When the first article of this series was written in March 2020 we were entering what we expected to be a brief, if global, crisis due to COVID-19 (Oaklander Model in a Time of Crisis). Its title, “Just for Now,” intended to frame therapy for a short time. But that article and a Zoom call to a few colleagues blossomed into a virtual venue where child and adolescent therapists worldwide participated at first weekly, and now monthly, in Zoom calls that have been part training webinars, part community-building, and mostly an opportunity to greet and learn from Violet Oaklander. Since then, we have held 15 Zoom meetings with an average of 80 attendees from 25 countries. Along with the meetings grew unexpected opportunities for international collaboration. Currently the JFN (Just for Now) articles have been translated into 6 languages, and we await similar translations of our guidebook (Oaklander Model Guidebook for Therapists).
Now we have the more pleasant but still pressing task of managing the return to a life not dominated by COVID. As we do so, I believe we will discover that, first, international therapeutic consultation will not just continue but will expand and enrich our healing efforts; and second, the Oaklander interventions which let us treat clients during the pandemic will let us help them (and us) transition from it equally well.
Oaklander Principles and Techniques in JFN and Transition Sessions
As the current case study is being written, in January 2021, COVID continues to rage throughout the world, yet we also have vaccines. On this cusp of a post-pandemic era, “When ‘Just for Now’ Meets the Future” details how to begin clients’ and our own process of transition from a prolonged shutdown. Most therapists had just weeks or even days to react to the global pandemic. Now we have not only the hope of recovery but the time to prepare for it by helping children, adolescents, and their families work through the anger and grief experienced during COVID and plan for life after it. And the timeless yet always-timely Oaklander principles and techniques are proving equally powerful in pandemic and post-pandemic therapy.
As Oaklander explains, children’s behavior during stress is their way of trying to get their needs met. So therapists must consider each individual’s response in light of that individual’s needs, and offer tailored, specific, more appropriate ways to cope with the trauma caused by the pandemic and the adjustments required by its eventual alleviation.
As an example, this article first reviews goals and guidelines informing care of the 10-year-old I called “Mary” in the first article, which illustrated use of the Oaklander Model in phone or online sessions and of technology for sharing the child’s projective work. It also indicates how Oaklander’s general approach, her classic Gestalt play therapy interventions, and current virtual tools can now facilitate emotional evolution out of crisis. Then, the piece details their actual deployment and assesses their efficacy in Mary’s case. Finally, the article suggests further session goals and activities. Once again, I thank Mary and her family for permitting me to reproduce her session notes, words (lightly edited for clarity), drawings and likeness.
Therapeutic Goals During and After the Pandemic
Build the Therapist-Child Relationship
Honest one-on-one connection and trust are paramount in any therapeutic relationship, but the universal stress and highly visible behaviors taken to avoid COVID intensified the importance of that bond. Even the relief of having effective vaccines has been tempered by delivery delays and controversy. As with all news that is unclear, the promise of vaccinations calls for an authentic, clear discussion, in developmentally appropriate terms, about what is happening. Therapists must ensure that the information shared is titrated to what the young client needs to know for health and safety and is appropriate for that client’s level of maturity. Communicate with the parents to find out what children have already heard in the family, on TV, or outside. Avoid assuming that children actually understand what they have overheard. They may have processed only the stress but not the facts and their significance for their lives. Inform them about what we know and what remains uncertain in a manner they can grasp and that supports their resilience.
Meet Heightened Challenges of Contact
Contact in Gestalt therapy refers to the client’s ability to be present—to utilize physical, emotional, and intellectual powers to connect with the self and with others. The earlier article Oaklander Model in a Time of Crisis focused on screens as limiting contact between therapist and client. And now therapists must also answer the new challenge of “Zoom fatigue” in children doing all or part of their school day, social occasions, and extracurricular activities virtually; feeling saturated with on-screen relating; and understandably resisting sessions. Recommendations include shortening sessions; involving a parent; engaging the child with interactive apps such as projective cards, sand tray, dollhouse and puppets and with physical movement; laser-focusing on treatment goals; and prioritizing the therapist-client relationship. In some cases, a break in treatment is best: The therapist can work with the parents, or give the family a break, until the child has the bandwidth to resume Zoom sessions.
