What to consider when having a conversation with the YOUNGER CLIENT about starting online therapy sessions?
By Lydia Sterry | Submitted 2024
Transitioning to therapy online with a child/teenager may seem daunting at first. However, there are many ways to adapt and to lessen the fear. There are rarely interventions in therapy where we need to "touch" a client. Therefore, maybe it’s about recognising what our common interventions are and then imagining adding a screen. From there we could start to visualize any barriers we might need to overcome to make a particular intervention possible. If you’re finding it hard to do this then this blog may be useful to you. It attempts to highlight how you could creatively use online therapeutic interventions with children.
Some of the interventions involve; ‘Simon Says, Charades, I-Spy Reading, Colouring, Worksheets, Videos, Show and tell, Board games, Feeling Faces, White Board, Puppets, Podcasts, Online Gaming, Screen Sharing their online life, sand tray apps and many other app options…’
Transitioning to therapy online with a child/teenager may seem daunting at first. However, there are many ways to adapt and to lessen the fear. There are rarely interventions in therapy where we need to "touch" a client. Therefore, maybe it’s about recognising what our common interventions are and then imagining adding a screen. From there we could start to visualize any barriers we might need to overcome to make a particular intervention possible. If you’re finding it hard to do this then this article may be useful to you. It attempts to highlight how you could creatively use online therapeutic interventions with children.
As with all of these interventions, it might be best to present the tool/intervention and simply wait to see how the child interacts with you. Being open to the unknown with the child in this space tends to enhance the therapeutic process. Having said that, it is nevertheless useful to have some things ‘up your sleeve’ to kick start the process if needed. Each one will be explored in detail below with this in mind.
Show and Tell:
Show and tell is the practice of showing something of significance to the therapist and discussing it. Children tend to love to show you their world. With online therapy, you have the chance to see their home, and particularly their room. If the child's computer isn't directly plugged into the modem, you could have the child give you a tour of their room explaining what the different items are and their importance. You might want to ask the parent/guardian to set up the session on a laptop or a phone to make this particular show and tell session run smoothly.
Try to have the child show off an essential comfort/self-soothing item (like a teddy bear or blanket) and work together to understand what makes it so comforting.
Try to have them take you to various rooms in the house that are of importance. They could share culturally significant items or rooms, like family heirlooms, religious items, other important ‘things’… and process what they might mean to the family and especially then the child. Some children may even show urns that contain loved-ones and share stories about them.
Puppets:
Some young children wake up when seeing puppets on a screen. Puppets could add humour and seriousness to a session. You may want to inform the parent/guardian before the session that you’ll be puppeteering, so they might expect some loud noises at some points. You may want to be open to the story the child decides to give. Or you may want to have a specific ‘theme’ or story prepared to tell the client. Sometimes being open to what themes/topics they bring on the day can be therapeutic as you both unpack them further. Bearing in mind that keeping the experience non-directive could be used to encourage imaginative thinking, autonomy, and free expression.
Overall you may want to be open at times to having a discussion of feelings, where they’re felt in the body, which parts of the story made those feelings ‘tingle’ and anything else that may arise within a feeling…
Online Gaming:
There are plenty of ways to play games online with children. You may want to avoid any games that involve substantial multiplayer or online community experience, that need to be downloaded, or that require a screen name. If you have to create a log-in, it might be worth making sure it is something non descriptive like "person1." Try to play Uno, checkers, chess, connect four with Skill Games Board…
You could play card games like Go Fish or Match with PlayingCards.io. You can even get a free Minecraft Server through Aternos. Minecraft is a useful game to discuss home life. It’s a digital way to ask about their environment. You could work with the child to build a home. It’s not particularly difficult for someone who hasn't played before, to learn.
You could talk about what makes a home safe. They might be open to focusing on "comfort zones," or "areas to avoid." Other questions may include:
Conversations about the HOUSE:
Is it real or imaginary?
Is it your house or someone else’s?
Is it positive or negative?
Would you like to own this house?
Who lives in this house?
Does the house look close or far away?
What’s the weather like in the picture?
What does the house need most?
Where is the house located?
Conversations about the TREE:
What kind of tree?
What is the age of the tree?
What season is it?
Where is the tree located?
What does it need most?
If you were in the picture, where would you be?
Conversations about the PERSON:
Is this person real or imaginary?
Is this person a male or female?
What is the age of the person in the drawing?
What is this person like? (personality characteristics)
What does the person in the drawing like most/least about himself/herself? (favourite things)
Would you like to know this person?
Ask all questions for both persons drawn.
If there are two poeple in the drawing, you could ask, if these two met, what might happen?
You may want to receive parent/guardian consent by asking them if they are on board with using online gameplay for therapeutic means and discussing the benefits and risks.
