Thank you to everyone who responded to our April Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
April Quandary: During the covid-19 pandemic, I’ve switched to doing teletherapy. With Marcia, a single mother of two adolescent girls all quarantining in their 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) Channel Your Inner Surgeon
What's wonderful about this scenario is that problems have come into the therapy space that might not have had Marcia and her therapist been only meeting in-person. Often, our clients describe their problems to us in the safe, therapeutic environment that is our office, a step removed from the troubles they describe. This provides grounding and perspective, so they can view their troubles differently and perhaps reenter life with new insight or skills. However, some of my clients (and I) have sometimes thought things might be easier if I was a proverbial voice on their shoulder during these difficult moments, walking them through solutions in real time. In fact, we therapists are taught that when a client's troubles do make their way into the therapy space—the most obvious example perhaps being a fight during couples therapy—there’s an opportunity for a corrective experience.
One of the most powerful ways for us to teach our clients is to guide them as they’re doing something, like a doctor being guided through an operation by a supervising surgeon, telling her how to move her hands. This experiential learning can be a game-changer. What initially appears to be a distraction from the session might actually be an experiential opportunity to grow in session, helping clients like Marcia in real time.
As Marcia’s therapist, I’d want to attune to her difficulties, naming the distractions and how they appear to affect her. Then, I’d help her identify how she might ground herself, and walk her through techniques that might help, like diaphragmatic breathing or naming sensations around her or in her body. Dan Siegel's Mindsight is a great grounding tool. I’d also express empathy for how hard this must be for Marcia to do during the distractions and encourage her to keep trying, thereby exercising her ability to manage stressors more effectively.
Jennifer Pietrzak, LCSW
2) Think Outside the 50-Minute Box
Be flexible and creative in your sessions with Marcia. If you normally do 50-minute sessions, ask if she’d like to try two 25-minute sessions a week instead, since she might be more successful getting her children to entertain themselves for shorter amounts of time. You and Marcia might even decide it could help to include the kids in some of the session. That way they can see what mom is doing and who she’s talking with. Maybe the therapist can engage with them too, giving them a constructive task so they’re more willing to let mom have her alone time.
I’d make it clear for Marcia that these shorter sessions won’t feel the same as having a whole 50 minutes to focus solely on herself, but involving the kids will validate their need for reassurance and attention and help Marcia set limits. It sounds like she might be embarrassed when she returns from dealing with them. I’d make sure to acknowledge that she might feel more exposed as you witness her parenting efforts and the kids’ lack of cooperation. I’d validate these feelings, offering reassurance and support, then perhaps follow with one of these creative strategies to make her time with you feel more productive.
Mindy Solomon, PhD
3) Look for What’s Changed
I have three suggestions for Marcia’s therapist. First, that he offer her an earlier or later time to talk, when the kids will be less disruptive. Many families must juggle their children’s needs with their own while managing other responsibilities. It’s especially challenging now with so many parents and kids self-quarantining.
Another suggestion is that Marcia’s therapist use these interruptions as an opportunity to discuss setting boundaries with her kids. Maybe Marcia didn’t recognize this as an area for growth initially, but there’s certainly room to explore it. She could talk to the kids about their disregard for their mom’s 45-minute activity that’s crucial to her well-being. I’ve found that most kids 13 and older are capable of self-regulation, can demonstrate self-control, and honor appropriate boundaries if the expectation is clearly articulated. This might also be an opportunity for Marcia and her therapist to explore family dynamics and parenting styles.
Third, Marcia’s therapist could delve into how the pandemic is possibly changing her family’s routine. Maybe the kids are feeling more stressed from being confined in close quarters with their mother and away from their peers. Asking how she and the kids are spending their days might provide some valuable insight into why the kids are interrupting her to begin with. If they are feeling more stressed, maybe there are opportunities for Marcia to help them all de-stress.
Right now, many kids are heavily engaged in social media—the latest Instagram posts, TikTok videos, Tweets, and Snapchat messages. Replacing some of this activity with chats about what everyone’s feeling can be a source of fun and stress-reduction. Covid-19 means stress levels are high for married parents and even higher for single parents. Recognizing that kids feel stress too helps to validate everyone’s experience.
