Guest post from Hanna David, PhD
Dr. David, counselor of gifted children and their families, has shared with us a timely post about considerations when conducting therapy online with students and families.
On-line treatment has been widely spread in the second decade of the 22nd century. Googling: ONLINE PSYCHOLOGICAL TREATMENT CORONAVIRUS has shown (until March 25) 67,600,000 results! However, written materials about the treatment of children, especially younger than 10, via video has been very limited in general, mainly because of the possibility of play treatment is almost non-existent through Skype, Zoom, WhatsApp, etc. No wonder that up to now I have not found any protocol for video-treatment of gifted children. I hereby offer some tips for such treatment based on my 2-week experience of treating 8-18-year old gifted children and instructing their parents through Skype and WhatsApp. As the coronavirus does not seem to disappear in the near future I hope that my following post – about video play-therapy of the gifted – will also be of some help for gifted children, their parents and their therapist.
This post will concentrate on five main issues:
- The concern of patients about their [older] therapists;
- The various difficulties young patients face when switching to video treatment;
- Technical failures: when the connection is interrupted, the voice is blurred, etc.;
- When younger siblings invade into the conversation;
- When “I am the video-treatment person”.
Some of these issues have been mentioned before; most of them are common to video treatment of non-gifted as well.
- What happens when the patient is concerned about their therapist?
Almost all child therapists have experienced the necessity of cancelling an appointment because of an illness, an injury or a misfortune, disaster or a sever condition of someone close to her. Children can understand, sometimes even at age 2, what is being unwell, and many of them already take part in a play role of: “a visit at the doctor’s clinic”, using kits that include a thermometer, a blood pressure gauge; a stethoscope, a plastic bottle with a colored medicine-like liquid given to them when their body temperature increases, or even without any accessories. There are children who put their teddy-bear to sleep, cover him with blankets, sing him a lullaby, and even ask everybody who enters the room to do it quietly because “teddy-bear has got a temperature”. Other children swing their doll’s cradle while “calming” her with unclear mumblings, try to “feed” her with the white liquid in “her” little plastic bottle while “persuading” her to sip some more drops because she “must become stronger”.
When “Corona Time” started, many kindergarten children were curious about the new situation, and many caretakers and teachers had to respond to the demand of children who asked for more knowledge. More intelligent children asked more questions at a younger age, but all educators have noticed that giving as accurate answers as possible – depending on the child’s developmental stage and emotional maturity – was needed. While this has been the case in many other critical situations, for example an illness or even a death in the family, there has always been an option of giving a general answer rather than profound answers that the child could not possibly understand or perceive. This has not been the case with the coronavirus.
The fight against the coronavirus has required as full cooperation as possible from everybody. Thus, parents, educators and caretakers have taught children how to properly wash their hands; how to keep “social distance” from others; and later telling even very young children that they could not meet their older relatives, not even their grandparents. Gifted children as young as 4-5 already knew the difference between a virus and a microbe and what must be done in order to minimize their nature.
This reality has created an enormous challenge for all therapists, especially for the older among us. Older therapists do not have to take care of their own children whose schools have been closed, and are not even allowed to meet their own grandchildren, so they are the most “natural’ group ready and available for video-treatment of children. But some highly gifted children know already at the age of 6 that older persons are more vulnerable to the coronavirus, and most death cases it causes are of 65+-year olds. The children’s concern about the health – even the life – of their therapists is accompanied, man a time, with the parents’ concern, which is well grounded.
The first rule in facing this challenge is telling the truth. When a child asks me if I am not afraid because of being old I tell her that indeed, I am old, and thus I do whatever I can in order to stay healthy. All “my” children know that this is true, as about 3 weeks ago, before people belonging to my age-group were advised not to meet others at all, I already told each child who entered my clinic to measure the distance between us, using my PowerLock 5-meter measuring tape [see the picture]. When the next week the children started the video treatment they already knew that I was telling them the truth about keeping as isolated from the virus as possible.
Many children, especially young, ask, at this point: “How old are you”? My answer is “67 and a half” or “next August I’ll be 68”. Accuracy rather than vagueness is a key for establishing trust. However, if you happen to have additional risk factor, it is not recommended to share this info with any of your patients, no matter how old or gifted they are.
2. What happens when a young child feels he need his parents to be present at the video-meeting?
Trust building is a main ingredient – if not the most important factor – of the treatment success. It is quite frequent to hear from the child’s parents, before the first meeting with the therapist, that they “can’t believe he will be able to stay in the clinic without us” or even “why can’t I, his mother, be present”? In most cases when the child is aware of his parents’ concerns they turn into a self-fulfilling prophecy; the child insists on his parents’ presence in the clinic. But when the parents are determined not to allow it the child eventually gives up, which helps building the necessary connection with the therapist and accelerates its strength. Thus, even if the child is a gifted 5-year old, it is almost always possible to agree upon “two breaks during the meeting when she meets her mother at the waiting room” or “leaving the clinic door open for the first two weeks”.
It is not possible to go through this process when the first meeting is not at the clinic, so just to make sure – we are talking about a child that has already established a satisfactory level of trust with the therapist. But even then, the transition to a video meeting is not simple. First of all: there is a technical problem. It is highly recommended not to use a tablet when the child is under 10, and operating the computer for such a meeting might be new for many young children even if highly gifted. Thus, a parent must “be there” both at the beginning and the end of the meeting. A parent is also required to “be close” in case of a technical or other problem.
But the transition from a two-people meeting to the situation when the parent is present or at least within a hearing distance is not necessarily negative. Here is an example that shows that this situation can have a positive effect.
