Charades

Photo by Jessica West on Pexels.com

Who didn’t love charades as a kid? Well, I didn’t because of my social anxiety, but most people really enjoyed it! Therapeutically, charades can help shy or anxious kids come out of their shell and can normalize being “silly” when the therapist takes their turn. It can also be a way to model different emotions or bring up topics related to the child’s treatment goals or history.

I can never think of things to act out, so I use websites like this one that have lists of prompts or this one that generate random ideas to act out.

Although the concept is pretty simple – you take turns acting something out in front of the camera while the other person guesses – this can be a challenge in telehealth. Kids often need prompting and redirection to stay centered in the frame so that I can actually see what they are doing. Also, the “ideal” home office setup does not leave me much room to act out my own prompts, so I have to try and choose things I can do sitting down.

This is a great opportunity to get creative and engage children through body movement rather than relying on verbal conversation, which is tempting in the telehealth session. Not only that, but hyperactive and restless kids stay engaged in the session better when I provide ways that they can move around and still be present.

What kind of movement-based activities have you done with your clients?

Thoughts on Recharging

I have been sharing telemental health tools to use with kids on Tuesdays, but this week I moved that post to Thursday. In the United States, it’s election day, and although I often don’t directly “talk politics” on this blog (even though mental health is political), I thought self-care was a more important topic right now.

I voted early!

Humans are basically cell phones with feelings, and burnout is when we run out of batteries. Most people don’t wait until their phone is completely dead to plug it in, and this means that it charges back up faster. Although you can still use your phone while it’s plugged in, there are limitations, such as needing to stay near an outlet.

We need rest, both to keep up with our responsibilities and to do the fun things that we enjoy. You can’t play games on a dead phone battery any more than you can make an important call or reply to an email from your boss. The fun parts of self-care are not possible unless adequate rest is happening.

For myself, I took the rest of the week off work. Hopefully that will give me time to recharge, plus the energy to do things I want to do and not just the things I have to do. I hope you also get time to rest.

The Three Conversations

The tweet that inspired this blog post

Image text:
“Every time you communicate with someone, three conversations happen:
1. What you said
2. What you meant
3. What they heard
Figure out how 2 and 3 diverge to fix a lot of miscommunication.”

I say this a lot, and I wanted to talk a bit today about what this means for parents. A lot of “disobedience” by children comes from them not understanding what is expected of them. Below is a scenario that I have heard countless times in my office.

Parent: I need you to wash the dishes.
Child: Okay.
Child: *Continues engaging in a preferred activity, such as watching a show or playing a game*
Parent: Why didn’t you listen to me? Wash the dishes!
Child: I was going to!
Parent: You never do what I ask!

Now both the parent and child are upset, and the parent will probably punish the child for not listening. But if we look at the three conversations happening, we can see that this is an issue of miscommunication rather than defiance.

The parent said, “I need you to wash the dishes,” but they probably meant, “I want you to stop what you’re doing and wash the dishes right now.” The child heard, “I need you to wash the dishes at some point, so for now you can keep playing your game.”

The child said, “Okay,” but did not immediately jump to the task. They meant, “Okay, I will get to it later because I am not ready to stop what I’m doing.” The parent heard, “Okay, I am going to indicate that I hear you but then do whatever I want.”

Transitions are hard. Transitions away from preferred activities are even harder. Kids need support with these transitions, which is why I recommend giving a five-minute warning (or series of warnings, depending on the child’s needs) before having to end a preferred activity.

When a child seems to be ignoring a request, it can help to stop and consider: Was I clear and specific with what I wanted? What does my child need in order to do what I asked? What are they telling me that I might not be hearing?

Kids are still learning how to communicate. (Most adults are still learning how to communicate.) They don’t always have the words for why something is difficult or why they aren’t ready to do something. Keeping the three conversations in mind can help you approach these interactions from a teaching perspective rather than a punitive perspective, which will allow your child to learn how to communicate rather than being punished when they do not fully grasp what they did wrong.

(Happy Halloween!) Photo by Daisy Anderson on Pexels.com

Flashback Stopping

A common symptom of trauma is flashbacks, or re-experiencing a traumatic event. Flashbacks can feel very real, and it can seem like the event is happening all over again. I created a worksheet with prompts to help someone pull themselves out of a flashback, made so that individuals can choose which prompts are most beneficial to them. There is no right or wrong way to use this tool; you can add prompts if you would like or eliminate those that are not helpful. These are similar to grounding skills and can be used wherever or whenever a flashback occurs.

For children, it is particularly helpful for adults to know which tools are beneficial. This way, the adults can cue the child to use their coping skills. It’s best not to ask the child questions like, “Are you experiencing a flashback?” or “Are you remembering ______ (traumatic event)?” This can bring the negative memories into the forefront of the mind if the child was just having a bad day or upset about something else.

