The framework of art-therapeutic care in virtual mode during the Covid-19 pandemic

1. The preamble

The lockdown, which has been an integral part of the response of all countries affected by the COVID-19 epidemic, has had an undeniable psychological impact. At the time I was working as a psychotherapist in a therapeutic, educational and pedagogical institute taking care of children between 6 and 12 suffering from various psychic pathologies. The children and parents we support already experienced significant psychoaffective weaknesses. This reality has obviously been anticipated by multidisciplinary teams since the start of government decisions and has opened up a specific practice for many teleworking professionals, as well as a global reflection on our remote interventions.

A group reflection was gradually developed between doctors, psychologists, educators and pedagogues during and at the end of this very special period of work, with multi-faceted contributions. Note-taking and continual discussion with colleagues helped shape the final draft of this work. The experiences of each other during this period could bring together most of the hypotheses that were brought into this circle of institutional work.

A summary note, published on March 14, 2020 in the journal The Lancet, drawn up by psychologists from King's College of London based on 24 studies carried out in ten countries, alerts us: "Different characteristics or consequences of confinement appear to be major factors of stress: duration in particular, but also fear of the risk of infection, inherent in confinement, frustration, boredom, lack of certain everyday consumer products, inappropriate or truncated information, loss of income, etc. quarantined staff are much more likely to report exhaustion, detachment from others, anxiety, irritability, insomnia, difficulty concentrating and indecisiveness. ?

They highlight:

o A psychic slowdown: far from everything, cognitive abilities decrease, which manifests itself in fatigue, a drop in attention and motivation, even apathy.

o Potential somatization: in this unusual environment, the body reacts to stress with sleep disorders, headaches, digestive problems.

o An increase in aggression: in response to promiscuity, individuals withdraw into themselves or become aggressive towards others.

It would be wrong to say that all families experienced a state of psychological stress. Such a generalization also misses most of what confinement teaches us: depending on the balance of the links between parents, children, school and our services, situations change in unpredictable directions which can sometimes be favorable to parents, children and even care devices. This reorganization is perhaps the main subject in what it brings to light as modalities of permanence and change within the systems that interact around the child and whose care pathway has been modified.

Particular vigilance must be taken in assessing the balance of family systems, their potential for resilience, the equally positive effects that can overcome such exceptional circumstances. Moreover, the unsuspected resources that children are likely to mobilize, including in terms of unconscious dynamics and creativity, correspond to highly complex processes that must not be forgotten. As such, it is by remaining faithful to working on a case-by-case basis that the methods of intervention remain effective. Nevertheless, the risk of mental disorders accentuated by confinement is a factor to be anticipated and deserves theoretical and clinical reflection.

In my recent observations, several scenarios can arise:

The risk of withdrawal: while some young people react by staying even further away from their family and social circles, others find themselves "trapped" with their parents in a falsely comfortable confinement that promotes fusional stasis. In this case, the situation paradoxically suits parents and children who are more anxious at the idea of taking their eyes off each other than finding ways of individuation that are essential to their respective balance. We notice this phenomenon in certain situations of children presenting psychotic disharmonies.

The accentuation of addiction factors: children already dependent on screens run the risk of locking themselves even more in a virtual world, especially if it is a network universe. The majority of problematic situations are associated with video games, Internet platforms and can trigger a real addiction as a substitute for outings that are now impossible.

The discrepancy in temporal rhythms: We have been able to observe worrying discrepancies in the sleep-wake rhythms of certain young people who live at night and sleep during the day or who find it very difficult to put together a schedule that structures their days. Some young people on the side of borderline disorders seem more subject than others to this shift during confinement.

The increase in interpersonal conflicts: the effort made by parents to occupy their children, remind them of the rules of daily life and provide a framework, in particular with timetables, can become exhausting and trigger situations of repetitive and systematized conflicts which increase the group anxiety in the home. The risk that had to be anticipated was that of an escalation of tensions leading to psychological or physical violence.