Screen sharing their online life:
You might want to have the child/teenager screen share and show you what has been interesting to them recently. (Websites, their social media pages/ online assignments…). You might use this opportunity to discuss (if relevant/curious) topics such as cyberbullying, reporting harassment, blocking people, how it feels to get a "like,", who or what they follow… Gamer clients could even give you a tutorial of the games they play (this may be an opportunity to discuss the friends they have made on gaming, what skills they have or how they contribute to the gaming party, to ask about problem-solving during the game, team building, inner game communication…). Online life sharing could provide insight around stress, struggles and what support the child has.
Simon Says:
Rules are simple. One person is designated as Simon, provides instructions to the other, which they must obey. The other player/s lose if they follow a command that does not have the phrase "Simon Says" in the beginning. Both the therapist and the client take turns to be Simon. They can give directives like "Simon says stand up. Simon says, sit down. Stand up. Gotch-ya. “ Simon didn't say."
Simon Says could be used as a therapeutic game by paying attention to how the client interacts with the game, makes decisions... Try to process with the client, any feelings of frustration around losing, the excitement around "telling a grown-up what to do" or anything else that may arise from this game.
Charades:
This is an imitation game where the intention is to guess the word or phrase that someone is acting out. The therapist can choose to take turns with the client as the person is acting out or guessing. Categories could be animals, sports, videogames, things in the sky, professions or anything else you both might choose...
The therapist can ask the client to think of topics beforehand, so the client has time to come up with some ideas. Others tend to prefer thinking on the spot during the session. You could use this game to process communication styles, gain a deeper understands of what is being acted out or anything else that may arise from this game.…
I-Spy:
Individuals take turns trying to guess which nearby object was selected in secret, through asking descriptive questions. The therapist and client can choose a theme for the round (like colours, soft or hard objects, shapes or things that they love/hate/meaningful to them…) The person who is "it" will spy something by saying, "I spy with my little eye (insert a guessed object)."
All sorts may transpire during this game. For example, some clients may choose objects that are not visible by the camera, they might block the object or choose something that is too small to see. This in itself can lead to therapeutic conversations and asking the client what might have been going on for him/her during this.
Reading:
Any book can be read out loud. The therapist can let the family know before the session, so that the client can choose a book to read. The therapist can also choose to read books they have. In the online session, try to remember to show the page and images to the camera. If the therapist has a library card, they can also reserve a digital book online, screen share with the client and read together.
You may want to practice reading the book before meeting with the client so you could do voices for different characters if needed.
There are a variety of free colouring pages found online. Simply type "free colouring page" in Google. Try to choose some and send them to the family before the session so that they can download, print, and get the necessary colouring tools available. This is a good option for families that have crayons or other colouring media in the household. Therapeutic intervention to discuss with the client may be around their choice of colour/decision making around what to colour/any judgments/self-critic while colouring/what may be meaningful to them in the picture or anything else that may arise…
Worksheets:
There are a variety of free worksheets found online. Simply type "free therapy worksheets for kids" in Google. You could choose some of your own too and send some of your own to the family before the session so that they can download, print, and get the necessary materials to fill it out ready. This is a good option for families that have crayons and writing utensils at home.
You could try to focus on processing with the client the theme/topic on the worksheet and look at any responses that might arise while working through it. Sometimes being quiet and open to what the child decides to talk about as their colouring maybe useful.
Videos:
If your software allows for screen sharing, you both might want to share short therapeutic videos. Sometimes, depending on the sensitive information in a video, you may want to send it first to a parent/guardian for approval.
Try to have the video cued up, with the ads already skipped, and any unnecessary intros already jumped. You may want to then mute the client, so there is no feedback, and they can hear the video through their speakers and watch it on the shared screen.
If a client needs to ask a question or tell you something, they could communicate with a sign/signal that you have both worked out together beforehand. You might want to come up together with a sign for pause/go back/that’s interesting/ boring… Additionally, they can message you inside the video software, if they don't want to stop the video or use a made-up signs/ gestures.
At the end of each video, try to process the client's reactions around the content. Videos you might want to use in a session may include: (Hover over with the curser to be directed to them online.)
Coronavirus disease (COVID-19) from CDC
Be The Pond from Cosmic Kids Yoga
Depression Explained from Professor Puppet
What Causes Anxiety and Depression - Inside Out from Mind Set
Preventing Childhood Anxiety and Depression from GoStrengths!
A Student with Mental Illness from Chara Bui
We Described Our Depression To An Illustrator from BuzzFeedVideo (I do something similar to this with youth during session)
Do All Autistic People Think The Same from Jubilee
6 Middle Schoolers Versus One Secret 5th Grader from Jubilee
Do All Teen Moms Think The Same from Jubilee
Do All Teen Dads Think The Same from Jubilee
Do All Suicide Survivors Think The Same from Jubilee (this one may be useful to show to families who do not understand youth’s suicidal ideation or attempt to minimize it by believing it is only attention-seeking behaviour).
Board Games at Home:
If the child has any board games, such as ‘sorry’, snakes and ladders, connect four… you could have them set up the game and play the pieces for you. (It might be tricky to set up alone so you may want to ask the parents/guardian to set it all up before hand). Low cost theraputic printable board games can be found on the resource page on this website if needed.
