Working with children remotely has become commonplace during the pandemic, but it poses a specific challenge to the process: how to secure a confidential psychoanalytic space? In the office, the frame is a constant; therefore, any change stands out. Not so in a pandemic as everything is in flux. We may not even notice impediments to confidentiality.

The pandemic has given us the opportunity to think through how to create confidential spaces with children in remote work. This is crucial as there are children who will not get treatment unless the work is remote. It is not just children in rural areas who do not have access to care. Overextended parents in difficult circumstances may not be able to travel to get children to sessions, or the stress involved in getting to sessions is too great. Remote work might allow us to reach these children who need care.

To work remotely in an optimal way, a child (and analyst) needs a space to play, a device with a screen so patient and analyst can see one another, drawing materials, molding clay or toys, and a space that is private. Treating a young child remotely is more difficult than working with an adolescent who can, if all else fails, sit in a car if they have access to a car. Alternatively, parents can go on a walk or be at work during an adolescent’s session to afford privacy. In contrast, a child cannot be left alone.

In an ideal situation, the child will be in a room with the door closed, so that no one can see or hear the child and the patient will be free to be expressive both consciously and unconsciously. Parents and therapist often need to work together to create a confidential space. The younger the age of the patient, the more complicated this becomes. Some young children cannot be left in a room by themselves because they may not be able to control behavior that could be dangerous, such as climbing on a table, breaking objects, and so forth. When we are in our offices together with a child, we can easily watch out for safety and confidentiality.

Providing an analytic space for a child may involve sacrifice for the whole family. For example, if a sibling shares a room with the patient, that sibling may need to leave the room during the session. Open windows for a child alone in a room can be both a safety and confidentiality issue. Achieving privacy might mean that a child remains in their room with a white noise machine, white noise app, or fan running outside their door. The space used for sessions may need to be tested to ensure that the sound cannot travel. Family members may need to put on headphones to resolve sound issues. Sound and sight privacy can even be tested by the parents, child, and therapist together as part of a session.

It is understandable that confidentiality would be confusing to parents and children. Many young children have done some school remotely in the pandemic. Due to the difficulty of children doing school independently and alone on a screen, many parents sat alongside their children or nearby in the same room. Without discussion, parents may assume that they need to be nearby for sessions. If not discussed, we may not even know that a parent is in the room. Even though I have walked through these procedures with each child and their parents together, I check with children at the beginning of sessions to make sure they have shut the door, gotten their headphones and so forth to make sure that we are ready to start. Asking parents to use the same space and set-up for each session reduces the likelihood of breaches in confidentiality because the confidentiality issues for the space have already been tested and thought through. Many parents, if they understand, will work hard to ensure that a child has a confidential space.

Despite these efforts, there are times when confidentiality is not possible. If a patient’s family endures economic hardship, confidentiality can be much harder to achieve because there may be less space and less capacity for accessories like sound machines, etc. Also, the parent (or child) may not be able to tolerate a child having an analytic space. The behavior of parents around the issue of confidentiality can create moments for observation. If a parent acts out around confidentiality, or refuses it, like by sneaking into the session, it offers a useful glimpse into the relationship between parent and child. These moments can create opportunities for parents to work on boundaries and interactions with their child. Often these engagements will communicate considerable information around such issues as the level of aggression and the nature of the parents’ boundaries. For example, is the child silenced by the parent and do they feel free to object to the presence of the parent in a session? Alternatively, is the child pulling the parent into the session? Like everything else, these interactions around confidentiality can be communicative. Sometimes, a period of therapeutic work with parent and child together allows for the creation of an analytic space at a later point.

Even with in-person sessions, there are times when a parent and child are not ready for there to an analytic space for the child. This happens sometimes, for example, when there are separation issues and the child, parent, or both cannot tolerate the child being alone in the room with the therapist. In these circumstances, it is likely that the child will not be able to speak freely, either consciously or even unconsciously, until they can tolerate the separation. Often, children understand confidentiality intuitively if they sense you are trying to help them and their parents. Recently, I supervised a case in which a father worked to get his six-year-old set up for the session in a confidential space, and the mother, with the pressure of a crying baby, came into the room to get something. After the mother got the extra formula she needed, the six-year-old took her by the hand and said in a kind way, “Mommy you have to leave. I am in my meeting.”