Written by: Sarah Harris, LMFT-S, RPT, BC-TMH
There was a time when the thought of therapy was only associated with a client laying down on a sofa and a therapist sitting behind them with a clipboard in hand. Over time, that view of therapy has evolved. Especially in the last few years with the development of TeleTherapy/Virtual Counseling/Online Therapy, which involves a video and audio online platform.
There are many articles which provide information about Online Therapy logistics such as which platform to use, lighting, etc. Today, I want to address specifically Child Therapy. There is much to say on this topic, and I have tried to narrow it down to some of the most common questions that I have been asked by other therapists and supervisees.
Ask any Registered Play Therapist and they will probably tell you that when working with minors, it’s necessary to work with the parents at some point. This stays the same for online therapy. Keep parents involved in some way. Some ways that this can be done include:
- in session with the child as in Theraplay;
- at the beginning of the session;
- in a separate Parent session, maybe 1x or 2x a month.
I rarely meet with a caregiver at the end of the session, unless there is a concern that arose in the session. Then, after getting the child’s consent, I may bring the parent in for either the child or myself to share the info. The reason for this is that I don’t want the child to feel like I am reporting back to the parent what we just experienced in therapy. This lessens the trust and safety that the child feels in the therapeutic relationship.
Teletherapy is fascinating because the skills that we once used to build rapport with a client in the first session may not be enough when it comes to video. Now, we have to be even more aware and attuned to the client’s verbal and nonverbal communication. This is why it’s important to select high quality video and audio equipment, if possible. The idea is to maximize the quality of the teletherapy session, in whatever way it can be done. As a therapist, be aware of your appearance online. On camera it may appear washed-out. Yes, I said it. Be aware of what you are wearing. Is it distracting? You may need to increase your energy so that it is translated more effectively on screen. You may need to be more expressive or speak louder without shouting or sounding harsh. Be aware of your lighting, background, and eye contact, among other things. All of these things affect a client’s level of comfort in the session.
Have a structure for your Intake session, and inform the client about it, so that they know what to expect. This also helps to put everyone at ease. Be confident in what you are doing and exude that confidence and belief in the effectiveness of online therapy. Have a thorough Informed Consent that is specific to Online Therapy. Be sure to explain the benefits and limitations of online therapy. Additionally, it is important to discuss the rights of the clients, emergency contacts, and the crisis plan. Take note of the client’s physical location in every session and ensure that an adult is at home. Also, discuss a contingency plan in the events that technical difficulties arise.
As a TeleTherapist, privacy is discussed on a regular basis. Request that the caregiver create a private space where the child would not be disturbed by other family members. Discuss with the client if there is anything that you can do to increase a greater sense of confidentiality. In a session, the therapist and child can make a sign to hang outside the child’s door during the session. (“In Session. Do Not Disturb”). It could be helpful to have a noise machine outside the door. Another way to increase confidentiality is for both/either the therapist and/or child to wear headphones. This can be tricky if the child is moving around a lot, so if possible, wireless is best. Headphones can also help increase the audio quality, because as kids move away from the device, the sound quality decreases.
Keeping Kids Engaged in Online Therapy
- Ensure a high quality sessions (i.e. excellent audio and visual).
- For young children, keep it simple. Collaborate with the caregiver on setting up the device and area so that it suits the child.
- Be creative and interactive, and don’t be scared to have fun.
- Use the tools in your online platform (e.g. sharing your screen to show a video or to meditate, use the chat box for exercises such as, "type in 5 emotions that you felt over the past week", utilize the whiteboard for prompts such as, “Why don’t you draw what you’re describing to me?”, change backgrounds).
- Be sure the games and activities you use are age appropriate.
- Give control within limits.
- Validate their feelings.
- Show interest in their likes and dislikes.
- Give breaks during the session. These are therapeutic and may include:
- Movement: bouncing on a yoga ball, stretching, push-ups, dancing;
- Mental: they show you anything they want for 5-10 mins, listen to their favorite song;
- Breathing: slow, deep breaths;
- Artsy: make something, draw something, scribble, doodle.
- Offer shorter sessions for some kids who may need it, especially young children.
Remember that the most important “intervention” is the relationship that the child has with you. So be aware of your energy and body language. One of the advantages of online therapy is that you can actually see your face in the session. Check. Is it mirroring the client’s excitement when they buy a new house in Roblox? Can they hear and see your empathy as they fret about a teacher that they are convinced is out to ruin their life?
Use interventions that are relevant to your client’s Treatment Plan. Don’t just use it because that is all that you can find.
In non-directive play, you want to use many of the same skills that you would otherwise use, such as not asking questions. You may need the parent’s help in setting up the device so that there is a good view of the child’s play area.
In directive play, you can direct the client to choose the toys, based on what you want to do. The client can also choose what toys they want to bring into the session. Additionally, you can ask the caregiver to prepare certain items for the client to have in the session. This can include emailing a worksheet or a Feeling Wheel for the parent to print. There are many digital versions of games such as Uno, and apps that can be used in the session.
Here a few examples of other interventions that can be used:
- Time Capsule
- TeleTherapy Scavenger Hunt
- Emotions Hangman
- Cards: Bright Spots Therapeutic Fun- Thoughts and Feelings. A Sentence Completion Card Game
- Cards: Letting go of Anger- 52 Cards to help teens tame frustration.
- Making a playlist of songs and sharing about the feelings in the songs.
- CCPT approach as they played, e.g. using baby dolls and puppets to become the voice of the child
- Art-based activities (you can ask the parent to provide the child with the materials for the session)
- Meditation e.g. Headspace website. Yoga, relaxation sessions.
- Videos e.g. clips from the movie “Inside-Out” about depression and anxiety.
Give a time warning. I end my kid sessions with a ritual which I call “Free Choice”. It’s very self-esteem building and helps to transition the child from therapy time to home time (e.g. a 10 y.o. child may choose to demonstrate their favorite car-racing game or a 12y.o. boy want to share the latest songs that he has learned on his guitar). I set a limit of 10 mins for this at the end of the session.
This was a brief overview of Online Therapy with children. Many aspects of this are new and evolving, so I encourage you to regularly seek additional support, which may include consultation, trainings, webinars, readings and groups.
Sarah Harris, LMFT-S, RPT, BC-TMH is a AAMFT Approved Supervisor, Registered Play Therapist and a Board Certified TeleMental Health Provider. Sarah owns an Online Group Private Practice that serves NC, GA , and UT. In her free time, Sarah enjoys reading, running, cooking plant-based meals, and playing with her family.