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!

Mancala

“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 Pexels.com

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 Pexels.com (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 Pexels.com

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?

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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.

Scattegories

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 Pexels.com

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.

Thoughts On Self-Diagnosing

Many people struggle to acknowledge when they are having trouble with their mental health, and this happens for a few reasons. First, stigma about what it means to have mental illness can put people in denial about their symptoms. They don’t want to be labeled “crazy” or “unstable.” Second, mental health is health that relates to your brain. Your brain is the organ that is supposed to alert you when something is wrong, so when the issue is in your brain, it can be harder to label.

That being said, it is possible and common to notice mental health symptoms in yourself. This is especially true in the age of the internet, where education about mental health is more available than ever before, and people are more likely to realize that their difficulties aren’t just due to “laziness” (I hate that word, but that’s a topic for another day).

Photo by cottonbro on Pexels.com

Although the internet is also filled with false information about mental health, there are a number of helpful websites that can give good information about different mental illnesses, as well as online communities for moral support and to help people feel less alone. This, combined with poor access to mental health resources, can lead to people identifying with a diagnosis that has not been given by a mental health professional.

Now, as far as treatment plans go, an accurate diagnosis is very helpful because there is symptom overlap for many mental illnesses, and diagnoses with similar presentations might respond best to different treatments. This is why I spent five years in graduate school and why they pay me the…um, medium bucks.

That being said, no one knows you like yourself. Sure, OCD and anxiety can manifest similarly (or you can have both). Someone might come to me to be evaluated for OCD, and I might find that their symptoms better fit a diagnosis of Social Anxiety Disorder, but they were still right to notice that something was wrong and they needed support. But you would be surprised how often someone guesses their diagnosis before I tell them my professional opinion.

If you find yourself identifying with a set of symptoms, and engaging with that community helps you, I feel like that can only lead to more support for more people. The rise of telehealth should make psychological evaluations and treatment accessible to more people, but in the meantime, increased self-understanding and community support is a wonderful thing.

Get Grounded

Grounding is a mindfulness tool that helps us “detach from emotional pain” by “focusing outward on the external world” (Lisa Najavits, Ph.D.). When someone experiences a trigger and needs to pull themselves into the present moment and out of their body sensations, grounding activities help them do this.

Photo by Pixabay on Pexels.com

Look at the baby bird in the picture above. How many adjectives can you use to describe it? See if you can list 20 different words to describe what you see in the picture.

Notice how this activity shifted your focus out of your body and onto the photograph. Similarly, when someone feels stressed or experiences a trauma trigger, they can choose something in their environment and describe it in detail to focus their brain on the present moment rather than what is going on inside of their body. If someone is visually impaired, they can do a similar activity describing a sound they hear or how an object feels in their hand.

I’ve found grounding activities to be incredibly helpful for those with trauma as well as anyone working on better coping skills to regulate their emotions.

More grounding techniques can be found in my book, I Don’t Want To Be Bad!

Pictionary

Although I am not certified as an Art Therapist, I have done continuing education in art therapy and lead a group for teenagers who want to explore how their creative side can help them cope with mental illness. There are a lot of great ways to use art in a session, and even over telehealth, clients can bring their art supplies and work on something creative while engaging with you. But today I want to talk about an interactive activity that you can do in a telemental health session.

Photo by Sharon McCutcheon on Pexels.com

This website lets you play Pictionary in a private room with one or more clients at once, so it works with individuals or groups. You can specify the time limit and the number of rounds, and there is the option to add your own prompts. I have found that the prompts I input don’t show up unless I choose “Use custom words exclusively,” so if you want to go this route, I suggest creating a long list of choices.

One reason I like playing Pictionary with my clients is that it takes the emphasis off of making the image “perfect” and focuses more on the process of making the drawing. Some kids become frustrated quickly because their drawing doesn’t look how they picture it in their heads, but with Pictionary, the only goal is for me to be able to tell what they are trying to draw. This is great for emotion regulation, mindfulness, and learning to see art as a coping skill rather than a task that needs to be done a certain way.

There are some definite benefits to online Pictionary that don’t always apply in person:

  1. If you are trying to set a boundary with time limits, the game cuts you off when time is up, so you can use this intervention without having to be the “bad guy.”
  2. Auto-generated prompts are so handy!
  3. The website above gives you clues if time is running out, which can help with problem-solving skills.
  4. When using this activity in a group, the game automatically assigns an order – no arguments over whose turn it is or who gets to go first.

As with everything, there are also drawbacks:

  1. There isn’t an option to have no time limit.
  2. You have to choose words from options presented, and sometimes all three options are difficult to draw or are characters you or the child isn’t familiar with.
  3. It can be challenging to draw on a computer screen.
  4. On some devices, like tablets or smartphones, it can be hard to see the drawing tools, which can be frustrating.
  5. The words are presented in written format, and answers are given by typing them in, so this doesn’t work with children below a certain reading level. (For some kids who can read the words but have trouble typing, I have them just say their guess.)
  6. The game keeps score, and you cannot disable this option, so every game has a “winner” and “loser.”

Overall I really like Skribbl as a teletherapy option, but there are drawbacks to doing art on the device. You can get around the scoring, time limit, and written prompts issues if you use Zoom whiteboard or drawing on paper and holding it up to the camera instead of going through the website, but this takes away the option of automatically generated prompts.

Art is a hugely therapeutic tool, and I think we just have to determine for ourselves what form it can take in a telehealth session.

Photo by Marko Blazevic on Pexels.com

The Chicken or the Egg: Depression and Withdrawal

One thing many people already know about depression is that people who are depressed often withdraw socially. While it’s true that social support is an important component of alleviating depression, this sometimes gets misconstrued as, “If I want to help my loved one, I need to force them to be in social situations.”

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You might ask yourself, “Why can’t they just force themselves to be social? Don’t they know that would make them feel better?” The fact is, depression is exhausting. And for many people, social situations are draining. When a person is already exhausted, the last thing they are capable of is forcing themselves to be in a social situation.

Many of us have seen a loved one come out of a depressive episode as they have engaged more with others, so of course we want to recommend what we think will help! But there’s a logical fallacy at play here: often times, as someone’s depression improves, they want to be more social. It’s not that socializing is making them better, but the fact that they are getting better is what is allowing them to socialize.

Wanting to help a loved one who is struggling is a good impulse, but trying to force them to heal a specific way is never productive. You can be there for someone and show your support without trying to push them too hard, and you can help them get in touch with professionals who can treat their symptoms.

We’re All In The Same Boat

Last night, I sent out a tweet. Like most of my tweets, it probably wasn’t read by too many people, but it got me thinking, and I wanted to speak to this metaphor a bit more.

Since the pandemic started, I have heard and seen people stating that we’re all in the same boat. These comments seem to come from wealthy people who, aside from being asked not to socialize, aren’t being hit with the economic side effects of COVID-19.

Are we all in the same boat? Yes, but the boat is sinking, and some people are refusing to accept this fact because “The Titanic is unsinkable!”

Are we all in the same boat? Yes, but the 1% are safely life boats only filled to half capacity when we already don’t have the resources available to save everyone.

Are we all in the same boat? Yes, but some of us know we have a spot saved on the next life boat, and some know they will need to find some way to survive in the water and hope that help comes in time.

Are we all in the same boat? Yes, but for some it’s a moderate inconvenience, while for others it means death.

“We’re all in the same boat” doesn’t mean we are all going through the same crisis, and it shouldn’t be used to erase privilege or downplay what others are going through.