Teletherapy and Kids, Volume 9: Sand Tray Therapy

Check out other resources for telehealth with kids here!

At my first practicum site, the director told us that we were welcome to use any child-friendly intervention we deemed appropriate except for sand tray because she didn’t want to deal with the mess. Well, Dr. Karen Fried found a way to not only eliminate the mess associated with sand trays but also make this intervention possible on telehealth!

Photo by Jorge Sepu00falveda on

This site does not create a link that you send over Zoom like the other activities in this series. Instead, either the therapist or client screen shares. If the therapist is sharing their screen, they will want to grant remote access to the client so the client can create their sand tray.

Before using this activity, therapists should make sure they have completed continuing education to be competent in sand tray therapy.

I have to say, I really like doing sand tray work online. Here are the benefits I’ve found:

  1. Kids can put the same character in the sand tray multiple times, so there are more options.
  2. Kids can adjust the size of the characters the put in the tray, which opens up the scene for more interpretation based on which pieces they make larger or smaller.
  3. It’s really easy to save the image once the child is done, and it saves right to the therapist’s hard drive.
  4. No clean-up!

My hesitation with online sand tray work is:

  1. The existing research on sand tray therapy focuses on in-person, so it’s possible the online version is less effective and we just don’t have the data yet.
  2. There’s a sensory component to sand tray work that you lose when you go online, which I guess is the trade off of not having to vacuum sand out of your office.

What other techniques have you tried for telehealth? Let me know!

What Do Risk Assessments Look Like?

Content/Trigger Warning: Suicidal Ideation

September is Suicide Awareness Month, so my best friend, Cirien, helped me create a mock risk assessment. Many people wonder what it looks like if you tell your therapist you are having suicidal thoughts that you don’t want to act on, so I created this video to show how I respond when a client shares this with me.

Disclaimer: This only represents how I would handle the situation as a professional. I recommend asking your therapist what their policy is for responding to passive suicidal thoughts.

Passive suicidal ideation is very common, but telling your therapist about these thoughts can be scary.

What other videos would be helpful to see? Let me know!

I Don’t Want To Be Bad available at Full Circle Co-Op

A local book store, Full Circle Book Co-Op, has agreed to stock I Don’t Want To Be Bad! As with purchasing online, copies are $9.99, but part of the profits will go to a local business that does awesome things in the Sioux Falls community!

Come by and check out other local authors, have a beer, and find all the second-hand books you could ever read.

Teletherapy and Kids, Volume 8: Dominoes

More telehealth resources are available here!

Before I started working from home, I had a huge box of dominoes in my office. I rarely used it for its original intent, as kids much prefer to build with the tiles or make a path that they can then knock over. But when I was looking for games that could be played over telehealth, I found virtual dominoes! This is actually from the same website that hosts the Mancala game I shared before.

Photo by Miguel u00c1. Padriu00f1u00e1n on

This is, of course, the more traditional dominoes where you line up pieces with matching numbers of dots. I have not found a version where you can create tracks and knock them over, so if someone reading this has found something like that, please let me know.

Traditional dominoes can be a good therapy game, as it requires focus and planning, frustration tolerance, and social skills. There are some definite advantages to playing online:

  1. If one of your treatment goals is to work on executive functioning, the fact that the game will not let you “cheat” or change the rules helps keep the child focused on a specific goal.
  2. The computer keeps score for you, so if you are like me and don’t understand how scoring works, that part is covered.
  3. When it’s your turn, the pieces in your hand that you can play are highlighted, so the choices are more obvious to the child. (This is especially good because some kids who are still learning the game in my office will ask me to look at their hand and help them choose, which isn’t an option online, so the game sort of does that for me.)
  4. Who else loves dominoes as a therapeutic intervention but hates cleaning up all those tiles? On the internet, you don’t have to clean up.
  5. There is a timer bar, and if you do not take your turn, the game goes for you. This is a helpful focus intervention with natural consequences.

