Online Gestalt Play Therapy during the COVID-19 Emergency with Children in the care of a Home Paediatric Assistance, Pain Therapy (PT) and Paediatric Palliative Care (PPC) team.

AUTHORS: A. Pezzutto (psychologist with the Assistenza Domiciliare Pediatrica, Terapia del Dolore e Cure Palliative Pediatriche di Pordenone – Italy; psychotherapist in training; has chosen to work towards obtaining a certification in Gestalt Play Therapy and receives monthly supervision from Dr. Giandomenico Bagatin), M. Minetto (psychologist and psychotherapist with the Assistenza Domiciliare Pediatrica, Terapia del Dolore e Cure Palliative Pediatriche di Pordenone – Italy).

Home Paediatric Assistance

Since 2011, in Italy (Pordenone), a Home Paediatric Assistance, Pain Therapy (PT) and Paediatric Palliative Care (PPC) team (Servizio di Assistenza Domiciliare Pediatrica, Terapia del Dolore e Cure Palliative Pediatriche di Pordenone) has been active; the first of its kind in Italy. The team was created by the Complex Structure of Paediatric and Neonatology group, which is a part of the St Mary of the Angels Hospital (Complesso di Pediatria e Neonatologia dell’Ospedale Santa Maria degli Angeli). The specialised team was created with the purpose of taking care of sick children preferably in their home environment. It offers medical, nursing, psychological and social support in order to improve the quality of life of their young patients (with cancer or chronic diseases) and their families, avoiding the need for hospitalization as much as possible.

Psychology within Paediatric Palliative Care: home psychological assistance

Paediatric pathologies which need PT and PPC are life-threatening diseases (diseases for which treatment could be unsuccessful) and life-limiting diseases (diseases with a limited life prognosis). According to the World Health Organization, paediatric palliative care is “an active total care of the child’s body, mind and spirit, that also involves giving support to the family”1 (including parents and siblings).

The psychological support is given to all members of the family (both children and adults alike); it is for this reason that the team is composed to two psychologists: one is in charge of the parents (although they are also active within the hospital and continuously available to support the team), and the other is specifically dedicated to the support of sick children under the care of the team who reveal greater fragility and needs, and also supporting healthy siblings.

The team is multidisciplinary and is made up of four doctors (who work in shifts), two nurses and two psychologists. The two psychologists work together: the hospital employee primarily meets the young patients and their family; they assess their psychological needs and, if necessary, propose psychological home assistance to the sick children or to their brother\sister, which would be carried out by their colleague.

The red string that the team follows is home assistance, this is because the home is certainly the preferred place of care for both the family organisation and the little patients.

The aim is to take care of the patient in a comfortable and familiar environment, guaranteeing both quality of hospital assistance and reducing the inconvenience of going to the hospital.

The home also becomes the setting for psychological support: in fact, the Pordenone experience has shown that the feelings of fear, isolation and powerlessness, which are more often present in the case of illness, are reduced. The home can become an ideal setting to create a therapeutic alliance between the child and the psychologist and to foster the openness of children to psychological aid.

Gestalt Play Therapy in the Home within PPC

Since September 2019, the team’s psychologist who is dedicated to children has been applying Gestalt Play Therapy (GPT) in the home, in order to offer to sick children, and to their healthy siblings, a psychological space for processing and expressing emotions related to the experience of illness; which can be perceived in a more or less traumatic way, depending on the individual.

Shortly Before the COVID-19 emergency there were nine children, aged between 3 and 11 years, in active psychological care. Three children out of nine were healthy siblings, while the remaining six were sick children (two of them with incurable chronic diseases and four with cancer).

When a psychological need is observed in a young patient , or in their siblings, we suggest a specific course of treatment to be followed to the family first, and then to the children directly, explaining which kind of intervention will be tried at home and illustrating how the GPT method works. We explain to them that GPT is a therapeutic method developed by Violet Oaklander in California in the 70s.

Through the use of many expressive techniques based on playing, this method allows children and teenagers to live sensorial, emotional, corporal and cognitive experiences, which support and allow them to face and overcome difficult situations such as a cancer diagnosis (their own or their sibling’s), the following therapy treatment (their own or their sibling’s) or living with a chronic pathology (their own or their sibling’s).

It is important to highlight that GPT is based on play, but this play is an extremely serious activity for the child; it is rich in purpose and through it, development on many levels (emotional, mental, physical and social) is favoured, and they experiment new ways of living. Using GPT is not just simply playing with the child, but consciously and competently using creative and expressive techniques that act as a bridge into the children’s own world and favours the expression of past experiences and the connected emotions (even for the more inexpressible ones!).

GPT was applied in the home with these nine children, with weekly meetings of 45 minutes\1 hour for the first month and then twice a month, but with the same duration. Four out of the nine children have continued to benefit from weekly care, as opposed to twice a month, because they have consistent psychological needs and the psychological support could not be interrupted; this proves how important it is to place the children’s psychological wellness at the heart of the treatment, sometimes also changing the initial idea of treatment timing. The PPC recognizes the importance of individual treatment plans: every child has a personal treatment process, tailored to his\her needs, for they are at the centre of the treatment plan, and the only one who can express his\her emotions.

The conclusion of the psychological support consists of a progressive reduction in the frequency of the meetings and the children’s preparation, but also their family’s preparation, to the termination of the treatment process.

GPT is based on expressive techniques and practical tools like plasticine, colours (crayons, paints, markers etc.), dolls, puppets, books etc.; in this specific setting GPT is carried out in the home and not in a traditional psychologist’s office, so the team’s psychologist uses a wheeled suitcase to carry the materials from one house to another. The suitcase has become a valid tool for carrying materials which are useful for home psychological support, and it is appreciated by the children and their families, who observe it with curiosity and laughter at the same time.