Nandranie Busjit Bhalai, LCSW
4) Have a Game Plan
Under the current circumstances, a parent being interrupted by his or her children during a teletherapy session isn’t at all unusual. If the clinician can schedule an appointment for after the kids’ bedtime, or before they get up, that solves the issue speedily. However, since this isn’t always possible, having some plans in place is key.
These plans and their success depend on the children’s ages, of course. Let’s say the parent is raising a two-year-old and a newborn. Maybe the best option would be trying to hold sessions around nap time. Let’s say they’re a little older—five and seven. Set them up with a drink in a sippy cup and something that will engage them, like Sesame Street or Mister Rogers’ Neighborhood, and then tell them something like, “It’s Mama’s time for her counselor. Your job is to watch this until I’m all done. Then you can come and get Mama and we’ll have a snack!”
If the kids are older, it’s important to teach them the importance of boundaries and respect. The parent might say something like, “I have something important to do and need to be able to trust that you can respect my time. You can watch a movie or read a book or do your homework while I’m occupied. I will not be responding to any disruptions unless there’s an emergency. It’s important for our family to learn to work together, and this is one way we help each other.”
Ultimately, it’s up to Marcia to prepare for success, but if her therapist finds she’s allowing too many interruptions, this could actually be a point of discussion in therapy, a way of helping her develop better parenting skills and better self-care skills.
Nancy Johnson, MS
5) Lean In, Then Find an Outlet
One of the best things about doing teletherapy is that I can see firsthand what it’s like for Marcia as a single mom with two kids. Even if I thought I had a clear picture of what parenting them was like from our in-person sessions, seeing her in action offers me a glimpse into her reality that I wouldn’t have gotten otherwise.
First, I’d acknowledge that her plate must be beyond full. Then, I’d tell her that she and I are in this together, and we’re going to take full advantage of the opportunities that teletherapy allows us. Given how hard it is to find alone time, I’d help Marcia accept that some interruptions are inevitable. But by anticipating that they will occur, we can make our sessions even more productive. I’d coach her through this by saying something like, “Don’t stress when we’re interrupted. In fact, we want the kids to interrupt us. This way, we can role-play different ways to help you set boundaries.”
I’d continue: “Let’s try new ways to respond to them while keeping your cool. And if need be, before our session is over, I’ll ask you to close the door to your room so you can vent about all those things you wanted to say but didn’t get to.”
This is one of the things that got me through parenting. In a particularly tough moment, I could be very composed if I knew that later there’d be space for me to call a close friend and scream out what I’d been feeling earlier. For our own sanity, we all need an outlet.
Of course, it’s also important for parents to tell their kids what to expect when they’ve asked to not be interrupted. I might advise that Marcia say something to her kids like, “When Mom says she needs alone time, I’m not going to answer your questions.” Or “When you ask me something while I’m on the phone, the answer is no, unless it’s an emergency.” Or she could hand them a timer, set it for the duration of the session, and tell them that they can talk after it rings. I’d have her explain that we all need time for ourselves: “This is Mom’s time, and you have your time.”
If Marcia isn’t used to getting alone time because she doesn’t set boundaries or her children don’t recognize their importance, I’d want to work on that with her. Even if she sets small boundary-setting goals, like enforcing a single minute of alone time for herself, that time will eventually grow as she becomes more comfortable setting boundaries. If Marcia worries that this isn’t a nice way to treat her kids, I’d emphasize that there’s a difference between being aggressive and assertive.
I’d end our session with this: “Marcia, the first time you enforce boundaries, you might only get a minute of free time, but I promise you that it will grow. Now, let’s shut that door and scream!”
Susan Cohen, LICSW, LMFT, ACSW
We'll post a new response to each Clinician's Quandary on the first Tuesday of every month! See how to submit to next month's Quandary here.
Next Month’s Quandary: I’m offering teletherapy during the coronavirus pandemic, which is working well for most of my clients. Sam, however, who is extremely anxious and suffers from panic attacks, has repeatedly told me that our video sessions aren’t effective because he doesn’t feel grounded enough to work on his issues when I’m not physically in the room with him. How can I change this and the boost the impact of my teletherapy sessions with anxious clients?
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