Cons of online dominoes:

  1. There is no option to play without keeping score.
  2. There is no option to change the rules if you want to take a more child-focused or non-directive approach.
  3. There is no option to turn off the timer.

Basically, like a lot of these games, the computer programmer didn’t think about what would happen if you were playing the game with a child who wanted more control of the game itself. (If you hadn’t already noticed, this is a theme among online board games.) Hey, if there are any programmers reading this, is this something that could be developed? Hit me up because I’d love to talk about options.

As always, thanks for reading!

Photo by Craig Adderley on

What is Therapeutic Fit?

If you’ve ever had a therapist, you might be familiar with the term “therapeutic relationship,” referring to your connection to your therapist. What you might not realize is that your feeling of trust and connection to your therapist is actually the most important piece of your treatment, more than your therapist’s specific qualifications (beyond basic competency) and more than your therapist’s preferred modality.

Photo by Frank Cone on

When I say “therapeutic fit,” I am talking about that relationship with your therapist. Not everyone will be a good fit for you, and that will not be your fault – or your therapist’s fault! I did a quick Google search as I wrote this blog, and it said that there are 7.8 billion humans in the world. Odds are, you aren’t going to like some of them.

Therapists are humans. We have mannerisms, personalities, and interaction styles that some people might find off-putting. If you have a first appointment and find that you just do not like the therapist, it’s possible that you need to take time to get to know them and get comfortable in that environment. But it’s also possible that that therapist just is not a good fit for you. (Of course, if the therapist acts in a way that is unprofessional, inappropriate, or unethical, this is another story – you have the right to report unethical behavior! But I’m referring to disliking someone for reasons you might not be able to articulate.)

It’s okay to request another therapist. Every therapist I know who has been practicing for more than a few months has had clients request another provider because of fit – it has happened to me! If I am being completely honest, I don’t love hearing that someone requested another therapist, but I am happy to hear that they felt empowered to seek the best provider to help them, even if that isn’t me.

Reasons I have heard that someone asked to change therapists include:

  1. The client wanted a therapist who understood their specific cultural experience
  2. The therapist shared physical attributes with the client’s former abuser, which was triggering for the client
  3. The therapist fidgeted in a way that the client found distracting
  4. The therapist had a very serious personality, and the client preferred to work with someone who had a more friendly demeanor
  5. The client wasn’t sure why, but they just did not feel they could open up to the therapist

You can request a new therapist for a specific reason or for no reason at all! If your first therapist isn’t a good fit, I hope you can make a change and find the right person to help you.

Square Breathing

This is a technique that is similar to the Bubble Breathing worksheet I posted several weeks ago. Some people have trouble visualizing the bubbles or prefer not to use the imagery of breathing out the negative emotions but would still benefit from some breathing techniques.

Since square breathing involves movement to trace the square, this is a great activity for adults to do with kids to model how the activity is done and to show how taking big, cleansing breaths can bring down negative feelings.

Image text: This is an activity that you can do anytime, anywhere that you start to feel upset, angry, or sad. To start, use your pointer finger to trace a long line up as you take a big breath in. Then, hold your breath and trace the line horizontally in front of you. Next, breathe out slowly as you trace a line down. Hold your breath again as you trace a line back across the square. Keep doing this until you feel your body become calm! Each time you trace your square, try to go more slowly than the last time. If you’d like, you can say a four-word calming phrase as you go. One you can use is, “I am feeling calm.” Slowly think or whisper, “I…” as you inhale, “Am…” as you hold your breath, “Feeling…” as you exhale, and “Calm…” as you hold your breath again.

This and more activities to help kids self-regulate and share their feelings appropriately are available in my book, I Don’t Want To Be Bad, available in paperback or on Kindle at Amazon!

Teletherapy and Kids, Volume 7: Mancala

(Don’t forget to check out the rest of this series!)

“Mancala” refers to a group of board games that originate in Eritria and Ethiopia, but most Americans think of one specific variation when we hear this term. In therapy, this game helps kids with strategy and executive functioning, and I was excited to learn that it was available online for use in telehealth sessions.