It is most helpful to practice this when calm so that the skill comes naturally when flashbacks pop up.

Chats

Photo by Andrea Piacquadio on Pexels.com

I am sure that anyone using Zoom is aware of the Chat feature. It’s how I share custom links with clients to join me in online games, but it has another use that has come in handy in my sessions.

Talking and therapy seem to go hand-in-hand, but for a number of reasons, a client might prefer not to engage in verbal conversation. Reasons I personally have experienced include:

  1. Clients with selective mutism might be unable to speak during sessions
  2. Autistic clients often have nonverbal periods, sometimes in response to stress
  3. In telehealth sessions, clients might be worried about privacy and think that someone might overhear what they say

In all three of these cases, a client might be able to write down what they want to say even if they cannot verbalize. Sometimes, a client with selective mutism or experiencing a nonverbal episode might be unable to type what they want to say, but it is helpful to show flexibility and offer different ways to communicate.

Although I am hesitant to endorse “text therapy” because I need more information on its effectiveness and safety issues, using the chat in a telehealth session means you can still see the client on video while using the chat, which addresses those concerns.

In my office, I’ve had clients write down things they would prefer not to say to me. Although some kids have slower typing speed, children who were able to write things down in sessions have been able to communicate using the chat, and it is much easier to read their handwriting!

Why Do Kids Lie?

An issue that a lot of parents bring up, either in the initial intake or at some point in their child’s treatment, is lying. “Why is my child lying to me?” “They know I will catch them in the lie!” “I’ve told them it’s important to tell the truth!”

Photo by Pixabay on Pexels.com

In my book, I talk about how kids want to make good choices but sometimes have trouble with this. Often times, a child who makes untrue statements is not trying to lie.

What? How does that make sense?

Children’s brains are still growing, and the area that is slowest to form is the frontal lobe, which is the part in charge of impulse control. Basically, young kids are still learning how to stop and think before they act. When an adult asks a child a question, the child’s response can be based on a number of impulses: Are they afraid they will be punished? Do they have a history of trauma and feel like they need to protect themselves? Do they want to please the person asking the question?

Let’s look at each of these scenarios. For the purpose of this exercise, let’s pretend you found candy wrappers in your child’s bedroom, and they know they are not allowed supposed to have food in their room. You ask your child, “Did you have candy in your room?” knowing the answer, and the child says, “No!”

The first reaction, fear of punishment, is pretty simple. The child knows they will have a consequence for the behavior. They are not necessarily thinking, “I want to deceive my parent,” but they are thinking, “What answer means I will not get into trouble?” Because this response is on impulse, they are not considering how realistic the lie is. It is entirely possible that the child has gotten away with dishonesty in the past and learned that saying the “right thing” will avoid punishment. In this situation, you can reward your child for telling the truth even when it is difficult (while still having consequences for the behavior they were lying about) to show them that there are benefits to telling the truth.

Children who have histories of trauma and neglect often hide food, which is a topic for another post. Kids who have survived abuse often had to lie to keep themselves safe (a more extreme version of what I described in the last paragraph). In this case, it could be beneficial not to present the question in the first place. Instead, you can tell the child that you know they broke the rule, using a calm voice and reminding them that they are safe. Use this as a teaching opportunity to show that it is okay to make mistakes and to address their trauma. This way, they can learn that the lying behavior is no longer needed to stay safe.

In the third scenario, I would argue that the child is not lying (at least not deliberately). They are giving the response that they think will make you happiest rather than the response that is most true. In this case, it can help to tell the child that the answer you want is the true answer, regardless of what the truth is. Then ask them to take a moment and think about if they want to change their answer. This teaches the child how to stop and think before giving an answer and helps them build their impulse control skills.

Rarely do children misbehave just for the sake of it. It is true that children will seek negative attention sometimes, but if you can get to the reason behind a behavior, you can address it productively.

Let’s Talk About Burnout

I wrote this post for mental health professionals, but it’s something a lot of people can relate to right now.

Pictured: A master of self-care

The demand for mental health has spiked in the pandemic, and while it is fantastic that people are reaching out, therapists are scrambling to meet the demand. We are living in the same world as our clients, while being that source of support and healing.

To be honest, I am exhausted. Many of my go-to self-care activities aren’t available right now because I live in an area where numbers are rising, and since my husband works as a nurse, we are being extra careful. I decided this week to really explore what burnout looks like for me so that I can be mindful and take care of myself. I owe it to my clients to be at my best, I owe it to my loved ones to have something left to give them at the end of my work day, and I owe it to myself to be well.

I am sharing my burnout levels as a template so that others can think about what their warning signs are. I doubt it’s possible to be Level 0 in 2020, but I left it on anyway to be aspirational.

