Working remotely with children and adolescents from a psychodynamic perspective
This is a summary of the discussion of meeting 2.
A Preference for Zoom
It was recognised that most of the group felt more at ease with working online. Some of the initial anxiety had lessened.
The first issue that was raised was the question of whether some people may prefer to have their sessions via Zoom even when the pandemic is over. This was discussed in relation to adolescents. Some clinicians felt that having a Zoom session was more convenient for young people as it was less disruptive to their daily schedules. Having the 50 minutes on the screen, and not travelling to and from the session could allow adolescents to attend more of their after school activities.
This led to the question of the plus and minus of travelling to the session. If this was with a parent this was seen as a possible positive time with a parent - being together in the car, or a negative thing in that the adolescent may feel more pressure to talk about their session to the parent.
Should the therapist keep open the option of a Zoom session with an adolescent after the pandemic. This however may raise a financial issue, for such a session via telehealth may not be rebateable.
The Screen as a Protective Defence
A number of people found some children and adolescents were much more emotionally engaged via Zoom than when they were actually in the room. It was wondered if the greater distance provided by the screen enabled them to feel safer to reveal their emotional worlds. It was noted that some hard-to-reach children and adolescents may paradoxically be easier to reach within the safe distance of Zoom.
Issues with Adolescents
It was wondered if the convenience of a Zoom session in their home may make it easier for poorly motivated adolescents to be involved. However it was also discussed that having a session in the home may not be private enough for some adolescents, feeling their parents are too close by.
Working with Young children
It was generally agreed this is a very difficult age group for the use of Zoom. Some people reported the movement in and out of the shot of the camera made it difficult to know if the child was doing this purposely – and may be communicating something in this ‘there’ and ‘not there’ activity, or is the child not aware that when they move they may not be able to be seen by the therapist. Others felt that this movement away from the camera may be a reaction to feeling invaded by the focus of the screen. It was wondered if this was similar to an infant who has to avert their gaze when eye contact with another is too much. In regards to this feeling of the small child feeling invaded one therapist shared her experience that this intensity of contact seemed to be diluted when she played with dolls and spoke to the child through the dolls. This enable the child to re-engage.
Who controls the session?
It was generally agreed that the loss of the familiarity of the consulting room made it difficult for the therapist to make sense of certain things. For example a small child was moving around so much that the therapist could not see them. Yet it was unclear to the therapist whether the child was purposely doing this or was not aware that when they moved away from the camera the therapist could not see them.
Relatedly there was the issue of who begins the Zoom session. Should the therapist open up the session, with the child and/or mother be the ones who wait, or should the parent do this, putting the therapist in the waiting position. It was reported that there was further uncertainty in some cases as the child or parent was not always in the same room when the Zoom began. The child could be in their bedroom, the bathroom or the family sitting room. Others also reported the child being in the middle of a meal when the session began.
There followed a discussion as to whether it is possible to be fully emotionally engaged with a child or adolescent via the use of a screen. Does the absence of actual bodies in the room make the emotional contact feel ‘virtual’? Clinical material was presented of a child and adolescent who played a great deal with screens in the consulting room – one with a video game and another with detailed discussion of movies. While the material from both these cases felt very rich with symbolic meaning the therapist felt it was emotionally flat and wondered if these symbolic representations had a two dimensional quality to them, so the feeling were symbolically communicated but were not actually felt or emotionally connected to by the child and adolescent. This raised the issue of whether the use of a screen made it difficult to fully engage in an emotionally experienced way. Some people felt the remote contact did not prevent close engagement, suggesting the sensory cues of the sounds and movements on the screen were enough to feel there was a deep connection.
Report of the U.S Psychoanalytic Association Forum on remote working
Some participants shared their experience of joining this meeting. One of the main messages from this meeting was that clinicians need to explore what will work for them – that clinicians should try and see what works - that it was important to see what frame is possible with each case. It was also reported that therapists should not lean forward into the screen but rather sit back in a relaxed position and make an attempt to move their body about, replicating what would normally happen in a face to face meeting.
The Need for the Therapist to have some Thinking Space
Some therapists found the intensity of the screen to screen contact to be too intense and exhausting. They experienced looking at the screen drew them away from having some space to think and have their own thoughts. In this regards some preferred the phone than the video as this seemed easier to remain in contact but at the same time to have moments of reflection.
The Need for Personal Contact
The issue of feeling exhausted was raised in relation to not having the child or adolescent in the room. It was felt that therapists are fellow human beings and need to have direct contact with people in an embodied way – that there was something deeply unsatisfying in the remote contact.
Infant Observation via Zoom
An interesting discussion arose from observing an infant through the lens of Zoom. This happened to a group who had begun observing the babies in their homes but then the virus made this impossible and all the mothers agreed to do this via Zoom. The observers noted that a number of mothers focused the camera on the baby in their crib. They noted the relative absence of the mother and her interaction with her baby. Watching only the infant in this completely focused way enabled the observer to totally immerse themselves in the experience of the infant. This heightened the emotional intensity of the experience. The group wondered why the mothers had done this – was it a relief to ‘hand the baby over’ to the observer. Some of the observers felt like screaming out for the mother to come into the shot of the camera – is this what the babies were feeling, or was it something the mothers were feeling – all alone with no one around. This in turn made the group wonder if this reflected a possible dynamic that is very powerfully experienced in the lockdown of the pandemic – the new mothers did not have family and friends coming to be with them and importantly supporting the ‘socially distanced’ mother.
The Meaning of the Pandemic for children
The forum thought about what was the meaning of the pandemic for the small child. What impact did it have on the child that intimacy was possibly dangerous. Even the therapist and child could not be in the same room. What sense did they make of people wearing masks? This also led to a discussion of the effects of the social environment children and adolescents are now experiencing. The background of global warming, the current Australian bushfires and now the pandemic must make the child sense this constant backdrop of uncertainty and danger.
Notes taken by Peter Blake
[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.