Photo by Kelly Lacy on

This is a quick game that even young children can understand how to play. I’ve found that some teenagers who are hesitant to talk to me become more comfortable in their sessions while playing this game because it distracts them from their anxiety enough to really engage with me.

I think it’s interesting to note that, although I’ve had Mancala available in my office for years, it was rarely played before I transitioned online. Come to think of it, many teenagers who felt it was juvenile or silly to incorporate board games into their in-person sessions really seem to enjoy them in the telehealth setting. I’ll have to explore why that might be.

Anyway, pros of telehealth Mancala include:

  1. The computer randomizes who goes first so both the therapist and client get turns starting the game.
  2. Since the game is point-and-click, kids with fine motor skills deficits don’t struggle with that aspect.
  3. You won’t lose half of the beads to a black hole in the corner of your office.
  4. There is a timer, but if you don’t take your turn before the time runs out, it seems that nothing happens. So it helps kids stay focused on the game without stressing them out with a countdown.

Drawbacks I’ve found:

  1. As with most telehealth games, the rules are coded into the game and cannot be changed. Mancala has so many variations you can do, but this version doesn’t allow kids to explore that.
  2. I’ve noticed that some kids tend to zone out when playing this game online. I’m not sure why, but I’ve noticed it with this more than with some of the other games I have covered.

I really like Mancala for telehealth, but I wish there were options for rule variations. If anyone knows of another website that does this, or a way to tweak the rules on the site I posted, I’d love to hear about it!

Working at Home or Living at Work?

This week, I took a couple days away from my clinical practice for a “staycation.” Since I am not currently traveling (thanks, COVID-19), I chose to book a local hotel room (taking precautions, of course). As soon as I checked in, I felt a sense of relief that I haven’t had in quite a long time.

Photo by Roberto Nickson on (The view from my hotel room wasn’t quite this good, but I think the image captures how good it felt to finally leave the “office”)

There are so many things that I love about working from home. You can’t beat the commute, I haven’t forgotten my lunch in months, and I can involve my cats in my sessions. But the trade off is that I am quite literally living at work. I never leave the office for the day – instead, I go into the next room. On weekends, I have to go into work to get a sweatshirt. I used to joke during busy times that it felt like I lived at work, but now it’s true in a literal sense.

Part of being a psychologist means compartmentalizing my work life and my home life. This becomes much more difficult when I’m never more than ten feet from the office.

For any professionals reading this who are still doing the #WorkFromHome life, I really encourage you to find safe ways to get out of your office, overnight if possible. The last few days are the most relaxed I have felt since I left my real office on March 27, and I still don’t know when I will be back. Take care of yourself!

Photo by Madison Inouye on

When Teens Need Therapy

A version of this article was published in Hood Magazine in April 2019.

Adolescence is a time of change, confusion, and testing boundaries. No matter how close parents are with their children, part of growing up involves pulling away from parents and realizing who they are outside of their role within the family. If you feel that your teenager could benefit from the support of a mental health professional, what should you expect?

Photo by Pixabay on

If you are asking yourself, “Is my adolescent struggling enough to benefit from therapy?” you would likely benefit from consulting a mental health professional about your teenager’s needs. Although a certain amount of “teen angst” might be expected, many could benefit from additional support outside of their families. Furthermore, if your teenager asks you if they can meet with a therapist, listen to their concerns. They are asking for help and support. Teens might not feel comfortable or do not have the words to put to what they are feeling. Fighting, self-harming, or breaking rules can be nonverbal ways that your teenager is asking for help.

When talking to adolescents about therapy, the language used is important. Avoid stigmatizing language or focusing on misbehavior. For example, saying, “You seem stressed out lately, and it might help to talk to someone,” is more productive than, “You have been so rude and disrespectful lately. You’re going to talk to someone.” Therapy is a resource, not a punishment.

