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?

Toys

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.

Camera Position

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.

Interactive Activities

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.

Legal Position

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.

 

2 thoughts on “Working Remotely 1

  1. Kat Mikhailouskaya says:

    This comment is from Kat Mikhailouskaya
    Hi Peter, Just to share a couple of thoughts, feel free to copy/paste to share with the group. As I work with adults some of it may not be relevant, but nevertheless can’t help but notice some things about online therapy. I remember someone mentioning in our first zoom meeting couple of weeks ago that perhaps it may be unethical to continue therapy via Skype and that therapist said she temporarily suspended treatment for her clients. I admit I also felt uncomfortable to “promote” Skype to my clients and encourage them to continue as I recognize my own need for income rather than their benefits. I appreciate that some of my clients come to explore childhood trauma and such treatment can wait 6 months or so and be resumed later. So I was struggling whether to offer to wait it out or push for Skype. Luckily I work with adults so I can give them a choice. As a result 50% did suspend therapy. Couple of those returned after 2 weeks needing support.
    Those who were willing to “try” Skype often commented on following issues: – feeling pressure to talk and getting uncomfortable with silences online, experiencing silences as “weird” -feeling like they needed to talk louder and clearer as not sure I can hear each word, felt unnatural to them – feeling “this is absurd” to try and continue talking about trauma/family/histories while the pandemic seems to overwhelm the world – feeling disconnected and alone in the room, with increased sense of isolation. Feeling sick of screens added to that.
    Lastly I myself sometimes no longer know if the client continuing treatment online is pleasing/satisfying my need to continue or they genuinely need to continue. I found that talking about the issues above with clients helped a lot and also talking about permission to pause treatment helped, although inevitably resulted to decline of my caseload.
    I suppose stopping altogether or continuing despite the feelings of aversion (whatever online therapy may arise) aren’t definitive options, but should be discussed with clients. I found it helpful to let them know that I’m available for Skype but ultimately they don’t have to.

  2. gmmptibr-ca says:

    Comment by Kat Mikhailouskaya

    SUMMARY OF ICAPP MEETING ON WORKING REMOTELY WITH CHILDREN AND ADOLESCENTS HELD ON APRIL 28, 2020

    This was the second meeting sponsored by ICAPP to discuss and share views on working remotely with children and adolescents due to the Covid-19 virus. Seventeen people attended. Working after the Pandemic is Over. The meeting began with a discussion as to whether these ways of working remotely may remain , to some extent, after the social distancing rules are relaxed.

    Will some people prefer this way of engaging.
    It was noted for some families this may be a more convenient and comfortable way of working. Working remotely has the advantage of not having to travel to and from the consulting room. For busy parents this may be their preference.

    Also for some adolescents this remote meeting means there is less time devoted to their therapy and as such is less disturbing to their other school or social activities. The related topic of travelling to and from the consulting room was discussed. There was a feeling that this period could be a very positive time for the child/adolescent to have some special one on one time with a parent of caregiver. That this could be a very important transition period before and after the therapy. Alternatively it was thought that driving home with a parent may cause a difficulty in that there may be pressure on the child/adolescent to talk about what happened in the therapy.

    The issue of whether there will be a preference for remote working would also be determined by the financial situation of the family, as there would be no rebate for sessions after the pandemic is over. Finally it was thought that each clinician needed to think what was the meaning behind the request for a preference of working remotely.

    The Positive and Negatives of working remotely.
    There was considerable discussion on how this new way of working could be both helpful and detrimental to the therapeutic process. Because it makes therapy more accessible this may help children/adolescents would are not terribly motivated. It was also felt that, being remote, this may enable certain adolescents to be more prepared to engage, as it may give them a sense of being able to control or regulate the distance between themselves and the therapist.

    On the negative side it was felt that talking to the child/adolescent in their home may feel like an invasion, for it may be difficult to have a private, confidential space in the home. Also the child/adolescent has to walk out of the room immediately into the family situation, so it does not provide a transitional space after having a session.

    Working with Small Children.
    It was generally agreed that this is possibly the most difficult age group to work with remotely. The group thought about the technical issues with a young child. The therapist is dependent on the parent setting up the room and the contact. Some people have found it is unclear whether it is better for the therapist to start the meeting with an invitation or if it is more effective if the therapist is the one to be invited. There is also the problem of not being sure of where the meeting will be. It could start in the child’s bedroom, or the kitchen or sitting room etc. Others noted that preparing the child for the meeting can be a problem.