The famous suitcase!

Changes after the COVID-19 emergency: online GPT in PPC

The paediatric patients could be affected by COVID-19 with a higher risk of disease, especially if they are immunosuppressive and multiproblematic patients2. For this reason, since the beginning of the COVID-19 emergency, GPT in the home has been suspended as the required hygiene standards could not be guaranteed (for example the 1-meter distance).

Despite this limitation, we are aware of the importance of giving continuity to psychological care: these children are particularly vulnerable and they need support to maintain psychological wellness/wellbeing during illness (either their own or their sibling’s3; their illness doesn’t stop during the COVID-19 emergency! As such, we believed that it was fundamental to continue the work, even if at a distance. But how?

Immediately, thanks to the collaboration and helpfulness of the parents, simple video calls to say “hello” were held to maintain a close relationship and “contact” with the children. In these video calls, the psychologist had a special 4-legged collaborator (their dog, whose name is Dalì).

Dalì… a special colleague!

Seeing each other on a display is different from seeing each other face to face, so involving an animal is a good icebreaker! It helps children to stay focussed and to be present, moreover it promotes a new vision of the therapist, making them more familiar and human. In this way, the children’s openness to the psychologist was facilitated, even online.

These short greetings with video calls became (from halfway through March 2020) more structured and focused sessions, which made it possible to carry on with the GPT work previously done in the home, online, through WhatsApp and Zoom video calls.

Partial Conclusions from the ongoing experience

• Out of the nine patients in active care before the emergency, currently seven are continuing with online GPT. With two of the children, who are 3 and 5 years-old respectively, it has only been possible to have video calls to say hello, without a therapeutic purpose, to stay in touch: it will be useful for when the psychological support will be able to start again in the home.
• Every child received video calls to say hello once a week, and the bona fide virtual GPT meeting was carried out with the same frequency (weekly for some and bimonthly for others).
• The collaboration of parents is fundamental in order to carry out online GPT meetings: it is necessary to plan a setting where the tablet\smartphone\computer can be positioned in a stable way in order to allow the psychologist to see the children doing the activities proposed by them.
• All of the childrens’ parents are available and enthusiastic about the continuation of psychological support with technologies.
• The children also appreciate the possibility to continue GPT online, especially in this time of a global sanitary emergency. They are confident with technologies and they are curious about its use; they are demonstrating how important psychological support is, even though it’s done in an unusual way.
• It is difficult to always keep the setting clear: sometimes during the session a brother/sister, a mum/dad, a grandmother/grandfather enters the room and activities are interrupted or disturbed. In some cases, a slow internet connection can also be a problem.
• When the psychological support was done in the home, not all of the tools typically used in GPT could be used (for example sandpit, clay etc.): with online sessions, the number of tools is further reduced. We are using drawing, storytelling, play-doh (for families who have it at home), reading books, projective cards (Ex. Dixit Cards), relaxation exercises and contact games. We’re also inviting the children to propose and use games that they have in their home.
• It is important to pay attention to the children’s level of focus: it’s good to make sure that there aren’t any distractions and that the children pay attention throughout the online session.
• The online sessions are shorter than the face-to-face ones: half an hour or 45/50 minutes at most.
• COVID-19 rarely becomes an object of discussion during the session, unless it is introduced by the psychologist. In fact, these children were living a personal sanitary emergency before COVID-19 and the therapeutic goals are still focused on this.

With C. (8 years – Wilms tumor), for example, we work on anger connected to her hair loss; now it is growing again and in the drawing, shown below, she represents herself on her birthday, in June; she imagines her hair short, while still growing!

C.’s drawing (8 years – Wilms tumor)

S. (12 years – with a rare chronic condition that is worsening – poor prognosis within the second decade of life) is continuing her sessions of accompaniment and psychological support; she is aware of her incurability and GPT, in this case, is used to help her make sense of, and appreciate, her life, because she is facing it with great courage and strength.

Activity on the timeline of her life: pleasant events compared to unpleasant events (S. 12 years – rare chronic disease)

For all children that the team is in charge of, we are continuing with the psychological support started before the COVID-19 emergency, but we are also giving time for worries, during the online sessions, concerning the current abnormal situation.

N. (7 years – sister of a child with cancer), for example, chooses this card to describe her present mood.

“I feel like a caged bird”

(7 years – sister of a children with cancer)

R. (7 years – leukaemia) expresses her anger for what she has experienced, saying: “Everyone deserves to experience what I have experienced for 9 months locked inside of a hospital and in my house!”

• The video calls give the children the chance to enter inside the psychologist’s house, and not only the other way around (home psychological support)! The children can also get closer to the personal world of the therapist. This, although it is an aspect to which you must pay attention and set boundaries, encourages a greater openness of the children with the psychologist.
• Every video call ends with the so-called “butterfly hug”, which is a type of bilateral stimulation in the EMDR protocol, but in this case it is used by the psychologist only to greet the child, so as to make them feel physically close even through a display.

BIBLIOGRAPHY

1. World Health Organization (1998). Cancer Pain Relief and Palliative Care in Children. Geneva.
2. Y. Dong et al. (2020). Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics, doi: 10.1542/peds.2020-0702.
3. A. Guarino (2006). Psiconcologia dell’età evolutiva. Edizione Erikson.
4. Fondazione Maruzza Lefebre D’Ovidio Onlusa (2009). Cure Palliative per neonati, bambini e adolescenti. I fatti.