The scarcity or increase in school work: parents can remain very distant from their child's school work or become so involved in it that an imbalance can be spotted by professionals. The fact of taking up elements with the parents seems essential in many situations where the school becomes an issue that goes beyond learning and opens up a reflection on the often imaginary psychic elements that it comes to cover.

What recommendations should be given in this specific context? There are no miracle recipes and the support provided, the listening and the mobilization of professionals are put in place according to the way in which the links were forged with young people before the epidemic. It is the singular characteristics of the relationship that form the matrix of caregiver support within an ITEP system. Also, it is by counting on the awareness of this intersubjectivity that remote work retains a certain interest. Ensuring the continuity of the link is a major mental health issue of which all teams are aware. This was the priority during this very special stage, including in the treatment with art therapy. Keeping a framework while taking freedom and flexibility in the improvisation of this new method of intervention was personally the great challenge in this event.

Working by telephone or using the Internet has made it possible to identify central elements of current support:

o The need to support the creation of an appropriate form of timetable for children according to their profiles and above all by involving parents and foster families in the process and by promoting the establishment of rituals and benchmarks specific to each family, which made it possible to maintain the cohesion and identity of the family circle which could quickly crumble.

o The importance of explaining the reasons for confinement in a calm way, without referring to war metaphors which can fuel anxiety.

o Remind parents of the importance for children of scheduled outings by respecting the instructions so as to allow, with their authorization and supervision, essential breathing moments (we have been able to observe situations where parents forbade any outing!) situation of confinement can place adults in an infantilizing and regressive posture which weakens them in their position of authority vis-à-vis their children. This is why it is also important that professionals support parents in appropriating the laws imposed by confinement so that they become positive guarantors of the framework.

o Assessing available space is a major issue. In a home with a small surface area, the place of work mixes with that of family life, which can create tension and confusion, including concerning everyone's places.

o The organization of fixed call slots with certain professionals avoids duplication and gives families the feeling of being tracked. Nevertheless, calling for "nothing" can have the merit of creating space on the psychic level and sometimes "a step aside" in the representations and affects of the day that are particularly reduced and trying.

o Board games, do-it-yourself, manual activities and plastic arts seem to be very popular in some families and not at all in others, which deserves questioning and remediation.

o The need for coordination within teams to avoid saturation of messages sent and received. Use of centralized log sheets by the department head, updated once a week based on call notes from professionals. The log sheet allows you to know the situation described by others and avoids asking the same questions to the families and knowing the important elements to be developed during the sessions.

2. The implementation of therapeutic monitoring systems during the Covid-19 epidemic in the institution.

If the rumors of the Covid-19 epidemic had been heard for a few months, no one could have foreseen that the reality of the health risk would give rise at the beginning of March to a decision as unprecedented as it was sudden: confinement. of an entire population and the application of rules of social distancing, prohibiting any idea of contact and physical proximity.

The institutions of the medico-social sector had in turn to interrupt all reception of the public and this without much idea or preparation to come and alleviate the most worrying situations: those which were in progress as well as those which were not to lack manifest. Authorized travel and meetings were kept to a strict minimum and accompanied by restrictions. With the closure of schools and childcare facilities, concerns about the direct consequences of such measures have given rise to an inflation of discourse and psychological, health and educational advice often relayed in an anarchic manner. We feared the frustration of the children, their fear, the abandonment of “rhythms” and the delay in learning at school. We also feared “confinement” within families, often in a small living space. However, it appeared that the extent of the problems was not located where it had initially been feared and that the resources that the actors of care (doctor, psychologists, therapists) could make available to children and their families were more in the personalization of "telework", the pace and methods of making contact from a distance, the quality of the "report" and the development between us of each of these contacts. In short, the creation in a very intuitive way of new care devices in a new framework of institutional intervention.