A child who has not dared to express his deep negative feelings towards school, other family members, his siblings or even his parents is finally speaking about it with his therapist knowing that his parents are listening but cannot stop him or even intervene. He uses the opportunity to “speak up”, after he had already practiced it with his therapist, in order to “show” his parents that his feelings were acceptable, “telling” them that there is a possibility that he is “to blame”, that he feels being accused for no reason, and that he is ready to speak about his “bad behavior” with them.
3. What happens when technical failures occur?
During a video conversation it is quite frequent that the connection is interrupted, the voice is blurred, the therapist or the patient moves and her picture disappear from the screen, etc. We, older people, are used to hearing time and again that “children are better than us with computers” or “the young generation was born with a screen”. However, generalizations tend to be statistically true, but they cannot be applied to all cases. In addition, a child can be a champion in computer-games, or even an excellent programmer, but this does not necessarily make him more knowledgeable in fixing hardware problems… Sometimes a child who got his first smartphone at age 5 has had no experience in using video programs that are much better functional with a large screen. We need a larger screen for a better opportunity to follow the nuances of the patient’s expressions, her home-environment, the design of her room and many other important things that we have not had the opportunity to see because we always met the patient in our clinic.
In order to minimize the problems while using Skype or Zoom, the therapist must make sure it is installed on her computer. Both programs can be downloaded for free; even a technophobe can download them if she is determined to succeed. The next step will be to try using it in order to make sure it works. After that, you, the therapist, need to send the email address you used for it to your patients. When you do that, you demonstrate confidence, as if to say: most probably both you, my patient and your parents need me now more than ever, and together we shall overcome any technical problem!
But we cannot deny that using a video tool for a counseling meeting might cause an unexpected problem, including the potential of disconnection of the conversation and even the patient’s decision to terminate the whole process. In order to prevent such a situation, or at least minimize its prospects, I recommend preparing a back-up video tool, another program that should be installed in a different computer or smartphone, as well as an available telephone, if possible, a hardwired phone.
All these details seem very technical, but unlike in a face-to-face therapy session, when the therapist depends mainly on her own capabilities and experience, in a video session she must make sure these “technicalities” would not be on the way. This is true especially for highly-talented children and adolescents who sometimes have less patience than others, and in many cases hate to waste time until the line is fixed and the conversation resumed.
4. What happens when younger siblings invade into the conversation?
When our patient, child or adolescent, is sitting at the table during our conversation, whether in her own room or not, the basic rule or privacy in treatment, namely, that only the two of us are present and nobody gets in during it, changes. When everybody is at home younger siblings, who usually want to interfere with their older brother’s and sister’s life, find it harder to control themselves. It would not be fair to blame them or their parents for “not disciplining” them. “Corona Time” is not a good time to educate younger siblings, so both parents and counselors should be understanding when a sibling enters the room where our patient is conversing with us. A younger sibling usually believes that her older sister has a more interesting life – she goes to more places, meets more people… These beliefs are reinforced when the younger child feels she has nothing to do while her older sister is “on Skype”…
Here is a least of the most frequent scenarios that might happen when the younger sibling enters the room in the middle of the video meeting:
The older brother drives him out. It can be done by shouting, yelling and even pushing, kicking or hitting him. It is not our task to intervene. We must remember that while we are speaking with our patient, the sibling is under a parent’s care, the sole commander of what goes on in the house. The fact that we saw what happened does not mean we are part of it and certainly not that we have a role in it.
Our patient tries to involve us into the situation, saying things such as: “You see, I always tell you how unbearable my brother is”. In such a case we should ask our patient to call the parent. When our conversation is resumed, we might be asked to explain our reaction. One single sentence should be enough: “Your parent is the chief commander at home!”
The younger child enters the room, waves at us, “makes a face” in front of the screen, or says something that she knows would make her brother angry. If our patient did not react physically when the sibling leaves the room, we must praise her for her self-control and for not being impulsive.
If and only if our patient wishes to speak about what had just happened, we are to explain to her that her younger sibling was jealous because she was probably bored, and because she also wanted to have “someone special” to speak with. This explanation can develop, if the child shows an interest, to deeper ideas and thoughts about envy and jealousy. Quite often with gifted children being aware of a more abstract idea, sometimes at a very young age, leads to a deeper interest in the subject and curiosity that results in self-studying it.
5. What if “this kind of treatment does not feel like me” or just “I cannot do it”?
In spite of my warm recommendation to offer each patient the possibility to continue their treatment by video conversations, it is, first of all, up to the patient. If the patient or her parents decide they do not want to try it there is no problem.
But there are also many therapists who feel they cannot do it. The reason does not really matter. Some therapists find it hard to adopt a new method, preferring to stick to things they are familiar with; to protocols they had been using or rules such as “I am not to be in my patient’s house”. Some others have the self-perception: “I am a technophobe”. Younger therapists may not be able to treat other children when their own need care. In all these cases, and in many others, it is recommended to stop the treatment in order to get back to face-to-face meetings in better days.
The worst possible scenario, in my opinion, is that a therapist who is overwhelmed by her own anxieties continues meeting patients. Such a scenario might be harmful to all patients: adults, adolescents and children. But gifted children and adolescents are even more vulnerable to such a situation. As one of the most typical characteristic of the gifted is sensitivity, many are extremely sensitive to their therapist’s feelings. Indeed, transference in treatment is important, and counter-transference is unavoidable, but when the therapist’s anxieties are projected upon her patient, and even worst – the patient is concerns about her therapist’s life – such a situation is not just unethical; I would define is as immoral.