Burnout Level 0
Everything is good! I feel great and have plenty of energy! The tasks I need to accomplish are getting done. I am doing things I enjoy in my spare time, and I feel good about how I am doing at work. I might be experiencing stress, but it’s typical, daily life things that I can manage easily.

Burnout Level 1
I am experiencing more stress and anxiety. I might not have a lot of extra energy for my hobbies, but I am trying to make time for them. My overall self-care, like making good food choices and keeping up with hygiene, are minimally impacted, and my functioning at work is good. I might not even notice that I’m hitting early burnout.

Burnout Level 2
I have no time or energy for hobbies, socialization, or things I find fun. When I force myself to do these things, I have trouble enjoying them. I am stress eating and not choosing healthy food, I am much more tired than usual, and I might be having trouble sleeping. I might be drinking more alcohol than average. Work is still good, but non-urgent tasks get put off more and more.

Burnout Level 3
My hygiene is taking a hit: I might be showering less and forgetting to brush my teeth. I am either missing meals all together or snacking on “junk” food. I am very tired but take a long time to fall asleep. I am irritable with my loved ones. My focus at work takes a hit; in addition to putting off deadlines, I notice I’m having trouble focusing in meetings but am keeping up in sessions and can push through with enough coffee. I’m also probably drinking too much coffee. I start having physical symptoms, like headaches, stomachaches, and sore throat.

Burnout Level 4
I feel physically sick, very anxious, and have few positive emotions. Things that would be mildly inconvenient normally give me feelings of rage. My sleep schedule is a mess, and although I can push through to the weekend, my work performance is not up to standards. I have no energy to interact with loved ones, socialize, or do activities that I enjoy.

Burnout Level 5
I am not functioning at all and need an immediate leave of absence from work.

I cannot think of a time when I have hit Level 5, fortunately, and I would like to keep it that way. Lately, I think I have entered Level 3. It could be worse, but I have plans in place to ensure I don’t hit Level 4. What are you doing to take care of you right now?

Animals in Therapy

Hands down, my favorite part of telehealth is meeting everyone’s pets. A close second is my clients meeting my pets.

A while back, I shared a story about my cat, Vera, and how she was affected by trauma. I’ve shared this story with kids at my practice for years as an allegory to some of their own experiences, and if my boss was not severely allergic to cats, I would train her as a therapy cat and bring her to work every day. Let her earn her keep a little bit.

Pictured: a freeloader

Research has shown that pets help people manage stress, especially those living with mental illness. Animals bond to their humans and respond to our emotions. Even pets with no special training often try to comfort us when we become upset.

Talking about pets has always been a great icebreaker with kids, but when a pet joins a session, even more options for interventions open up! Clients can explore how petting the animal makes them feel. They can look at their pet’s body language to practice social skills. With well-trained dogs, I’ve even had parents play Simon Says so the dog can model good listening for the child. Possibilities are endless!

Bringing pets into sessions has led to some awesome therapeutic work that would never have been possible in my “real” office.

Armani wants attention too!

PESI Presents: A Step-by-Step Guide to Successful Virtual Sessions with Children, Adolescents and Families

Friends, I have some very exciting news: on Monday, December 21 and Tuesday the 22, I will be presenting a certification training for telemental health with children and adolescents! The training will be live on those dates, but PESI will be recording the seminars and making them available for purchase to be completed at your leisure.

The brochure for my training

This training is something I have been working on for months. Before March, when a young child was referred for telemental health services, best practice was to refer them for in-person sessions. Of course, that has not been a safe option for quite a while now. I have had to scramble, adapt, and learn quickly, and now I get to share what I learned with other professionals!

My hope, by making telemental health accessible to a younger demographic, is to make mental health services available to kids living in rural or under-served areas even after we have found ways to make in-person services available again.

If you provide therapy services to kids, check this out!

Repressing Versus Compartmentalizing

As a therapist, I spend a lot of time telling people that it’s okay to have feelings, and it’s healthy to express those feelings. You can think of “bottling up” feelings like making a purchase on a credit card: you still have to pay later, and the longer you wait, the more interest accumulates. When we see someone have a huge outburst in response to a minor frustration, this is all the feelings from before coming out all at once.

You will pay for it later! (Photo by Pixabay on Pexels.com)

This does not mean that we need to let out every emotion all the time as soon as we feel it, though! To use a personal example, sometimes in a therapy session, a client might say something that gives me an emotional reaction. It would absolutely not be appropriate for me to burst into tears in the middle of someone’s therapy, so I compartmentalize that feeling to deal with when I am not working.

Compartmentalizing is like buying groceries with a credit card but then paying it off before it accrues interest. The difference between compartmentalizing and repressing is that you go back and deal with that emotion in a healthy way before it has a chance to fester or build up.

Be mindful of how you compartmentalize feelings, especially during times of high stress. It’s tempting to bottle things up – I will feel better now if I insist that everything is fine, but in the long run, I will pay for it with interest later.