[This section of the website is available for people to raise any questions they may have about child and adolescent psychoanalytic psychotherapy. It is also designed to engender a discussion between child and adolescent therapists - so their experiences – their discoveries, their ‘experiments’, their playful moments that worked and didn’t work , their doubts and their excitements can all be shared. As this is such a difficult area of work it is imperative that we learn from each other.]
WORKNG REMOTELY WITH CHILDREN AND ADOLESCENTS FROM A PSYCHODYNAMIC PERSPECTIVE
Summary of Meeting held on April 2, 2020
Thirty-two clinicians attended a Zoom meeting to discuss the issue of working remotely with children and adolescents. The group included people from New Zealand, India and a number of different States across Australia.
The aim of the meeting was to share experiences of moving from face to face consultations to working remotely due to the Covid-19 pandemic.
A Transitional Object
The meeting began with a discussion of how one may transition a child/adolescent from the consulting room to online meetings. It was felt that if possible there should be a discussion with the child/adolescent explaining the move to an online way of working. Some people thought it would be a good idea to give the child something from the room ( a small toy or play equipment e.g. plasticine, or pencils, or paper) so this could act as a transitional object, bridging the space between consulting room and the online meeting. It was also discussed that the therapist may wear a particular piece of clothing each week (e.g. a t-shirt or shirt) so this could act as a physical anchor for the child. It was felt this was especially important for disorganised children. It was a further mentioned that giving a child something from the room was suggesting to the child that they will be returning with this item sometime in the future.
The Greater Distance as a Possible Aid
A discussion arose about some children seemingly being less defended when using Zoom. It was wondered whether the greater distance of working through a camera allowed some children to feel more relaxed or less threatened. It was noted that this may be the case with some ASD children/adolescents as this form of working may be less impinging. It was mentioned that this may be related to Sue Reid’s thoughts that autistic children/adolescents are very threatened by eye to eye contact. Someone discussed how they found that a child who usually plays in the consulting room was now talking to her much more on Zoom. This shifted the whole feel of the therapy, as if the child seemed to be relating in a more adolescent ( false) way.
This undefended reaction was also thought about as a possible ”honeymoon” effect, with the child being excited to be using this technology and having the therapist in their own room/home. This raised the issue of whether it is more difficult to experience the child/adolescent’s negative transference in this remote setting. Beginning and Ending of Sessions
Working with Zoom (or some other audio-visual link) brought up the issue of the therapist starting and ending the session. Should the therapist arrange with the parent a short “waiting room” time for the child/adolescent so the child/adolescent is waiting and ready when the therapist starts the Zoom session. Related to this was the issue of how the therapist ends the session. If the child is alone in the room, does the therapist clicking “end session” leave the child alone in the room, suddenly cut off? Would it be better to have the parent come in near the end of the session so there is someone with the child when the session ends?
Parents and Remote Working
There was quite a broad discussion about the position of the parents in remote working. It was felt that with small children it was probably best to have the parent in the room with the child. This would be of assistance with the technology – in case it dropped out etc. as well as helping the child make a bridge to the therapist. The question of whether the parent plays with the child (either actively i.e. initiating the play, or passively i.e. allowing the child to initiate ) was raised. Some of the therapy may be observing the parent and child playing together and then at a later stage talking and thinking with the parent about this play. With small children especially this may be an opportunity to help the parent think and understand what the child may be communicating through their play. In this sense parents may be co-therapists.
The question of parent work was also considered as an alternative to direct Zoom work with children/adolescents. It was felt that if the family was functioning in a disorganised way – so that a private and reliable space in the home could not be guaranteed – then it may be better to try to work with the parents.
It was considered important that the therapist should have a way of contacting the parent if this was needed during the session. Phoning the parent to come into the room may be required to stop some dangerous/wild activity, or it may be needed to support the child if they are feeling overwhelming distressed.
Can the Screen contain the Feelings?
Several people felt that the actual physical room represented a safe space for the child/adolescent. Moving on to a screen or phone or text may not feel containing enough for some children/ adolescents. We wondered if this was especially so for adolescents as they may treat the consulting room as a place to bring their worries. A place that is separate from home and family- the developmental task of individuating away from the family being prominent in this situation. Are children more adaptable than therapists?
