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Reflections on using art therapy with children online

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During my two-year graduate Art Therapy study at New York University, I always wondered how, we, as future art therapists could hold online sessions with our clients. Now this was back in 2011 when technology was just on the cusp of being used in therapy. And for sure, we had a few classes devoted to understanding technology’s effects on our mental, physical and social wellbeing as well as how specific populations such as adolescents, were already using technology as part of their art therapy treatment. While I was intrigued about jumping on the online therapy (also called ‘tele-health therapy’, ‘tele-therapy’ ) bandwagon, a big chunk of me was apprehensive about it for comfort sakes (too many variables to control at once to make the online space relaxed, safe and nurturing) and because research on the topic within our field was still in its infancy which would require much trial and error from a newbie. 

Since then, it would seem that the virus has flipped the world on its head literally, showing us its underbelly in terms of what is essential and what is not, and where the gaps lay in our healthcare systems.

The journey: feelings and discoveries

feelings

Indeed, it made me sad to not see my clients at their schools anymore and to ask their caregivers to give me some time to figure out my next steps via online therapy. In the latter, if any well-seasoned therapist knows, interruptions in therapy are not good for a client’s general progress. At the same time, I do not regret my choice to work remotely primarily because I found myself to be in the vulnerable group as we learned more and more about who the virus was attacking. 

Also, it is worth mentioning that on top of juggling two jobs—my practice and another non clinically related work—online therapy only made the weight heavier. I was now busy researching on how to set up my practice online and figuring out the ethical protocols, including privacy related issues.

Like most therapists, I have always kept a comfortable physical distance from my clients, other than the occasional handshake before a session commences, or putting a hand on a client’s shoulder after an intense session. Being in the same room meant I could catch my client’s direct and indirect cues such as their breathing, sighs, and twitches, as well as anticipate their needs, such as giving a tissue after some tears were shed. All of these may not sound significant to the non-therapist, but they add to create a unique sense of connection, an intimate closeness that can only be felt by me being physically there and consciously present. 

I had no idea how any of what I said above would translate to tele-therapy with my young clients, especially since they have either attention related disorders, autism, and/or trauma related issues. And a multitude of questions bombarded my head daily: I wondered whether the same emotional connection can be achieved via a webcam, what it would mean to be emotionally present but not in the same physical room, and most of all, how could I keep their focus and trust that what I am doing will work? 

discoveries

 Interestingly, I was dumbfounded at what I found once I started my journey with tele-therapy. First, instead of me feeling physically distant from my clients, I actually felt like being pulled into a new dimension of closeness with them. Here I was in my client’s homes and they in mine. I came to ‘know’ them in new ways. One client introduced me to her pet goldfish on screen, another showed up in his pyjamas while holding fast to his stuffed toy (a view of him that I’d never seen before) and another played hide and seek. With the first client, she often commented on how nice my house plants were. As I saw living and bedrooms of various sizes and of varying furniture and many in their relaxed attires, the physical distance between us seemed to be not so bad after all. 

It’s difficult adjusting to online therapy as a newbie

 But I did have some challenging adjustments to make along the way. First, I changed the welcome page of my practice website to include a COVID-19 and tele-therapy message. Second, I researched which online platforms would be secure enough to hold my session. It turns out Doxy.me is a pretty good one, although the sound quality is not always great. Third, I had to change my session hours to times when kids had more privacy. For instance, I was now talking to my 10:30AM Friday client at 2PM. Fourth, I have had to rely on using mostly basic materials with my clients such as paper, coloured pencils and markers. This aspect has also made me focus more on verbal therapy, including using cognitive behavioural therapy to try and solve my client’s issues. While my clients with ADHD have been receptive, it is still a work in progress for my other clients. And lastly, I had to remind myself many a times to stay in my professional mindset while performing house duties in between sessions, including cooking, throwing a load of laundry into the washer and cleaning the dishes.  

Biggest learning point thus far: the difficulty of pacing sessions & ending properly

The biggest learning point thus far for me though has been the pacing of sessions online. It is really quite different with all of my clients. My clients with Attention Deficit Hyperactive Disorder (ADHD) for instance impulsively will press keys, even though they already know what the keys can do, and appear in the ‘waiting room’ earlier than they would normally show up to normal sessions; my clients with trauma related issues chronically show up late to sessions, even though there are no reasons for them to since their parents no longer have to drive, find parking or take the tram (train). Also, the pre-initial minutes of a session where I would normally see children take off their coats, get settled into a seat and make jokes all seem to have evaporated into thin air. I can no longer get a sense of the child’s state of playfulness before the session. Now, it was (and still is) all face to face from the get go and somewhat serious. 

Moreover, I sometimes struggle to end sessions smoothly. Normally, I have multiple ways of ending a session, depending on my client’s needs. When working with children, especially those with special needs, it is imperative to give a few signals or reminders throughout a session because they can be so immersed in their own world that they don’t hear your comments, such as kids with ADHD. These signals can include how long they have on an intervention, finishing up their artwork and collecting their thoughts and/or belongings before transitioning back to their classroom. Now, transitions for most of them are being interrupted by family members like a school pick up. For children with ADHD, I am finding myself having to repeat instructions more often than I normally would in my normal face to face sessions; for a specific client in particular, I am still unable to close the session before they do. 

A personal challenge

I think the most unsettling aspect of doing tele-health therapy thus far is that I have to see myself constantly during the session. Now, mind you that I have not had to observe myself in my role as a therapist since my training days in 2013-2015. And now I am being confronted with a mirror, aka the webcam. I felt (and still feel) distracted whenever I catch a glimpse of myself listening. Sure, I can ask my clients to turn off their cameras but that would be a selfish act on my part and would make the emotional connection inconsistent. And if anything, children prefer consistency more than anything else. At the same time, I am sure that they are also jarred by looking at themselves on the screen, which may be adding to the complexity of the treatment process as well. And sure, reducing self-consciousness may be at the heart of a good therapy relationship but so, too, is consistency, face to face interaction and trust. 

Future hopes 

While I am pleased at how quickly I was able to switch lanes and set up my practice online, I have yet to fully adapt to the ins and outs of using the technology well and comfortably as a newbie, including using the video aspect of it. This is not to say that I am not appreciative of this new tool; in fact, I appreciate the fact that technology (or online video platforms in general such as Facebook, WhatsApp, etc.) is allowing us to stay connected during these anxiety provoking times and that platforms for therapy work are out there (Thank you Doxy.me). I only hope that this is a temporary solution, or that it remains a choice for the foreseeable future, especially for art therapy’s (or for any other expressive arts’) sake. Without proper (educational) training, it can be quite an overwhelming experience for both therapist and client. I remain bothered by the fact that I am not able to tell my young clients who already struggle with uncertainty and change when we can resume sessions at their schools again, with rather comfortable furniture and cozy privacy. 

Until the next blog,

Stay healthy

Stay calm

Stay connected! 

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