Help Clients Avoid Guilt Feelings
Children’s typical egocentricity—attributing the cause of events to themselves—may well have increased during the pandemic and should continue as a focus post-COVID. Some children and adolescents may in fact have engaged in high-risk behaviors impacting family members and friends. It’s important to address and process this possibility with the child and family, especially in the developmental context of children’s and adolescents’ need for increased independence, often at odds with safety. To help manage their sense of guilt or shame, the therapist should explain to them and to parents that young people are supposed to be out with their friends, but that the pandemic made this healthy behavior hazardous.
Focus on Immediate and Upcoming Therapeutic Goals
Now is the time to help a child both process the current pandemic reality and prepare for a future without a pandemic. Be open as well to helping the family express anger and grief.
Pre-existing difficulties you may have advised them to set aside “Just for Now” may have resurfaced during the prolonged confinement. Even without these, it is likely necessary to confront issues such as divorce; illness and death due to COVID-19 or other causes; emotional, professional and financial losses; having to leave school or other programs; or cancelled events and outings. You may also need to help members of the family work through a post-pandemic plan.
Attend to the Presenting Problem
COVID-19 stresses everyone, but may have exacerbated a client’s specific presenting problem, such as anxiety, obsessive-compulsive disorder, depression, denial and angry outbursts. Equally, at this point children may have developed one or more of these problems even without any underlying issues. In either case, addressing them is a primary therapeutic step:
Anxiety may display as excessive worrying to the exclusion of anything else. But in a family affected by COVID-19, some worry may be appropriate. The therapeutic challenge is to ensure that the anxiety does not generalize to cast a shadow over the future.
Obsessive-Compulsive Disorder may appear almost the norm, given pandemic-era practices of hand- and surface-washing, stay-at-home orders, social distancing and masking. But the therapist will watch for exaggerated safety behaviors and obsessive thoughts accompanying those habits, and will encourage a return to moderate precautions.
Depression may occur with children isolated from their peers, extracurricular activities, extended family members, and favorite teachers. These losses may have worsened children’s and adolescents’ pre-existing emotional shutdown or agitation. Again, the therapist will work to instill a sense of hope and excitement for the COVID-free future.
Denial may persist even at this point, with thoughts such as, “I’m young so the virus won’t affect me;” “Everyone’s overreacting;” or “They already had COVID, so they’re safe.” Therapists should first help clients acknowledge the current risks, since stress denied may return, sometimes even stronger, once the source is gone and experiencing it feels more manageable—a delayed reaction that will spoil the joy of returning to normalcy.
Fatigue related to the prolonged lockdown brings the same risks as denial. We went from “Let’s just get through the spring” to “Well, we’ll have a normal summer” to “ We’ll start school in person” to “As a hybrid” to “Online” and finally to “We’re locked down for Christmas.” Again, the therapeutic goal is to help clients admit and mourn the reality of not being sure when it will end, so they can fully enjoy it when it does end.
Anger is a typical response to a very frustrating situation, and for some children and adolescents has been their primary mode of expression. They may also have shut down their anger and become withdrawn. In either case, they have lost their ability to access and vent their true feelings. Yet again, truly experiencing anger and grief will permit, later, truly experiencing relief and happiness.
Family stresses attend any regional, national or global disaster, and COVID-19 qualifies as one of the most profound. After months of crisis, parents increasingly lack the emotional strength to tolerate their children’s manifestations of anger and grief. Suggesting regular 1- to 3-minute “family gripe sessions” may assist parents in meeting their children’s, and their own, need for emotional expression in a way that’s tolerable and relieving for all: Each family member gets a turn to gripe, following certain rules:
Just listen—no interrupting, and no arguments about the content.
Content must be developmentally appropriate for the children to hear.
When the timer goes off, move on to the next family member.
When sad, angry and any strong feelings come up at other times, family members should make (or ask a parent to make) a note of it for the next scheduled gripe session.
