The challenge
It was an overnight change, a shocking, radical shift from being with – surrounded by toys, sand trays, big balls, tents, tunnels, and revelling in the therapeutic space, richly stacked with every thinkable resource for doing therapy with children and adolescents – to being suddenly dumped in a desert of sitting in front of a screen, staring at an upset child who wanted to be with me in the therapy room.
I still don’t know who had the biggest internal earthquake at this sudden desert experience, the therapists or the children? The challenge to the team was to find resources, to innovate. We worked hard to do just that.
We very quickly realised that we were totally exhausted after our first week of doing online therapy and the WhatsApp group contained up to 40 messages a day from desperate, tired, exhausted therapists who were stuck in a world we could never love to be in. The reality is that the books we sent to the children to prepare them for the online training worked well and there was an element of exhilaration for some children to see us online, in our own homes. Other children complained and struggled more with the transition, but generally therapists reported that the transition went much better than expected.
We decided to have a weekly debriefing group for all the therapists of the agency, where we could just support each other in this desert of limited human contact. These weekly sessions became our lifeline, the place we could complain, moan, share difficult sessions, cry, get help and above all were supported by a devoted group of therapists all feeling exactly the same.
The Solution
Three months later, the scenario looks very different. All the therapists have adapted – no, had to adapt. There is no longer only the Zoom screen in front of us. Some therapists have a big screen on the wall, due to the irritation to their eyes from long hours in front of the screen. There are document cameras next to the computers to display images of everything that is appearing on the empty part of the desk next to the computer. This can be toys, play-dough images, cards depicting feelings, family roles or pictures enabling the child to read a therapeutic story or book.
In some rooms there are toys all over, well organised in cupboards and shelves and others in boxes, containers and spread around the chair where the therapist sits in front of the computer. Puppets, soft toys, the brain puzzle, sand tray figurines, physical metaphors and everything which could comfortably migrate from the therapy rooms to the Zoom room in the homes of the therapists.
We have learned that there appears to be different responses of children during therapy after we started to work solely online:
The biggest surprise was that children and adolescents who are usually doing well in therapy in the therapy room, continue to do well with online therapy.
Children and adolescents who struggled with therapy, or who were inconsistent in their engagement in the therapy room, are doing exactly the same with the online therapy.
The vast majority of adolescents are doing much better with online therapy than with face to face therapy. It is possible that this is the space where adolescents nowadays share their most intimate details with people they have barely met. Having the familiar or sometimes unfamiliar therapist in front of them means that the therapist finally adapts to their world and they fully engage with gusto!
Younger children initially struggled as they missed the toys and metaphors they used. Creative parents have bought a plastic tub, painted the bottom blue, put sand in and bought sand tray toys and this fully replaced the frustration of not being able to use the sand tray.
Younger children bring their own toys into the therapy space and they always bring with it amazing metaphors of their own life which can be used during the therapy session.
Younger children are more in need of seeing the familiar toys of the therapist, the puppets or soft toys, animals of pictures they previously made, to help them with the transition into the therapeutic space. They even surprised us by going out of the therapy space and coming back with a replacement for toys they used in the therapy room and continued with the therapy process as if nothing changed.
Children enjoy therapeutic stories read for them by the therapist or parent over Kindle and screen share in exactly the same way they enjoyed the reading of these therapeutic stories from books in the therapy room.
Children can be active in movement, physical games and dancing in the therapy space in a similar way that they do in the therapy room, although they cannot always be seen. The conversation with the therapist keeps ‘holding’ the child in the therapy space. Doing some of these activities with the child, also provides some exercise for the otherwise very passive therapist!
Children are enjoying writing and drawing on the whiteboard which is a facility of Zoom screen share, exactly the same way they use pens and paper in the therapy room. And the therapist can save it immediately on the laptop to import it to the child’s file.
There are some adolescents and children who do not want to be seen. Instead of having to go and hide under a blanket or cushion, they switch off their camera and feel safer while continuing with the therapy session.
Only a few parents and/or children totally refused to engage with online therapy. In the majority of these cases, it appeared that parents had more resistance than the child.
EMDR/BLS is still being used. Most parents have downloaded the app which enables them to get the bilateral sounds. Many parents have connected their device to stereo speakers in the room to enable bilateral stimulation. Some children are using ear pods hanging over their ears. Some parents are tapping shoulders, feet or knees. Other children are marching up and down.
Some children also tried to hide in the room and as most children and adolescents are seen with the parents, the parents explained to the therapists what was happening and therapy continued.
A couple of children left the therapy space in their house; most of them returned for the rest of the session. The few children and adolescents who refused to return clearly made a significant therapeutic statement.
