online therapy

Dr Fiona Zandt, Clinical Psychologist and co-author of Creative Ways to Help Children Manage Anxiety discusses the move to online therapy, and how activities can be adapted for virtual sessions.

The process of moving to telehealth over Covid has opened up lots of possibilities and challenged us to adapt and work in the online space.  We’ve discovered online therapy rooms, amazing websites we never knew about, and the versatility of a virtual whiteboard.  It was a steep learning curve and there was a temptation to leave behind all our previous ways of working and feel that we needed to do everything differently.  In reality though most therapeutic activities can be really adapted for use on telehealth.  Most of what you do in the clinic with children can be done in some way online and what follows are some ideas about how to adapt the activities you might typically use in a clinic setting for online use.    

Many of the concerns that I worked with therapists through during the move to telehealth related to the need to be in front of a screen.  For those of us who were experienced in working with young children the idea of needing to sit was initially a challenging one.  While it may seem obvious it is worth making the point that online sessions can, and should, involve movement.  Many children will join sessions on an i pad or laptop, which allows them to move and show you different angles.  From a practical perspective it is worth checking what screen a child is using so you have a sense of if and how they might be able to move and also what they can see.  Explaining to parents that children will be moving during the session and checking if they need help to do so or if there are any concerns about doing so is essential.  As therapists we are likely to have the experience of not being able to see the child at all times, which can feel uncomfortable and different from our experience in the clinic.  We may need to direct the session accordingly, asking a child to hold something up to show us or encouraging them to tell you about what they are doing, however we can still use many of the activities that we use in the clinic. 

Using basic materials has become important in the absence of being able to offer children the materials we have in our clinic room.  Most of the activities in our books utilise really simple materials, such as paper, markers and scissors, which most families will have at home.  If you need something more specific for an activity think about the sorts of things families are likely to have on hand.  For example, envelopes and brown paper bags both make useful vessels and can also be turned into puppets while boxes from the recycling can usually be repurposed if you need some cardboard.  Depending on the family you are working with you might like to ask ahead of time for them to have one or two things ready or you might be able to talk about this at the start of the session, problem solving what you could use if they don’t have something to hand.  Often older children are able to locate simple supplies for themselves during the session. 

Some activities can be moved into more of a worksheet format.  Take for example, our Worry vs not a worry throw activity, which involves throwing a ball at a target to indicate whether something is either a  “worry” and “not a worry” for them.  This is a really simple activity that is often very useful in the assessment phase, normalising a whole range of worries for children and engaging those children who are less inclined to talk about what is worrying them.  This activity can readily be completed on a virtual whiteboard.  You simply draw a line down the middle and work through example worries, listing these on the appropriate side of the page depending on whether or not the child thinks these are a worry.  It is important however to be mindful that children often lose interest more quickly with worksheets and think creatively about how you can make these activities more interactive.  For children who like writing and drawing you could have them label two envelopes and sort pictures into these to indication what they worry and don’t worry about.  For more active children you could ask a child to write “worry” on a sheet of paper and “not a worry” on another before placing them on the floor and encouraging them to jump on the appropriate piece as a way of responding to examples of worries.  Children will generally be happy to tell you which paper they have jumped on even if the camera is not positioned so that you can see this. 

While online therapy means that we can’t be in the room making something together with the child it still provides a lot of opportunities to use art and craft.  The child can make something and share it with you, you can make something together, or the child can explain what they’d like you to make and you can show them as you do it.  One of my favourite things to do over telehealth has been to make something with a child using polymer clay.  I’ve had children direct me as I’ve made pendants that symbolise something important to them.  Sometimes we’ve inscribed some helpful words on these as a reminder of something we’ve talked about in the session.  I then cook these according to the directions, thread the pendant onto a keyring or chain depending on what the child has chosen, and pop it in the mail.  Parents have often let me know that children have been overjoyed to receive these parcels and it’s been a lovely way to reinforce our connection as well as the learning from the session.

Working online has meant that we can’t rely on having a room full of engaging toys and activities for children.  Most children will have some toys at home that can be used during therapy sessions.  Many therapists have shared ideas about scavenger hunts, in which children might be asked to collect items that evoke particular emotions or help when they are experiencing an uncomfortable emotion.  Beyond this however, it is worth reflecting on how you can use a child’s own toys in a therapeutic manner.  For example, children can arrange their own toys into families or acting out stories with their teddies and dolls.  In my experience this has been both more engaging and more manageable than the online alternatives I’ve found.  Similarly, I’ve often used my puppets to engage the child in play with their soft toys. 

Often when looking at toys and activities for my clinic room I seek out materials that can be used in multiple ways, minimising the amount I need to store.  Having moved from my large clinic room with a spacious storage cupboard to a small corner in my house for online therapy has emphasised to me just how important this is.  I’ve had far less storage space and so have had to choose the materials I keep on hand carefully.  Simple materials like popsicle sticks and playdoh have been prioritised as I can use these in many different ways. 

It can also be difficult to have a whole range of online activities at your fingertips.  Choosing online activities that you can adapt for use with children with different needs and at different developmental levels is often helpful.  Two of the online resources I went looking for early in therapy were an online spinning wheel and a virtual dice as both could be used to adapt a lot of the activities I use in the clinic with children.  An online spinning wheel that can be modified so that you can change the items on the spinner is really useful.  For example, if you are working on building emotional awareness with a child you can modify the wheel so it lists aspects of a child’s experience, such as look like, think, feel, do, and say and spin the wheel so that you can better help them understand an emotion like anger or anxiety. You can also feel the wheel with calming strategies and practice these in the session as you spin the wheel.  There’s something about the game like nature of these activities that means children tend to engage well in these and by having a turn we have a great opportunity to normalise their experience and model helpful strategies.  Having a couple of websites that you can access quickly and can use in a number of ways is often more manageable than having a larger number of online resources that take longer to locate and are more complicated to use.    

Face to face therapy doesn’t always go to plan and neither does online therapy.  Sometimes systems glitch or your attempt to share a website compromises the connection.  Working online can also increase the likelihood that we will have ruptures with children and families too.  We have less non-verbal cues to help us tune into the child’s emotional state and have to work harder to ensure we are creating therapeutic presence.  Being kind to ourselves, slowing everything down, and ensuring that we keep ourselves grounded and remain connected to the child is essential.  Allowing extra time for activities often helps, as does ensuring that you have a back-up plan.  It is worth considering, for example, how you might present an activity if you can’t make the online whiteboard work and have some markers and paper close by just in case.  More generally, talking with families about some of the challenges that might arise when working online and thinking together about how you can manage these can help. 

Working online has much to offer child therapists and has opened up a host of new ways to engage children in therapeutic activities.  Most of the activities we used in our clinic rooms can be readily adapted for telehealth with a little thought.  If you are interested in more practical and purposeful activities that can be modified for working online check out our books, Creative Ways to Help Children Manage Anxiety and Creative Ways to Help Children Manage Big Feelings.  You can also check out our free resources and sign up to receive our blog posts at https://childpsychologyworkshops.com.au

Dr Fiona Zandt, Clinical Psychologist 

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