Case Study: Two Transition Sessions with Mary
Delivered to client’s home
Materials for Sessions
Projective cards
Drawing supplies:
pastels, markers, regular- and larger-sized paper for collage and frame
Clay and tools
Puppets
Collage materials:
magazines, scissors, glue stick, liquid glue
Mini sandtray with sand and miniatures
Snacks
Sessions Plan (Case completed 1-5 in Session 1 and 6-7 in Session 2, but divide as you see fit.)
Check-in with cards
Invite client to draw two pictures:
“Draw a picture of what you felt like during COVID.”
“Draw how you would like to feel when it’s over.”
Anger: “Pick 5-10 of your own anger words and write them down in an Anger List.”
Talk about situations bringing up those anger feelings, and invite client to choose two to make out of clay.
Work with the clay pieces.
Grief: “Think about what experiences you lost during COVID and make a collage of them.” (e.g., social, academic, family, extra-curricular activities)
Help client compare the present time with the past and the future.
Choose and work with puppets that represent past, present, and future to client.
Help client and family create a structured schedule with appropriate limits:
Schedule during COVID
Schedule after COVID—what you would like it to be
(e.g., screen time now vs. screen time after COVID)
Work with the polarities about the transition, using the sandtray:
“What will be easy adjustments?”
“What will be difficult adjustments?”
First Transition Session: Focus on Anger and Grief Caused by the Pandemic
Check-in with Cards
Among the materials I dropped off at Mary’s home were two sets of cards: Medicine Cards and boldly-colored cards showing people, objects, and scenes. The rationale behind providing so many options is, as Oaklander teaches, that making choices—even about which type of cards to pick—strengthens the child’s or adolescent’s sense of self.
Before I could even give a prompt, Mary quickly chose the card depicting an old woman. She said she picked it because:
“In the pandemic a lot of people are getting older and COVID is dangerous for older people.”
Then I asked her to pick a card for how she’s feeling right now. Choosing the turtle card, Mary explained:
“I picked the turtle. Turtles are slow and people are slow to make the vaccine and I’m just not doing anything except for this in the day. Before this, the day went slowly.”
Draw Two Pictures
Knowing Mary’s dysgraphia makes fine-motor skills laborious, I asked her if she would be ok with drawing two pictures. She agreed, and I reminded her that drawings can look like anything, and this isn’t an art class: They can be just colors or lines or shapes, and stick figures are completely fine.
First, I led Mary through a relaxation exercise: “Take a breath and let it out, and it can make some sound…. Try that again and notice that maybe your shoulders will drop when you do that. If you want to close your eyes you can, and just scan your body from your head to your toes. Notice if you have any pressure or tension. Just notice it. And I’m going to make a sound (I rang a chime)…. Listen to it for as long as you can…. I’m going to ask you to think about this time in the pandemic and what it’s been like for you. Maybe there’s one thing that stands out for you, or a few things. Notice how you feel, who’s around you, if anyone, and in a minute I’m going to ask you to draw a picture of this. The drawing can be in colors, lines or shapes if you like … don’t have it be your best drawing. It doesn’t have to make any sense to me, only to you.”
Mary drew a picture with four stick figures and some objects at the bottom. I asked her to describe this picture:
“This is of me being, like, regular and a little bit mad and sad and claustrophobic, and this happens a lot—makes me more mad than usual. On the bottom are things I like to do that make me happy: Playing sports, baking and doing art.”
I asked her how it was to draw that picture and she answered,
“It was relaxing,” with a big smile.
I then asked Mary again to relax, close her eyes, and imagine the scene she would like to have when the pandemic was over: “What would it look like? Feel like? Who would be around you?” Before I could finish the prompt, she quickly opened her eyes and began to draw a picture with a blue sky and two people hugging, and said:
“It’s a bright sunny day. People can hug and masks don’t exist anymore and people are hugging and it will be fun, and people can be more happy and not so afraid. Some people are already doing this, because they are people who want to get it, and already hug and don’t wear masks. Made me a little bit madder and kids might not get the vaccine until next year. Also sometimes people in class are in each other’s cameras, so I know they’re at each other’s houses, and it’s so annoying they are not following the rules and … there would be that many more cases and we will have to be doing school like this longer.”
Anger List and Clay Work
I took Mary’s stated annoyance as a cue to go to the anger work I had planned but needed to see her readiness for. I showed her a template with words that define anger feelings: the “Anger Terms Form.”