Of course, there has also been the very awkward moments. Seeing an adolescent in their own bedroom, without a parent present, felt very uncomfortable. If the bedroom of the child or adolescent is the only private space to conduct the therapy session, there are few options in an unknown, lockdown world. We have put some safeguarding rules in that no adolescent is seen without the parents knowing the time of the therapy session. The invitation for the online therapy session is also sent to the parents and the parents’ electronic device is used. The parents were also asked to come into these sessions at least 1 to 2 times, unannounced, to check whether the adolescent is fine or needs anything to eat or drink. Of course, it never appeared that this was unusual for the adolescents who mostly start to engage in therapy as soon as the sessions started.
There have also been some extra visitors in the therapy space. For example, a sibling refusing to leave the therapy space. The therapist surrendered and completed an excellent session about sibling rivalry.
Then there was Jamie, who apparently in a different dissociative state, arrived and had no idea who was on the screen. He was furious and demanded that the parents immediately switch off the screen as he did not know this person on the screen. No amount of explanation from parents helped. Jamie was adamant, shouting and screaming. With the first moment of silence the therapist said “Hallo, I am so glad to meet you. I see you don’t know me” and introduced herself to the child. Calm descended as another state arrived and consoled the new dissociative state that this is the friendly therapist who helps Jamie and the therapy session resumed.
Therapists also started to ‘feel’ the atmosphere in some houses. Overstressed parents were identified and many parents received more support during this period of lockdown. Therapists finally accepted that anything can happen at any time. There were some cats, dogs, hamsters and mice attending therapy as well. To get the perfect therapeutic setting in the house of a family who lives with highly dissociative children or child, is not easy. The answer appeared to be that it is easier for the therapist to adapt the therapy than to fight the inevitable. Parents worked very hard to create a therapy space but it was not always successful, yet therapy continued. It appeared that most of the children were resolute that they would continue to use their own therapy space, notwithstanding the changes and challenges.
The initial despair of therapists also slowly made space for silent acceptance of this is life, right now. The main benefit is that the vast majority of children’s therapy continued with a smooth transition from face to face therapy to online therapy within one week. Excitement reigns in every therapy support group when there is a new “gadget” or a new method or therapy tool which is shared or invented.
But, the therapists generally remain very tired and extremely exhausted at the end of each week. We quickly found that it is better to have space between sessions in order to move, drink something and recover somewhat. Continuous back to back sessions causes significant stress and exhaustion. One theme remains – we all want to go back to the therapy rooms as soon as possible. The children are starting to miss us more, the novelty is gone, but therapy continues. Some sessions had to be shortened as the 1.5 hour sessions that we usually have, became too difficult for some younger children.
Due to many children waiting for assessment, we could no longer allow them to wait and we have also started to assess children online. We all thought it was impossible, yet are finding excellent results. All parent discussions, parent groups, parent training, reviews, meetings and also family observations are done on line. It is business as usual, except that in the hearts and minds of the therapists, there remains an enormous need for the ‘normal’.
The Unknown
It somehow feels like we have reached the eye of the storm, we have survived the first part but are sitting with the unknown in front of us. Not because of the children, but because of the gnawing need to return to the therapy rooms, to be physically with the children and to be together again. Perhaps, we are just a species where physical ‘being with’ is critically important. But the unknown is equally critically frustrating. Only time will tell. There is a big group of children who are very impulsive, who will not be able to abide by the rules of social distancing. There are those who impulsively make physical contact with the therapist and the ones that love to spit. There is the reality of not being able to use the waiting room, not being able to use the sand trays, the toys, the play dough. How do we navigate that, when that was our normal life? How does the therapy room look without using what is in it? Do we hide the toys?
Then there is the problem with masks. How do you fully read the child’s expressions with a face mask – that is if the child will wear a face mask which is highly unlikely in the vast majority of cases. Who will wear the mask? Surely not the therapist! The therapist is the emotional regulator of the child in the room. This does not only include eyes staring from above a mask! Or will it be better to use a screen? What is the message the child will get? What happens if the child sneezes or coughs? None of the therapists can rely on the highly dissociative child to adhere to social expectations, and will a screen stop them from accessing the therapist or will it become a challenge to break the rules. We are all looking for answers. We thought moving therapy on line was the actual challenge, but now we think the main challenge might be the journey back to the therapy rooms.
But in the meantime, therapy continues 7 days a week as usual and a big cheer for all the brave therapists who moved with the times and the shocks and adaptations to keep the therapy process for the children rolling. Trauma is still processed, attachment is still happening, dissociative states are still revealed and worked with and integrations are still taking place!
Perhaps the biggest benefit is that therapy can now be done over much bigger distances. Families who drove for many hours to come and see us, now have the luxury of remaining at home. Children who could only be seen fortnightly can now be seen weekly. And the unreal reality is that it is highly likely that for at least the majority of adolescents and many children with complex trauma and dissociation online therapy has finally become a possibility in a world where distance no longer really matters!