In my establishment, it was the words “contact” and “link” that federated and around which teamwork began to be organized. From the start, all the members of the team instinctively came together in a messy proliferation that conveyed panic and uncertainty but also revealed the shared conviction that the competence and point of view of each on such and such a situation, on such and such a patient was complementary. This strengthened us and quickly allowed us to build quality “teleworking”; this revealed to our patients and to ourselves that mutual respect and understanding existed in the team and that a similar concern united us.

The virtues of this shared clinical knowledge should finally find their justification and their expression with the decision-makers in a spirit of authentic “institutional psychotherapy”; taking care of each other, "healing" the institution, carrying the framework, it was to make us more effective for our users. This efficiency has been organized and improved from week to week, as if a certain method was gradually and spontaneously being forged between us in a whole new framework of therapeutic intervention.

It is therefore with all these elements that teamwork was able to be put in place as soon as the confinement began in France, on March 17, 2020. After the stunning effect of the announcements, intense coordination work was born. Doctors, psychologists, educators, teachers, psychomotor therapists, art therapists have consulted by telephone and via various messaging platforms to set up an intervention table. The starting point being that each child can have a speaker different every day. Each therapist was able to get in touch with the parents or foster families of the children and thus establish slots closest to the day and time of the intervention in the establishment when this seemed possible. We had to try several contacts because the family dynamic began to loosen up as the days passed. It was intense work involving modularity, permanent adaptation to the schedules and availability of families. Personally, I was able to emphasize the need for continuity in the mediation intervention. Some did not understand the interest or feasibility of weekly intervention as an art therapist because the means of communication during remote contact remained the verbal approach. I had to insist on the possibility of giving myself a chance to undertake a continuity of contact by using means specific to my expertise in this field. I had to “push doors” and have a solid conviction in the face of any attempt at opposition from the side of the multidisciplinary team.

3. The specificities of follow-up in art therapy in virtual mode

I will address all of my arguments, taking the precaution of qualifying my remarks on the basis of observations based mainly on empiricism.

Within the families and with the children, the contact made on my initiative as an art therapist validated by the medico-psychological team for an initial telephone interview, then by videoconference, was very much appreciated. This, among other things, may have reinforced the feeling that the institute could act as a “sentinel” and sustainably increase the therapeutic alliance with patients. The specific modalities of the implementation over time was the major questioning of the team members: to offer sessions to patients yes, but how? The time to become aware for my part of the therapeutic issues, it was often a question of making a simple phone call allowing to take news, to introduce myself as an art therapist within the establishment, to get to know parents or the host family of the children, to exchange some information on the state of the child, his needs. Their regularity as well as the way in which we relayed these exchanges between the members of the team gave the feeling of a rather motivating and constant concern for the families and extended their capacity of projection in the "world after" the crisis.

My device was part of the continuous care of eleven children in face-to-face and individually for a weekly session. Eight children were kept in this exceptional context; the other three children, due to lack of parental support for my proposal, interrupted the protocol of the relationship previously initiated. This reveals the importance of the family unit subscribing to the work undertaken. At the beginning, I didn't really have a "recipe" or even a specific method to put in place in this context. Like everyone else, I had to improvise, however, keeping in mind that this very special care was intended to be the continuation of a desired device, integrated and acquired in a therapeutic alliance already fixed in the establishment. I learned a lot from listening to some of my patients and their families, which encouraged new initiatives on my part.

On the family side, some parents have drawn on "family historical reserves" to tell us and pass on to their children such and such an episode of their past life. So for a certain number of children I was able to discover them in a new light in a space that belonged to their daily life: the bedroom, the dining room, the home garden. The period of confinement had its virtues, revealing the unprecedented potential of the situation. There were families and children who were able to organize themselves very quickly, take advantage of this time granted by the need for health to live together, play, create spaces, help each other, get closer, reinvent themselves. . Forced into isolation, the child and the family group drew on their reserves and their creativity, bringing in turn food for thought and elaboration in the preparation of my sessions.