I then asked her to choose two of the terms that she would like to make out of clay.
She chose two but worked with one in particular:
“This one is me and my sister. We’re painting outside and then we were showing each other our paintings. ‘What is that!?’ And I said, ‘Stop trashing my work.’ And she said ‘it’s called constructive criticism.’ And later I was singing—my show is sooner, so I said, ‘We have to focus on my show and not yours.’”
I asked her, “Name it: what word—maybe # 8—hitting?”
“I hit her but not hard. I’m me and I am painting with my sister and … she was saying things … and I said I liked my picture and she said, ‘Yours could use some work.’ And I got really mad and annoyed and she ‘gave me a face.’ Mad because she wouldn’t apologize … and she said, ‘I’m not mean, just ask everybody else.’ “How would you like it if …? Don’t mess with me, don’t talk to me like that—I’ll do it even harder!”
I asked Mary what she would like to do with the clay: She could do anything she wanted to express her feelings. She replied:
“I would like to destroy the table because that was where the art was on … and that caused the argument. I’d put myself on top of that and be the good person. If you weren’t mean to me, that wouldn’t happen to you, and I destroyed your table because you were the argument. And then I might even add this. And I’m just going to roll out clay and I’ll add a crown!!”
I recalled that Oaklander recommends supporting the child through specific steps in processing anger and aggressive energy, especially identifying and owning the anger (“I am angry at this”). For Oaklander, aggressive energy is part of the expressive anger process if the child is in contact with the therapist and feels safe; if there are clear limits; and if the action is exaggerated/theatrical in a spirit of playfulness and fun. So with these guidelines in mind, I enthusiastically stayed in contact with Mary while she made the clay pieces, talked through her anger, and smashed the pieces with the mallet:
“The crown is … I destroyed it, and I am the best one. Yes! Because I wasn’t the one that started the argument.”
I asked what it was like to smash the clay and she said, “That was fun!”
Having allowed Mary to experience and express her anger, and thereby to strengthen her sense of self and her contact with blocked emotions, I could then move into the area of grief.
Collage
To process her grief, I asked Mary if she would like to make a collage with the materials I delivered to her home, including varied magazines with many options of images—again, facilitating the strength-building power of providing choices.
Mary made a collage, choosing to be in her the collage of a girl in a tree, and said:
“I’m the girl in the tree, I don’t have anybody around me and I have to do hard things by myself. I’m lonely and I can’t find anybody that can help me.”
I asked, “How is it to be you?”
“It’s pretty annoying … because I always have to do things on my own. And people are never where I am and they’re too afraid to come where I am and I’m too afraid to go near them.”
I asked, “Does it fit for how you’re being at this time?”
“The only people I can be near is my family, and the other people I have to stay far away from. And people who can help us, we can’t come close to them. Let’s say we’re in class in person and you need help … and the teacher knew because they can see what you’re doing, but can’t help you. And the screen can’t show you everything.”
I continued, “As Mary, what would you say to the girl in the picture?”
“Maybe there’s always light at the end of the tunnel. So she can just keep doing what she’s doing. And one day she won’t be lonely and people won’t be afraid of her.”
An objective of this session was to help Mary identify and express her grief, in this case through the projective activity of making a collage about what she has lost during COVID-19. (On conceptualizing and working with grieving children, see Hidden Treasure, chapter 7, at http://vsof.org/store.html.) In subsequent work, I would process more of the grief that emerged in the collage.
Puppets: Past, Present, and Future
To begin Mary’s transitioning out of the pandemic, I used puppets to explore her view of the past, the present, and a post-pandemic future. (Due to COVID, Mary’s puppets were used exclusively by her.)
I had her spill out the puppets onto her floor. Mary chose two girl puppets to represent the past, an animal in a trash can for her present, and a “Grandfather Smurf” with big eyes for her future
“Past: two girls together; Present: trash can figure; Future: people will have wide eyes when they see things that they couldn’t see before and Corona is showing and they’re so amazed by things they haven’t seen in a long time. I wish it was the future already. I would say, ‘You’re lucky you already got the vaccine … he’s over 75.’He said, ‘Well, people will get the vaccine in a few months.’