    At the start of a session they have been confronted with the child being fed their meal or engaged in some other activity, so it is hard for the therapist to engage. In certain cases it was felt the therapist needs to talk to the parent as to how they may provide a more stable setting. The control and position of the camera was an issue with this age group. It was wondered how the child felt seeing the face of the therapist filling the screen – did this feel too invasive? Should there be another camera where there can be a longer shot or position for the therapist. With small children who are particularly active people have had experiences of them taking over the camera so they may block the camera, leaving the therapist blind, or they move the camera around so much it is hard to visually follow.

    The discussion then focussed on whether this is a communication from the child and should be treated that way, or whether the therapist’s functioning was being challenged and the therapist should ask the parent to take charge of the camera. Certainly it was felt that the child being in his own place and being able to play with the camera gave him/her more control. This could be an issue with very controlling children and make it impossible to work remotely. One child who was playing hide and seek was outside of the camera so the therapist had no idea of what was happening. With small children it was reported that they seemed to engage and respond much more if the therapist spoke through a toy .e.g. a monkey, or teddy bear. This displacement seem to ease the possible intrusiveness of the therapist’s face on the screen.

    The Meaning of a Screen.
    There was a long discussion of what does a screen represent to both the therapist and the child/adolescent. Some people reported that rather paradoxically hard-to-reach children/adolescents seemed to be less defensive when working via a screen. Did the screen give them some sense of safety or at least a way of managing the intensity of intimacy. This may also be very important in working with adolescents – who wish to get close and wish to move away and be independent. The issue of relating via a 2 dimensional technology was considered in relation to the depth of contact as well as the depth of symbolism that can be experienced. Does this ‘virtual’ reality make it look and feel very meaningful, but is there still some awareness of the ‘virtual’ nature of this.

    Some people felt that deep contact could be made with someone over Zoom. Indeed, the very focussed nature of the technology could allow for more detailed and concentrated perceptions. There was an interesting discussion of undertaking infant observation via Zoom. It was noted that when the camera was exclusively on the infant when they were very young, this allowed the observer to fully concentrate on every little detail. This led to the observer being very identified with the infant. The issue of screens was also raised in relation to what meaning did children give to screens, especially seeing people wearing protective screens when dealing with patients of the virus. Would this heighten obsessional concerns about being invaded by germs. This lead to a discussion about the broader world of today and how this must be impacting on children and adolescents.

    Children/adolescents are surrounded by messages of global warming and in Australia to the terror of bush fires. It was felt this broader context needed to be considered in working with these age groups. Also it was raised that we are working in this remote way using technology as a ‘protection’.

    Reports from Other Meetings.
    There was a discussion and feedback from people who viewed the American Psychoanalytic Association’s online discussion about working remotely. What came across in these discussions was a feeling that therapist had to try things and see what happens. In this sense there was a feeling that therapists had to find their own personal frame that worked for them with each person they saw. It was also mentioned that therapists should sit back from the screen in a relaxed position and also be aware to move occasionally and not be in a rigid position on the screen. It was further noted that David and Jill Scharff had written quite extensively on this way of working over a number of years.

    Another aspect arising from this online discussion was the importance of the therapist acknowledging the loss of their usual way of working. Also not actually seeing people was a ‘personal’ loss for the therapist. The therapist is a human being that also needs real contact. It was felt this had to be ‘mourned’ to some extent so people could adjust to the reality of getting on with doing the best they can under these difficult circumstances.

    The Pressure of the Screen.
    Several people spoke about the pressure to be ever present and to deliver some therapeutic engagement when you are trapped in the confines of the screen.

    It was felt that it was important to not always be in visual contact – to look away or turn off the camera – so as to provide some separate thinking space. In this way a number of people stated they preferred to use the phone. In a related topic it was discussed that seeing some people on Zoom seemed much more difficult than others. It was wondered why not seeing some people on Zoom, but rather connecting to them on the phone felt much easier and a relief.

    The Problem of Transitions.
    People raised the issue of the strangeness of working from home. While this was a benefit in not having to travel to work it also blurred the line between work and home. That to some extent this was disturbing our professional and personal identities.

    No date was made for another meeting. It was felt that we would see if there was still a need for people to share their experiences in another few weeks.

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