I have to confess; I have always been resistant to online therapy.  As a therapist, I believe in and understand the many non-verbal and biological components of psychotherapy. And, actually, this position is shared by many psychotherapists and is one of the reasons why there is such little research in telehealth in our field. Before March 2020 and COVID19 I had already started to explore the advantages of online therapy.  As a traveling art psychotherapist living in a mobile region, I have had clients who requested to continue their work with me as they moved, and I have honored these requests as much as it is allowed by licensing limitations.  I also explored my own Jungian analysis on a distance platform as there are no certified Jungian analysts in Dubai at the moment. And, even then I was still quite resistant to offer online services, particularly with children.

When we moved to our home offices, we offered our services and some of our families explored this new avenue with us.  We started with shorter sessions before moving to the full 50-minute session. On the first week of telehealth, I could sense a glimmer of the power of this therapy for my young clients. And, most of my insights were confirmed by science.

Firstly, the literature concludes that the therapeutic relationship can be adequately established in online therapy. And, this is the most important indicator in psychotherapy. In general, telehealth is a great stigma reducer and it supports inclusion as it facilitates access to mental health. There is now significant evidence of its effectiveness, particularly in the treatment of depression and anxiety in children and adolescents.  But most of the research is on CBT.

There is limited research about online art therapy, but I am sure this is about to change. Studies emphasize the need for secure, encrypted video technology, privacy, technology support, credentialed clinicians, and consistent feedback. The main challenge for art therapists is seeing the process of art-making and even the final artwork, as the screen can’t do justice to what has been created in the session.  And, it is not recommended for clients who have issues with reality testing and/or emotional regulation.  What works includes openness towards accommodations, asking clients to take pictures of the artwork, establishing a common vocabulary, and encouraging clients to create space for their art in their homes and in their family.  

What is significantly different in art therapy is that children establish a relationship with the art as well as the art therapist, this relationship with the art mediates and supports the therapeutic relationship holding the connection even in the physical distance.  When the art therapist is not there, your artwork and your connection with the art is there to support you and accompany you. Children deeply understand this and can connect with their work.

What I have noticed in my practice is that some of my young clients have shown empowerment as a result of the virtual platform.  The fact is that they are more in control, they start a session, and choose their space of comfort while also demonstrating mastery over the technological aspects present in the session.  As one of my clients stated: “I no longer need to be driven to see you”. This increased sense of control and mastery has been confirmed by research, telehealth can reduce the sense of risk, possible power imbalances in the relationship and lower dependency. Overall clients feel more responsible for their change.

The situation with teens is interesting as well, “in a 2016 study of teens in Australia, 72% of adolescents said they would access online therapy if they experienced a mental health problem, and 32% said they would choose online therapy over face-to-face meetings,” (wwww.verywellfamily.com).  But this is a whole other blog.

Ok, let’s wrap this up. Yes, online therapy is different, but different does not mean better or worse. It has its pros and cons, just like anything else; and it is not for everyone. What do we need to remember? First: have a good connection, privacy and access to art materials. Then, focus on engagement, with children the interplay of structure with a child-led emphasis appears to work best. Playfulness, exploration and humility go a long way.  This is an opportunity for children to work on their social behaviors, joint attention, perspective taking, storytelling and self-expression. An opportunity for children to feel empowered and able to take care of their own mental health.

As I sit in my home office, I wonder how face to face will feel when we start to create our new normal.  Even in our recent reopening children under 12 continue to access our services online. I wonder how some of my young clients will respond to having to come to the office and loose some of their newfound powers.  

References

Collie, K., & Čubranić, D. (1999). An art therapy solution to a telehealth problem. Art Therapy, 16(4), 186-193.

Cook, J. E., & Doyle, C. (2002). Working alliance in online therapy as compared to face-to-face therapy: Preliminary results. CyberPsychology & Behavior, 5(2), 95-105.

Hanley, T. (2009). The working alliance in online therapy with young people: Preliminary findings. British Journal of Guidance & Counselling, 37(3), 257-269.

Levy, C. E., Spooner, H., Lee, J. B., Sonke, J., Myers, K., & Snow, E. (2018). Telehealth-based creative arts therapy: Transforming mental health and rehabilitation care for rural veterans. The Arts in Psychotherapy, 57, 20-26.

Sanders, M. R., Baker, S., & Turner, K. M. (2012). A randomized controlled trial evaluating the efficacy of Triple P Online with parents of children with early-onset conduct problems. Behaviour research and therapy, 50(11), 675-684.

Schueller, S. M., Stiles-Shields, C., & Yarosh, L. (2017). Online treatment and virtual therapists in child and adolescent psychiatry. Child and Adolescent Psychiatric Clinics, 26(1), 1-12.

Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R., Prosser, S., … & Kenardy, J. (2008). Online CBT in the treatment of child and adolescent anxiety disorders: Issues in the development of BRAVE–ONLINE and two case illustrations. Behavioural and Cognitive Psychotherapy, 36(4), 411-430.

Stasiak, K., Fleming, T., Lucassen, M. F., Shepherd, M. J., Whittaker, R., & Merry, S. N. (2016). Computer-based and online therapy for depression and anxiety in children and adolescents. Journal of child and adolescent psychopharmacology, 26(3), 235-245.

Wong, K. P., Bonn, G., Tam, C. L., & Wong, C. P. (2018). Preferences for online and/or face-to-face counseling among university students in Malaysia. Frontiers in psychology, 9, 64.