Maybe the future would say to me, ‘There’s always light at the end of the tunnel. There’s a bunch of bad things and at the end you’ll feel more happy that you felt before Corona started because you feel more free. And if it was like before … you wouldn’t know what it was like.’
I’m the past … and I don’t know what the heck these people are talking about, what the heck is Corona. I’m feeling I want to go to my friend’s house, have a sleepover and eat a bunch of dessert. Did you hear from the man: ‘I have no idea what they’re saying because I don’t know what’s going on.’”
When I asked Mary’s past to talk to her future, she narrated:
“I don’t even know what you’re talking about … to the man: ‘You’re going away and you’re a crazy person.’”
Then she hit the future puppet and threw it. I asked her about the present:
“I’m the present, I am hiding in this trash can and other people are definitely not. I might be an animal. I’m not scared … it’s fun scaring them because they think I’m a disgusting animal thing and I just hide in there and they have to throw stuff in …. I like seeing their reaction. Because Mary likes to just have fun, I guess, and do a bunch of … she likes to do things that are funny. And sneak up on her siblings.”
I asked her, “Which puppet—past, present, or future—do you connect with?” and she said:
“I connect with the present the most. It’s more funny, it’s not that annoying and weird and it likes to stay safe … except I don’t like being in a trash can. Because nobody’s going to see me if I don’t pop up.”
Second Transition Session: Planning for Post-COVID Life
While children have always needed structure, they need it during COVID more than ever. And they’ll continue to benefit from scheduled activity long after the pandemic, when every family member is recovering from its overwhelming, dysregulating stress. So it’s vital to help families set limits, especially when school, work and home time have become so blurred.
Structured Schedule
In the second session I asked Mary and her mother to write a typical schedule of her current activities during COVID-19. Mary’s dysgraphia makes handwriting difficult and she’s keyboarding all day in school, so I had her dictate her schedule for her mother to type:
“Current schedule during COVID
Monday through Friday
Wake up
Go downstairs and eat breakfast
Workout with a video
9 am—Go to school on Zoom
10:15-10:30—Break
10:30-12—More school on Zoom
12-1—Lunch
1-3:15—More school on ZoomAfter Zoom school:
‘Chill’ on Ipad
Watch TV
Sometimes—play ‘Among Us’ online with my friends
Sometimes—play ‘Rummikub’ with my family
Sometimes—do another workout video
Play with Bubba [Mary’s dog]
Sometimes—do an ‘Outschool’ class on Zoom. Drawing Baby Animals Outschool class every week. Clay class on Outschool. Teach myself how to sew.
Dinner
Read, watch more TV
ShowerWeekends
Wake up, go downstairs with my family, get ready to go for a walk with family and friends (socially distant). Ipad time. Reading time. Play games. Do some workout videos. Watch lots of TV :-) [Mary asked me to insert that smiley face]. Realize that I have too much screen time so I try to find something artsy to do. Eat dinner. Watch family movie.Sometimes—go get a smoothie or Starbucks. Bug my sister and brother.”
As a way to ease the transition, I had Mary plan the future, and dictate the schedule she hopes she will have when the pandemic ends:
“Projected Post-COVID schedule
School days
Wake up, get ready to go to school, go to school. Come home, do HW if I have it. Go to after-school activities in person. Go to dance class, singing, Yada, soccer, cooking class.
Dinner
Workout video. Read, shower and play.Weekends
Wake up late.
Take a walk with family. Go out for breakfast or lunch. Bug my sister when she has a friend over. Go hang out with friends. Go to Yada in person. Go to birthday parties. Have my own birthday not during COVID.”
As I discussed in earlier presentations, during the pandemic screen time has gone from a necessary evil (worrying many parents about its impact on developing brains and how to limit screen time) to an irreplaceable lifeline. As seen in Mary’s schedule, most aspects of her current life occur via a screen, so planning now for a transition back to in-person learning, exercising, and socializing would help her.
I asked her, “What could take the place of screen time when you don’t need it for every activity?” Her response:
“Screen time after COVID
No TV/YouTube or iPad games on school days, like before (our rules before COVID). Will use screens to text and Facetime friends. Sometimes will play games like ‘Among Us’ with friends.
