Anastasia Taylor, a Fort Worth therapist, uses the board game Candyland to counsel her young clients. As these children and teens reach the “candy castle” by the end, Taylor’s goal is to help them process their emotions.
Each color of the board game is assigned a feeling. When the client lands on a color, they share a time when they experienced that particular feeling.
But now that the COVID-19 pandemic has forced Taylor and many other North Texas therapists to provide their services exclusively through telemedicine, the therapist-client experience is not the same.
Therapy for children often involves hands-on activities. That’s harder to accomplish remotely. For example, the kids are “not moving the [Candyland] pieces,” said Taylor, executive director of Alliance Child & Family Solutions. “So there’s some of those limits.”
As a result, “we’re not seeing as many young clients come through,” she said, “because at that age, there’s not as much we can do when we’re not so close,” especially without parent involvement.
At a time when mental health needs are higher than ever and COVID-19 prevents many from meeting in person, teletherapy presents a challenge for children, many of whom rely on a technique called “play therapy,” North Texas counselors say.
Studies have shown rising mental health issues for adults, but there has been little research on the same issues for children, said Dr. Brian Dixon, a Fort Worth psychiatrist. Nevertheless, he believes kids have been more stressed because of the pandemic, even if it’s too early for definitive diagnoses.
Taylor’s use of Candyland is an activity used in play therapy. It’s a technique where therapists consider play as the child’s natural language. They use games, toys, coloring and other forms of play to help children open up and develop skills to cope and deal with conflict.
Taylor says that play therapy is necessary for children, who might not have the developmental skills to express themselves otherwise. There are two types of play therapy: non-directive and directive.
In non-directive play therapy, a child, usually ages three to 12, explores a “playroom” set up with different toys, ranging from sandtrays to dollhouses. The therapist watches the child play and then reflects on common themes.
“I’ve seen one child go to the dollhouse and they’re acting a complete scenario of domestic violence and the police getting called to the home,” Taylor said. “Sometimes you see the exact opposite, where they’re acting what they want their family to look like. It’s really just an interpretation of their actions and how the child sees their own world.”
Directive play therapy can be used for children and teens and offers a more guided approach than non-directive play therapy. With this approach, the therapist usually has a better idea of what the child is struggling with and will use more talk therapy with games or activities to surface their mental health issues.
Dr. Dixon said that it’s hard to conduct play therapy online, since it often relies on physical interaction. For example, a therapist might ask a child to talk about how they get ready for their first day of school. This can help them talk about anxious feelings. But a younger child might need to act out getting ready for school in order to express himself or herself.
Taylor believes play therapy via telemedicine is still possible, even if options are more limited. She said that directive play therapy is much easier to manage online. She virtually reads books with clients through YouTube videos, where a narrator reads the plot. Taylor pauses the video at different sections to discuss characters and themes.
She also sometimes asks clients to complete “scavenger hunts” around their homes, showing her objects that help them laugh and feel safe.
Still, many therapists in North Texas report a significant decline in the number of clients willing to engage in play therapy, because of the difficulties with doing it online. Other therapists have stopped offering it altogether.
Role of the parents
In addition to using play therapy — and sometimes in place of it — some counselors are coaching parents.
Dr. Brooke West, a play therapist in North Dallas, said some of the families of her youngest clients have decided not to pursue teletherapy. As an alternative, she is offering filial therapy, a type of play therapy that teaches parents basic intervention skills.
“It doesn’t really work online with the little bitties,” Dr. West said. “So what we’re doing is we’re offering filial … And we are offering feedback on what they can do and what they did well and what they can change.”
According to Dr. Dixon, parents play an important role in teletherapy — and that can lead to disparities in some families’ ability to access such care. “Some of the parents are frontline essential workers, they’re still out working, or working in a warehouse,” he said. “And so I’ve had a couple parents say, ‘…I can’t take any additional time or effort or money to do this stuff.’ ”
However, parents like Jen Sarduy find that teletherapy reduces the burden of a stressful commute. The Fort Worth resident’s 13-year-old child previously received in-person therapy but has since switched to teletherapy. “I feel as free as a bird,” Sarduy said. “It’s so good to be able to have my child in teletherapy, because I know at first how hard it was to get to that office.”
Laura McLaughlin, a Dallas therapist, also decided not to offer play therapy online. She said there was not enough evidence to support its effectiveness. She was concerned that young kids’ brains haven’t developed to the point where they can benefit. And it’s often hard to get kids to sit in front of a screen for the length of a typical session.
“What studies show is that … children don’t learn through screens, because they don’t understand the context,” she said. “They really only learn when it’s face-to-face in person…”
Dr. West has decreased her session times in order to reduce prices, but also cut down on children’s screen time. “They’re online with their friends so much, I don’t want to become yet another hour that they’re having to sit in front of a screen,” she said.
Overall, Taylor believes that teletherapy is effective, even if it’s different from what most therapists and clients are used to. “It’s different in understanding that it’s not a comparison to what was, but just accepting that it’s a new and different type of relationship between the therapist and the client,” she said.
If you need help
— North Texas Behavioral Health Authority has just launched a dedicated COVID-19 mental health support line at 833-251-7544 to provide trauma-informed support and psychological first aid to those experiencing stress and anxiety during this crisis. The authority also continues to operate its 24-hour crisis hotline at 1-866-260-8000. Visit ntbha.org for more information.
— Here For Texas Mental Health Navigation Line: Grant Halliburton Foundation initiative connects North Texans with mental-health resources customized to each caller at 972-525-8181 or go to HereForTexas.com
— Dallas Metrocare Services: For help, call 1-877-283-2121 or go to metrocareservices.org
— Crisis Text Line: 24-hour support by texting HOME to 741741. More information at crisistextline.org