Through a Glass Darkly: Surviving Online Therapeutic Work with Children

For now, we see in a mirror, darkly, but then face to face. Now I know in part, but then I shall know just as I also am known.

1 Corinthians #12

Thinking about working online with children can elucidate therapeutic action. Much has been written about the mirror function as it relates to the development of the capacity to tolerate affect and to think. Most of us working online with children feel that what we see is analogous yet somewhat different from what we generally see in the office. This leads to questions about what should be reflected back. Winnicott wrote about the analyst surviving the patient's aggression as a form of therapeutic action. How can work online help us think about the elements of becoming a useful object?

During this global pandemic, a group of child and adolescent analysts have met weekly to discuss best practices for working online. Some clinicians attended a couple of times, some regularly. Clinicians from around the USA, Canada, the UK, and Europe attended. Some clinicians were completely new to working online and clearly anxious about it. Others had worked online for various reasons. Some worked with medically compromised children who could not be seen in person, for example, some met online to provide continuity during blizzards that prevented travel. Some worked in an area that was strongly influenced by a university academic calendar, so children, college students, parents who were professors frequently left town for more than three months out of the year.

As a group, we all acknowledged the stress and loss involved with the stay-at-home order prompted in March 2020 by Covid-19. Many analysts missed their offices; others missed particular toys they had left in their offices. We talked about the dollhouse being part of the professional identity for some of our group members.

The first concern that surfaced in the group involved parents who disappeared, who had not responded to calls or emails. Other parents dismissed the idea of working online. We speculated that avoidance by the parents resulted from stress. We wondered if they would reach out when they felt more organized or that their children still needed help. We found, over time, that some parents did finally contact us.

The next concern was about privacy. Many who hadn't worked online before worried they couldn't ensure privacy for their young patients, often because siblings share rooms or the child needs a parent's help in setting up an internet connection. Sam Roth (Group Member Communication May 2020) suggested that the first phase of work with a child involves tolerating being alone with the analyst, and that switching to online work could prompt a recapitulation of that phase in treatment. Some clinicians felt that arranging for privacy was a part of a therapeutic process that now included the family in a way that seemed different from in-person work.

The evocative phrase “through a glass darkly” has been used in poems, movies, books, and songs. It is actually a translation of a Bible verse in Corinthians that refers to the experience of seeing only a part of something, whereas seeing the

whole is superior. Our group described seeing teens from the nose up, or children out of the view of the camera, drawing or using clay. One therapist realized after a few months that a 13-year-old girl she was treating was taller than she. We not only have limited vision, but sound quality is also poor at times. We also might have the impression some kids are facing the camera to engage with the therapist when they are actually checking email or other websites surreptitiously.

Although the decision on the part of a parent or teen to turn on the camera implies an invitation, our group also described feeling like intruders into the family's home life. We became witnesses to home decoration as well as home disorganization. We visited children in their bedrooms or sometimes in the parents' bedroom. We witnessed the behavior of siblings. Our group noted that seeing is different from being described to. One therapist heard a young patient describe his stuffed animal collection, but seeing the room and the stuffed animals online was different. Another group member noted that the collection was “lost in translation.” Kerry Kelly Novick (Group Member Communication, June 2020) commented that perhaps it was found in translation. In seeing so much that is real, how much do we lose perspective concerning fantasy and play?

The next concern that surfaced related to a new sense of powerlessness – for the child patient and sometimes the analyst as well- while sitting in front of a computer. Some children ran out of the room, some closed the camera or put the phone in a drawer or even in a dark closet. The experienced clinicians recommended practical solutions such as letting parents know they might receive a text asking them to help re-establish a connection. We all speculated that this is similar to the child running out of the office, but noted we felt more helpless about the online experience. Some members described watching helplessly as children rummaged through their parents' drawers, in one instance finding condoms. We also wondered if we were seeing, in a new way, how powerless children feel in our office or in our presence.

Winnicott described surviving the child's aggression as an important step in establishing the child's capacity to use the object. Certainly, we survive these aggressive acts and return. Winnicott emphasized the importance of the object surviving without retaliating. He also mentions: “This thing that there is in between relating and use is the subject's placing of the object outside the area of the subject's omnipotent control.” (Winnicott, D.W. . The Maturational Processes and the Facilitating Environment. Int. Psycho-Anal. Lib., 64:1-276. London: The Hogarth Press and the Institute of Psycho-Analysis.)

One interpretation of this is that when the subject, in this case, the child, realizes he or she cannot control the parent or the analyst, it fosters a developmental step, the ability to connect or relate outside of the sense of omnipotent control. Children, in an online session, who turn off the camera, the microphone, put the phone in the drawer or iPad in the closet are certainly expressing a wish for control. Can they use this acting out therapeutically, to begin to connect to the therapist in a way that can become useful to them? Does our lack of control reassure them?

We also discovered that some of us have been using computers to play video games for quite some time, and that YouTube and Minecraft can be windows into the minds of the children we see. Some of us believe the ultimate goal is talking and setting limits on screen time. As someone who pulled for talking over playing video games, I was inspired by my colleagues who worked in different ways. I bought Minecraft so I could play it with one of my patients who for two years now has talked about nothing but the game. He was so thrilled I did this, and I felt so much freer to follow his thoughts in the session.

Our group came to agree an analytic process can be established online despite limitations. My own experience has been that having a peer group of child analysts from a wide geographical area lessens the isolation of the analyst's room, expands clinical horizons and can be fun. I also firmly believe we help each other sidestep the siren call of seeing children in person prematurely, before it is safe to do so.

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