It was suggested that children may be more use to, and familiar, with the technology. Is working in this way more of a problem for therapists? This may be an opportunity for children or adolescents to feel they have greater control or knowledge about what is going on - this may be why some children are more open in this setting.
The Therapist and the Frame
Working remotely means therapists need to rethink the issue of the frame. They are less held by the frame as their previous sense of stability and predictability, so important for any therapist, are now challenged. The therapist may be working from their home and outside of their usual office. In this situation they are no longer being held by their familiar physical surroundings.
A further issue was how much anxiety the therapist is now holding. There is the global level of uncertainty, the rawness of this new technological method, the anxiety of the technology dropping out or freezing or the sound being difficult to decipher etc. Does this level of anxiety make it more difficult for the therapist to be receptive to the child/adolescent’s anxiety?
This topic raised several issues. Should the therapist send a collection of toys to the child so they can be used as material for the session? If you have seen the child in your room would it be helpful to send a few of the toys? Or should the parents be asked to buy similar toys for the child’s session? Should the child be asked to use toys that they already have in their room?
Length of a session.
Several people stated that working with a screen over several hours in the day is exhausting. This may be due to the newness of the whole experience as well as the intense nature of a video session – one can feel you are always “on”. Apart from the strain on the therapist it was also felt that for children a 50 minute session could be too much. It was felt that sessions needed to be shortened. Perhaps to 25 or 30 minutes?
Is Assessment possible when working remotely?
It was noted that earlier literature from overseas was suggesting it is not possible to do an assessment remotely nor is it advisable to start a new therapy. However these suggestions were not in the context of the Corona Virus. If this way of working lasts for several months it was felt that some adaptation of assessment must be undertaken. Indeed some people noted that they have been asked to do assessment for forensic reasons by their employer. Is 50% better than nothing?
While all the uncertainties and doubts about his new way of working were openly acknowledged, it was also felt that given the length of working this way may be long term, it was important to try to explore what is possible. It was felt that the analytic principle of a set day and time was in itself containing for all parties. Certainly this regular contact, even if very short , would be supportive to the parents.
Adolescents and Working Remotely
It was agreed that the different age groups required different ways of working. For the small child it was felt that the presence of a parent was crucial. For the young adolescent (12– 14) it was felt there may be a need for more active and possibly structured technique., particularly if the child is very active. Their difficulty in feeling uneasy about playing and their awkwardness in engaging verbally may require such an approach.
For older adolescents , although verbally more capable it was wondered whether the audio-visual link may be too intrusive and possibly a phone contact may be more manageable.
If using a video link it was discussed what camera position would be most appropriate. If it is placed so the child’s whole room could be seen this made feel less invasive, although fine details of play, drawings etc may not be able to be seen. For children it was wondered whether focusing the camera on the play/drawing/creation etc may be more manageable for the child and to some extent replicates the consulting situation.
Another issue was what does one do if the child walks around with the camera from room to room, or points the camera out of the window, or purposely goes off the screen.
There was considerable discussion of how audio/visual technology could be used for directly interacting with the child. It was noted that Zoom has an option of using a whiteboard. This allows both participants to jointly draw or write something on a blank screen that both people can see. This was seen as a great opportunity to engage in such an activity as Winnicott’s squiggle game. Obviously mutual drawings or other games could be undertaken using this technology. Zoom also has the function of either participant choosing a different background to the screen, so a person may appear as if they are on the moon, in a jungle, on a desert etc. It was reported that some children have used this function to play out different adventures. Another suggestion was to explore playing computer type games that have an interactive element. Games like Minecraft and The Sims were mentioned in this regard. It was thought it may be helpful to explore with young people we know which interactive, non violent games are available.
The meeting ended with a discussion on what are the legal positions on using an audio-visual link with a child or adolescent. How secure is the link? It was suggested that Australia has no legislation on these matters, although using American standards, it was thought that any free service did not meet security standards, but paid or subscription services had an extra layer of security and would be accepted. There was also mention of particular platforms, such a Zoom who have special telehealth options. Another related issue was the use of recording a session. It was felt this could be a concern if such recording could be subpoenaed.