Research about outcomes for mental health treatment suggest that, while both adults and younger children benefit from psychotherapy, teenagers are less likely to have symptom relief. This is because the number one factor in therapy is a trusting relationship between the therapist and client. Teenagers who are naturally more guarded against authority will be slow to build trust, and parents who are impatient to see positive change are tempted to change therapists or pull their adolescent out of treatment if progress is slow.

Therapy does not always involve the client on the couch, pouring out all of their secrets. Many teens that I work with prefer to explore art therapy or music to process their feelings rather than talking. If they do choose to talk, the conversation might not focus on what the parent feels is the most important topic. If you want your teenager to benefit from therapy, you need to be prepared for them to use the space in the way that is most comfortable for them, even if it not what you picture.

Another obstacle in mental health treatment with teenagers is confidentiality. In order to have trust with the therapist, teens must have some level of privacy in their relationship with their therapist. Imagine how difficult it is to open up to someone knowing that they might call your parents and repeat what you shared! Find a therapist whom you trust to tell you what you need to know about your child’s treatment, and have an honest conversation with your teenager and therapist to outline limits and expectations for confidentiality.

Many adolescents, even when given the space and freedom to make their therapy what they need it to be, will still resist or refuse to engage with their therapist. If the teenager is self-harming, suicidal, or threatening others, they need ongoing supervision in either an inpatient or outpatient setting to maintain safety. However, teenagers who could benefit from therapy to treat mental health problems but are not in danger might insist that they do not want to participate in treatment. In these circumstances, I often recommend that we stop therapy because this teaches them that therapy is their choice, and they are more likely to seek counseling in the future when they are ready.

Mental health in teenagers is particularly challenging for both parents and therapists. With support and understanding, they can benefit from mental health services in their own way and at their own pace.

Teletherapy and Kids, Volume 6: Scattegories

Before checking out today’s post, please go to my resources page to see other telehealth interventions for kids!

When I think of Scattegories, I think of my first job at a dry cleaner. On slow days, one of my co-workers would get it out of her car, and we would play to pass the time. This is a game that I actually didn’t use in my pre-COVID-19, in-person therapy practice, but it is one that I’ve found interesting uses for in the past several months.

(There were no pictures of Scattegories but Scrabble felt similar enough to include here) Photo by Pixabay on

When I first transitioned to all telehealth, some clients and I did the Alphabet Game, where you choose one category and try to think of something for every letter of the alphabet. We would alternate between something “fun” (like animals or desserts) and something “therapeutic” (like emotions or coping skills). This is a spin on that activity.

In Scattegories, you are given a list of topics and a letter, and you have to think of something in each category that starts with that letter. This website lets you create a game using a private link. You choose the number of categories and time limit (or you can opt for no time limit), and send the link to your client. You can pick specific categories or add your own, or the game can choose at random.

In therapy, this activity can be used to work on executive functioning (having to think creatively, focus, and use the allotted time appropriately), bring up topics related to treatment goals (by making those topics the categories listed), and improve cognitive flexibility (by having to find creative ways to fill each category).

Why do I love Scattegories for telehealth?

  1. As with some of the other games, you can use a time limit to work on anxiety with timed tasks, or you can have no time limit at all.
  2. You can input custom categories based on the client’s treatment goals as talking points for your session.
  3. You can also choose from available categories to save time if you don’t want to come up with your own.

As with everything, there are also drawbacks:

  1. I really recommend manually choosing categories rather than hitting “random” because the online version has some choices that are less kid-friendly, like “name an alcoholic drink.”
  2. You can’t choose what letters you want to use for the categories because it is randomly generated (although you could play this game without the website above and choose the letters yourself).
  3. As with Pictionary, you are supposed to type your answers, which is challenging for some kids.

Scattegories is a game that I didn’t think of as therapeutic before I started using it with telehealth, but it has some definite advantages. Kids seem to have a lot of fun with it, and it helps us indirectly incorporate their treatment goals into a fun activity.