In a follow-up to part one of this popular Quandary, five more therapists offer tips for keeping the work on track during these sessions. Click here to read Part One.

uandary: During the COVID-19 pandemic, I’ve switched to doing teletherapy. With Marcia, a single mother of two adolescent girls all quarantining in a small apartment, this is especially challenging. She’s often distracted or pulled away to tend to the girls, who bicker in the next room, play the TV too loud, or knock on the door looking for her attention. When she returns to the screen, she’s flustered and unfocused. What’s the best way to keep our work on track during these video sessions?

1) Take a Cue from Family Therapy

I think it’s perfectly fine for Marcia to be pulled away by her children. I wouldn’t resist it and wouldn’t encourage Marcia to resist it either. This is real life, after all. The mother of two adolescent girls will have her hands full all the time. Pointers on how to deal with them is just about the best therapy she can receive. The time she puts in now with her children, who can’t respect her need for privacy for an hour, will have a much larger payoff later.

Rather than have her locked in a room talking to her therapist, I’d ask Marcia to bring the girls into the room with her and introduce them to me. I’d ask that she let me observe them and her interactions with them. I’m sure I can see some things that she might miss. For instance, which child triggers the other? Which one is needier? More compliant? This might also be a good introduction to therapy for the girls, should they need it at some future time.

Meanwhile, I’d encourage Marcia to be open about our work without spilling all the beans. The kids obviously know she’s talking about something mysterious, otherwise they wouldn’t be acting up while she’s on the call. I guarantee that if the girls were introduced to me, they’d calm down. They might even find something of concern to talk to their mom about. If not, their need for attention and curiosity about what Marcia’s doing would paradoxically wane once they were included.

My guess is that a big issue in Marcia’s family is inclusion versus exclusion—this is why the girls will calm down if included. I view their attention-seeking behavior as an opportunity to explore the possibilities. If the girls were younger, it would be a different story, but as adolescents, they know better. If they’re still seeking attention at this age, it gives me a big clue about what they need. With less resistance and more inclusion, Marcia might be surprised to find that the girls settle down, giving her space to do important things for herself.

Larry Laveman, LCSW
Solana Beach, CA

2) “In the Event of an Emergency…”

Teletherapy gives us a real-time window into our clients’ lives, and if boundaries with family members aren’t clear, then we therapists find that out, pronto!

If I was Marcia’s therapist, the first thing I’d do in our sessions—assuming the kids aren’t bothering her—is invite her to slow down and relax as much as possible for a few minutes, just to give herself some space to experience her feelings. If the girls are quarreling in the next room, I might help her acknowledge that although the girls may be stressed out, they’re not actually in danger. I’d advise Marcia to leave them alone to work things out, so she can take care of herself. I’d use the analogy of flying in an airplane: in the event of an emergency where you’re flying with another passenger who needs help, put on your own oxygen mask before assisting others. 

Together, Marcia and I would create a space for her own feelings, where she could hold compassion for parts that are having a hard time. I’d ask her, “Marcia, can we attentively create an opening for you to be present with your feelings, thoughts, and internal parts, and notice how they are? Are they realistic, cartoony, angry, sad, guilty, distracted, frustrated, or scared?” I’d also ask where and how she feels these parts in her body, and whether she can slow down and notice each part. “Maybe for today,” I’d say, “just focus on one part at a time.”

The point here is to allow Marcia room to move from outward focus on her kids to inward focus on herself. If she’s stuck focusing on them, I might ask, “Marcia, what might happen if the part of you that’s constantly drawn to the kids takes a step back? Do you think you might actually be helping them more if that part takes a step back so you can focus more on yourself?”

If Marcia can allow greater connection to herself in our sessions, it’s possible thatshe’ll be able to parent from a more grounded place and give the kids more of what they need.

Amy Ludwin MA, LCMHC
Burlington, VT

3) Meet Interruptions Head-On

Just as the coronavirus has urgently prescribed a total rearchitecting of how we do life, it also challenges therapists to generate the most impact in a virtual therapeutic interaction.

Decades ago, as a training social worker, one of my supervisors said, “Always make sure to meet clients where they are.” This phrase comes to me now, as I sit facing my clients onscreen. We can’t really gaze into each other’s eyes as we would in person, but there are still ways to do good therapeutic work.

One of my clients recently told me that her eight-year-old daughter was feeling anxious about finishing her remote-learning assignments, and asked if I could speak to her. The daughter proudly showed me her story boards, some Lego castles, and math sheets, and we all got into a spontaneous conversation about how learning involves discoveries about our own personal learning styles.

With mother and daughter in the room, we also talked about how to order the day’s assignments, charge through math problems, and how it feels to get easy assignments out of the way first instead of challenging ones. Mom and I wonder whether a teacher would have the capacity to notice as much as we’re noticing now.

I think there’s room for something similar to unfold in Marcia’s sessions if she and her therapist choose to involve Marcia’s kids. The unanticipated development in my therapy sessions arose out of current circumstances, where the household now needs to function as a workplace, school, therapy office, playdate venue, and a home with the usual duties of meal prep and laundry. My own client felt relieved once we explored her daughter’s anxiety. She needed me to meet her where she was, not to deem outside stressors as being in the way of therapeutic progress.

Lisa Friedlander, LICSW
Tewksbury, MA

4) Avoid Judgment

Like Marcia’s therapist, I’ve transitioned to doing teletherapy, and I’m trying to take in the gifts of meeting my clients in this way. Getting a thorough peek into their everyday lives has helped me get to know each person and their stresses better. I think meeting our clients where they are and normalizing that therapy during a pandemic might look different is important, both for ourselves as clinicians and for our clients. Reflect on your expectations for your clients and their work in therapy during this time. Brush up on crisis-management skills, especially if it isn’t work you typically do.

In this therapist’s shoes, I’d check in with Marcia about the change in therapy. If she’s also feeling bothered by the lack of focus, I’d help her brainstorm ways to keep her girls occupied and set boundaries with them to keep the apartment quiet during the 45 minutes she’s in session. Developmentally, adolescents should be able to occupy themselves for most of that time, but may need guidance about how to do so and what kinds of interruptions are okay. When she returns to a session flustered, I’d guide her through a quick grounding exercise—a few deep breaths, a body scan, noticing things in the room—and give a brief summary of where the conversation left off. Above all, I’d avoid judging her for having a life that doesn’t perfectly accommodate therapy right now.

Ellen Line, LMSW
Baltimore, MD

5) Consider a Trade-Off

The world of telehealth is so new for so many of us that we often pass over establishing ground rules that we might put in place were we doing face-to-face sessions instead. When we don’t have the luxury of managing distractions as we do when clients come to our offices, I try to engage both the client and those in their environment—in this case, Marcia’s two adolescent children—in a discussion about their needs and concerns during this very out-of-the-ordinary situation.

I’d propose that the first 15 minutes of the next session be with Marcia and her children, to discuss what the family needs for her children to allow their mother peace and quiet during her session. Getting a verbal commitment from the kids now could give Marcia the space for to have productive sessions later. I might choose to work with the kids for a few sessions, to remind them that their needs are important as well and tell them that we’re all feeling unsettled right now. 

Paul Lesnik, LCSW, TEP
San Diego, CA

This blog is the second in a two-part series. Click here to read Part One.


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