will also find ways—with our masks on and from far away—to play, love, and work. In my case, in Spanish, English, and increasingly more in Catalan. In the meantime, I continue to listen to dreams in patients who never dreamt before.