In my interventions I was able to feel free to use various mediations as long as they would have made it possible to feed content in order to be able to reconstruct together a potential space where everything would be possible: a bubble in a process of escape. A space enlarged by the presence of the computer screen which proved to be the transitional element between my home and that of the child. A technical device which separated us physically but also which brought us together thanks to the content produced during the sessions.

I wanted to maintain the duration of each of the sessions, namely 45 minutes. This opened only after a direct exchange with the family unit and thus to appreciate the nature of the climate in which the child evolves. It was agreed with them the importance for the child to appropriate the same personal space for the duration of our exchanges. In this context, serenity is always sought, or confidentiality must be preserved. The child then comes to free himself in this space of reception of his psychic contents. For the conditioning of the children for the session, I had to adapt to the characteristics of each child and to the context of their daily lives, namely the permanent presence of a family unit, brothers and sisters who were sometimes turbulent and often wishing to intervene. even participate in the sessions. On these occasions, it is recalled that the sessions have no collective character unless it is previously agreed that this group is exceptionally set up and prepared upstream.

As a practitioner, my mediation is that of the plastic arts. I wondered at the start about the interest of diversifying the different approaches in mediation: drawing, therapeutic storytelling, collage, music, singing, puppets taking into account the material that the families had at their disposal. All this renewed panel came to flesh out and enrich this new report.

In the clinic specific to art therapy, the work is carried out above all with the material to be developed brought and expressed by the patient himself, without a directive dimension. However, with regard to this unprecedented experience, it was necessary to propose, suggest and bring themes that could resonate and contribute to the most authentic adhesion. Thanks to this original setting, the children were able to indulge and work out thoughts that had hitherto remained repressed. Feeling less exposed due to the physical proximity in the face-to-face workshop, the screen was able to have a "filter" effect allowing less exposure of his emotional states and his psychoaffective lacks.

In any case, the priority was the construction of a new therapeutic framework that would be applied to the one that pre-existed in the institution. This allowed me to reflect and see the symbolism of the institutional framework despite the imposed distances: each of us carried within us the institutional dimension and its protective and containing aim. This period may have caused doubts in me, apprehensions in this zone of uncertainty or the questioning of a severely tested capacity for creativity.

4. Feedback from patients and those around them.

In a transferential relationship, it is essential to pay sustained attention to the feedback from each other concerning the nature and specificities of the system put in place. This allows us as a practitioner to adjust, soften or not different elements of the frame. This period lent itself to more listening, to relational intensity and to taking into account the subtlety of gestural language.

On the occasion of several sessions, mothers joined forces to draw with the child in a movement of real and authentic involvement. They were also able to elaborate on this with me at the end of the sessions. Like this mother, who discreetly starts coloring a mandala in secret during a session in front of her son. My reaction could have prompted me to exclude him from the relationship game at this precise moment. However, the priority consisted in not risking breaking the link with his child because the communication was carried out via his mobile phone. The subsequent intervention of an educator made it possible to transmit the message in a less frontal way and therefore more understandable for the mother.

In a surge of projection into the post-lockdown future, I also decided to carry out a personal plastic work in resonance with what was happening during each session. Something like a hot photo of a shared space-time, an in-situ countertransference vignette. The underlying idea was the possibility of rewarding each other during our face-to-face reunion in the physical setting of the workshop: the child sent me his drawings and in turn I offered my work done with them. All of his experiences can lead us to deep reflection on the importance of all the actors taking place in this reality: each of the practitioners, educators, teachers, children and their families. It is in fact this game with multiple references that has facilitated the setting up of care inside and outside the physical walls of the institution. Point of failure, breaking point, a very enriching and humanly invested new experience.

5. What impact at the end of the March 2020 confinement period after returning to the establishment.

While for a few months the "normal life" and the therapeutic activity of the establishment where I intervene seems to be regaining its rights and we are beginning to have a little perspective, the time has perhaps come to draw some reflections on this period of "epidemic wave", its repercussions on the life of an institution such as the institute as well as on the care of the patients who are followed there.