As the child moves your piece through the game, you could discuss together what’s it like "being a helper". You might want to process together what’s it’s like to assist someone who isn't able to touch or interact with the objects physically. This could open the conversation around experiencing separation while playing. Other conversations maybe around; possible temptations to cheat/not playing properly/winning/ losing or anything else that may crop up...
If needed, you could choose to use your own gameboards, and have the client describe which pieces they want you to move through your screen. Some may choose not to do this if the client tends to become easily distracted when they’re not engaging with the pieces.
Feeling Faces:
You may want to discuss feelings using any ‘feeling’ flashcards you may have in your therapy setting. You could show the face to the screen and have the child label and discuss the feeling. Then try to have the child draw the same face. During this process, a more in-depth discussion of feelings may arise or anything else that may crop up that the child suggests…
You could try to include goofy faces that are hard to replicate or animal faces (like a pig), as it may make it more challenging and fun for the child. You can even send the flashcards to the family to print out, so the child can choose feeling faces for you to identify and imitate. There are low cost printable flashcards to purchase in the resource section on the website if needed.
Whiteboard or a ‘boogie’ board:
In in-person therapy, some therapists use a whiteboard or a dry-erase board for various drawings/interventions. You may want to use Jamboard, which allows you to have an online interactive whiteboard. Some videoconferencing software includes the use of a whiteboard, such as Zoom Healthcare and TheraPlatform. You could create a Jamboard session, share the private link with the client and work on the board together, or they could work on it by themselves.
You could wait to see how the child interacts with you and the board. Other times you might decide to draw a line down the middle of the board or create circles around the board, to represent boundaries that the child and you might try to stick to. You could even take turns drawing a line until you have both have created an entire picture together. Then you could try to same thing without a line and discuss the difference. Lastly, you might import a colouring image page where the client could use the pen tool. If all fails using the software, you may want to use a standard piece of paper and pen and talk the child through the same exercises using maybe their right and left hand to draw on the page.
Podcasts:
If your software allows for screen sharing, you might share topics from Podcasts that are age appropriate. You could share a clip or the entire Podcast, depending on the length of the session. Depending on the sensitive information in a Podcast, you may want to send it to a parent/guardian for approval. The same as when preparing videos clips, you may want to have the clip cued up, with the ads already skipped, and any unnecessary intros already jumped. You could then mute the client from your end, so there is no feedback, and they hear the Podcast through their speakers.
Podcasts that may be useful in a session include: (Hover over with the curser to be directed to them online.)
The Better Mental Health for Kids and Parents Podcast with Dr. Fasano
Short and Curly with Dr. Matt Beard, Carl Smith, and Molly Daniels
Unspookable with Soundsington Media
Using Wellness Apps before/during a session:
There are many therapeutic (ish) apps out there and could be considered a useful route into deeper conversations during sessions. Below are a few you may want to consider. (Hover over with the curser to be directed to them online)
5 Minute Journal (iOS, Android): Daily journal for gratitude, positive reflections, and photos.
BoosterBuddy (iOS, Android) Game-based self-care app offering self-care, medication and appointment reminders, mood tracking, and games to improve coping skills and socialization.
Calm (Web, iOS, Android): Guided meditations accompanied by natural soundscapes.
Calm Harm (Android, iOS): DBT-based app designed to help users manage the urge to self-harm.
Daylio (iOS, Android): Daily mood tracker and micro journal.
DBT Diary Card and Skills Coach (iOS): Coaching and ongoing support for users who are currently engaged in DBT with a therapist.
Habitica (Web, iOS, Android): Gamified habit tracker and to-do list. Includes monthly self-care challenges from Take This.
Headspace (iOS, Android): Paid guided meditation program.
Mightier (Web): Paid clinically based games for kids with ADHD, ODD, or anxiety.
MindShift (iOS, Android): Anxiety resources and coaching for teens and young adults.
SleepCycle (iOS, Android): Sleep tracking and alarm clock.
SuperBetter (Web, iOS, Android): Gamified app designed to increase resilience and encourage good habits.
Stress and Anxiety Companion: Simplified CBT tools for dealing with anxiety and stress.
Virtual Hope Box: Provides coping methods and tools for veterans and others. Designed for the U.S. Department of Defense.
What’s Up (iOS, Android): CBT and ACT-based tools for dealing with anxiety and depression.
Conclusion:
There are still a whole host of other common interventions/ways of working that could be used in online therapy with younger clients. Some include mindfulness meditation, journaling, empty chair technique, therapeutic role play… You may want to start thinking about these and others that might suit your online practice.
I hope that you have come to the realisation that in - person therapy is not identical to online therapy and it's not worth even making any comparison. However, what we might want to do is look at the unique position of online therapy and focus on how it could open up spaces that might not be opened as wide in in-person therapy. Online therapy still has the potential to provide support, understanding, awareness and insights to clients and our expectations may just need to be less when relating through the screen (which might be a really good thing for us therapists).
If you would like to know more about online sessions with young clients simply email progressiveprocess@live.com.au or click here to book your free online consultation.