Still will do Outschool classes on Zoom sometimes.
Xbox for Just Dance
Still will do workout videosActivities that will take place of screen time:
Play dates, classes, sports, art, dance, sing”
Working with Polarities
Since many children have become adjusted to this period of restricted activity, I asked Mary, “What will be easier or better?” Her response:
“Hugging people outside my immediate family, like grandparents
Being able to understand class better
Playdates in person
Birthdays in person
Fun activities and classes in person
Traveling to Hawaii and other places”
I then asked, “What will be harder?” Her response:
“Might not get to type all my work anymore (typing is easier than writing for me)
If you get into a fight with a friend, you actually have to see the person every day.
I might forget to bring things that I really need to school.
I will have to wake up earlier and won’t have time to exercise before school
Can’t sneak food or toys during class
Can’t have my dog at school
Can’t just talk whenever I want during class because there is no mute button
This is making me realize that I actually like online school. Can I stay in online school?”
Working with the sandtray, I asked Mary to make a beautiful scene of the future. Mary used larger-grained, wet-beach-feeling kinetic sand, and described the elements of her scene:
“There’s these people who are not socially distant because they don’t have to be and they can go to really cool places like the beach …. This is a different place, like the farm, and you can go anywhere again. And it’s fun to make the scene.
I am, like, really happy right now because I don’t have to stay at home and I don’t have to wear masks any more. It’s kind of weird because we’re going to a lot of places but we’re just used to being home, and bigger places that are really pretty. It’s going pretty well, because it’s way more fun.
I’m the sea animals. I have no idea what’s going on because I live underwater and now people are trying to find me more than usual. Because now they don’t have to wear something called masks. I don’t know what they are. It’s annoying because they kind of follow me around and sometimes I need some space. Sometimes they kidnap my friends.
I’m the horse and the pen: The pen is guarding.… I like people and think it’s fun to have people go on my back, and now much more people are coming on me and this is actually fun because I get to move around and I like doing that. Usually people are nice to you. It’s fine to be penned in for 5 minutes and people go on my back.
I am the people: They look different … also these people are guarded by this metal wire so they don’t get to scare the animal. The people just wish they could come closer.”
I asked, “What would happen if the animals were to come closer?” Mary said:
“The animals would attack them or run away.”
Aha – so, “Are you used to having a metal wire or guard when you are at the beach and you see dolphins or you see horses behind a pen? Have animals at the beach or horses attacked you or run away?”
“No, I have gone horseback riding a lot of times and I was just at the beach and I saw a billion dolphins.”
I continued, “So, the metal wire is keeping these people safe, but you haven’t needed one before?”
“Yes.”
I asked, “Why do these people need one?”
“Maybe it will feel like people will need one because we have had to be physically distant from everyone.”
REFLECTIONS ON THE SESSIONS
These two sessions demonstrate how the Oaklander Model can be used to process a child’s feelings while we’re still experiencing the pandemic, and to help a child imagine a time when the pandemic is over. Their objective was to introduce the idea that the world could feel safe again. Using different media allowed Mary immediately to project her feelings onto the cards, drawings, clay, collage, puppets and sandtray. She accessed feelings of anger and grief, as well as a sense of hope. Mary consistently described her experience of working with these materials and expressing even difficult emotions as “relaxing” and “fun.”
Mary’s sessions demonstrate how Oaklander’s techniques enabled her awareness of a wide range of feelings she had experienced during the pandemic, even while she adapted to the isolation of being at home and doing much of her learning and living virtually. She seems to have benefitted from practicing, a healthy, self-reflective transition from the pandemic to in-person activities and relating.
Suggestions for Future Sessions
Each of the projective exercises Mary completed can be explored more deeply. Mary may revisit the virtual record of her creations at a later time and change or redo them to reflect the evolution of her feelings.
Mary can judge how well her predictions about easy and difficult post-COVID adjustments stood up.
Mary may consider which adjustments elicited anger, grief, or hope.
Mary can use the same projective techniques employed in these two sessions to explore any unexpected easy or difficult adjustments and her reactions to them.
COPYRIGHT 2021 KAREN FRIED