If we had to qualify this "wave", I would say that it took place in three stages: the occurrence of the health risk, the palpable reality of which surprised everyone, then the unprecedented experience of confinement and finally the no less strange of the “progressive de-confinement” whose terms remain unclear even today.

On closer inspection, such a succession of events only gradually reveals its complexity and it is probably premature to claim to identify its impacts, especially since they are combined in several registers. Within individual psyches, in the various more or less internalized collective representations such as the government, school, care institution, family unit; but also from the point of view of care actors whose practice has been disrupted and exported “remotely” for better or for worse.

At the establishment, the members of the team, surprised like the others but supposed to have "toolboxes" to mobilize in an emergency, were able to get out of it by calling on a creativity rather distanced from all theoretical knowledge and all a priori by trying to recreate a properly clinical setting with the means at hand. We have learned a lot from our patients. And we also learned a lot from our colleagues whom the experience allowed us to get to know better and with whom, paradoxically, we were able to find time to develop more easily. We got into the habit of contacting each other more frequently and consulting each other according to variable geometry groupings that were able to overcome the usual limits, a fixed framework, the only and too brief weekly summary meeting. Among the resources that this period was able to reveal for the better, the experience of confinement constituted in the life of our institute a real lesson in institutional psychotherapy which brought to life as never before the most fruitful aspects of multidisciplinarity.

The experience of confinement revealed other resources, but alas, on the patient side as well as on the side of institutional life, there was also some damage and over time the limits of any substitute approach appeared. For a number of the patients, the confinement had the effect of intensifying certain pathogenic modalities already present. For each there was the effect of numbing the psychic dynamism and in a certain way a particular form of post-traumatic reaction.

On the side of institutional life and taking into account what was happening in the country, the overabundance of recourse to means of distance communication (telephone, videoconference, social networks) may have led people to underestimate the irreplaceable value of a face-to-face relationship, whether it's a medical procedure, a lesson given by a flesh-and-blood teacher, educational support or even an art therapy session.

Alongside the undeniable good surprises, there was also the damage that the confinement experience caused in people's minds. There is also the damage caused by the experience of too “progressive un-lockdown" where we may have skated too much before the reopening and the resumption of usual activity is finally possible.

Among the harmful consequences of this period are those appearing under a rather particular "post-traumatic" effect and which one can fear will last, even in the process of becoming chronic. The surprise effect, the confrontation with an unprecedented situation in contemporary history and for which no pre-existing representation could prepare the psyches; the muted and sometimes palpable presence of the risk of real death; the reactivation of fantasies of “contamination” in which one can imagine oneself alternately persecuted and persecuting; the sudden deprivation of multiple freedoms; house arrest within a family group that may be feared toxic in some cases; the return to social isolation in others; the total lack of certainty as to the date of the return to normal and the feeling of uselessness of any personal projection. All the ingredients have been brought together to give rise to a fairly classic post-traumatic stress reaction well known to specialists in the clinic of trauma, medicine for war or other crisis situations. However, the containment measures having concerned almost all of humanity, this meeting around the same phenomenon could certainly have constituted a counter-traumatic compensation, in particular thanks to social networks. The fact remains that there were sometimes reactions of withdrawal and isolation whose intensity and duration far exceeded the existence and objectivity of the risk that had generated them.

Sometimes, without preexisting such tendencies, some children were simply afraid. And as a sort of identification with the aggressor, some began to "overact" and anticipate confinement. One of them did not want to go out at all during the entire confinement period. Another did not want to answer any phone calls whether from the teacher or the educational team, limiting himself only to following the art therapy sessions.

On the side of institutional life, like what was happening in the country, the use of remote interventions may have led people to underestimate the irreplaceable value of a “face-to-face” interview. This is one of the risks to which we must be attentive, especially since all these phenomena show us that the time of the event is not the psychological time and that predictability is not really required in psychopathology, that whether it is an institutional, family or individual plan.

From the individual point of view as from the institutional point of view, we are only at the time of "remanence", that of the partial but lasting persistence of a phenomenon after the disappearance of its cause.