V2 IJWC Spring 2023 Issue 75 International Journal of the Whole Child 2023, VOL. 8, NO. 1 Children and Families: Health and Wellness Games in Telemental Health with Children and Adolescents Jo Lauren Weavera, Jacqueline M. Swankb, Shatoi Scottc, Tonya Davisd aAlabama A & M University, bUniversity of Missouri, c-dAlabama A & M University Jo Lauren Weaver, Ph.D., LPC, is an assistant professor of counseling at Alabama A&M University. Her research interests focus on mindfulness-interventions, adolescent and young adult social media use, perinatal mental health and creativity in counseling and counselor education. Jacqueline M. Swank, Ph.D., LMHC, LCSW, is an associate teaching professor of mental health practices in schools at the University of Missouri. Her research interests focus on supporting the holistic growth and development of children and adolescents through nature and play-based interventions, counselor development, assessment, and international counseling. Shatoi Scott, Ph.D., LCMHC, CRC, currently serves as Assistant Professor and Program Coordinator of the master’s in counseling at Alabama A&M University. Her research interest explores rehabilitation counselor wellness, spirituality, and the intersection of trauma. Professionally, Dr. Scott has worked as a Licensed Clinical Mental Health Counselor for over ten years and holds current certification as a rehabilitation counselor. Tonya Davis, Ph.D., LPC-S, NCSP, is an associate professor of counseling at Alabama A&M University. Her research interests focus on psychological /psychoeducational assessment, biometrics, health disparities, technology/virtual reality interventions and mental health, strength-based coaching. Abstract The COVID-19 pandemic resulted in an increase in telemental health sessions, including transitioning clients to this counseling format that were accustomed to having sessions in-person. In using telemental health, counselors may need to find new ways to connect and engage with clients or modify existing ways for the virtual setting. This article focuses on the use of games within a telemental health environment in counseling children and adolescents. We examine the literature related to the use of game play and telemental health with children, discuss strategies to integrate games within a virtual counseling environment, and present considerations to implementing games in a telemental health setting. Keywords: games, telemental health, children, adolescents, counseling 76 Games in Telemental Health with Children and Adolescents While telemental health is not a new concept or approach to providing counseling, the COVID- 19 pandemic resulted in many counselors using telemental health for the first time due to lockdowns. This also required many clients who were comfortable with in-person counseling to transition to the virtual counseling setting. Counselors needed to consider how they could develop new strategies, as well as modify existing counseling interventions for the virtual environment. These include interventions commonly used in counseling, such as interactive games. Telemental Health with Children and Adolescents Telemental health can be provided in various ways, including live video, mobile apps, phone calls, and texting. For the purposes of this article, we are focusing on the live video medium of telehealth, which is synchronous audiovisual communication between the client and counselor via computer or mobile device. Prior to the COVID-19 pandemic, researchers endorsed the telemental health as a medium to improve accessibility and equity with mental health care for children and adolescents (e.g., Comer & Myers, 2016). Telemental health can help bridge existing gaps by solving issues of transportation and time commitment, reducing stigma, and avoiding waitlists (Child Mind Institute, 2020). Researchers also suggested that telemental health can be just as effective as traditional in person treatment for children and adolescents (Gloff et al., 2015). However, at the onset of the pandemic, only 43% of outpatient mental health facilities (N=8860) offered telehealth services (Cantor et al., 2021). Now, researchers predict the telehealth market will reach $266.8 billion by 2026 from $49.8 billion in 2018 (Child Mind Institute, 2020). In today’s world, children and adolescents are often familiar with engaging with others in virtual environments. According to the Children’s and Parents’ Media Literacy Tracker, 55% of children ages five to 15 use social media apps, 65% use messaging apps, and 97% use video- sharing platforms (Of Com, 2021). Additionally, the majority of children and adolescents likely participated in virtual schooling since the onset of the pandemic. Yet, to date, there is a dearth of literature that explores children and adolescents’ experiences and perspectives of telemental health services. However, a recent poll of parents (N=351) revealed 69% sought telehealth services for their child’s mental health services and 80% reported that telemental health is more convenient than in-person appointments (Child Mind Institute, 2020). However, counselors should not assume that youth will be comfortable with telemental health. Children and adolescents using telemental health services could be working with an existing or new counselor. Either situation requires acclimating to a new virtual environment. Researchers recommend adapting and using interactive activities to build rapport and keep the client actively engaged in session (Dueweke et al., 2020) such as therapeutic games. 77 Games in Counseling Counselors may integrate games within the counseling process to connect and engage with children and adolescents, known as game play (Schaefer & Reid, 2001). Game play has five aspects: (a) a goal, (b) competition, (c) rules, (d) interactions with others, and (e) increased cognitive ability (Reid, 2001). There are three main types of games discussed by Sutton-Smith and Roberts (1971): (a) games of chance where the outcome happens by chance (e.g., Candyland), (b) strategy games that involve problem solving (e.g., chess), and (c) physical games that involve motor skills (e.g., tag). Counselors may use games specifically designed for counseling or ordinary games not designed for a therapeutic purpose (Swank, 2008). Clinicians may also incorporate video games within counseling. While games can be appealing to different age groups, structured games are particularly appealing and developmentally appropriate for latency age children (beginning around age 7), as they transition from an interest in dramatic play to play more focused on rules (Bellinson, 2002). Some children and adolescents are reluctant to interact with a counselor, especially when they feel forced to go to counseling. Due to the appeal games have among children, counselors can use them to connect with youth. While therapeutic games may seem an obvious choice, children might be reluctant to play these games due to their obvious focus on therapy, such as games that emphasize talking, especially if they don’t want to come to counseling (Swank & Weaver, 2021). In contrast, children are familiar with ordinary games, and they involve multiple aspects that might be the focus of counseling (e.g., social skills [sharing, taking turns], following directions/rules, emotion regulation; Bellinson, 2013). Scholars have discussed multiple benefits of integrating games within counseling. Children often view games as fun; therefore, introducing games in counseling may help with developing a relationship with youth (Swank, 2008). The integration of games may also help reduce anxiety (Reid, 2001), and facilitate communication (Bellinson, 2002; Reid, 2001). Game play may challenge the idea that youth may have about counseling involving sitting with a counselor and being expected to answer questions by engaging them in an activity. Counselors can also observe children’s behaviors during game play as part of the assessment and diagnosis process (Swank, 2008). Game play also provides an opportunity to develop social skills (Bay-Hinitz & Wilson, 2005; Reid, 2001; Serok & Blum, 1983; Swank, 2008) through interacting with the counselor, peers when used in group counseling, and family members during family sessions. Finally, children can develop insight by reflecting on how the game play relates to situations in their lives (Reid, 2001: Serok & Blum, 1979), as well as engage in reality testing (Bellinson, 2002; Reid, 2001). This provides opportunities for problem solving (Swank, 2008) and skills building, including coping skills and emotion regulation (Swank & Weaver, 2021). Thus, there are multiple benefits of integrating games within the counseling process when working with children and adolescents. In telemental health, game play can be a vehicle to build rapport and possible ease the transition to an online platform for therapy. Game Play within Telemental Health Adapting existing activities and games can aid in acclimating to telemental health (Dueweke et al., 2020). For those clients working with a new counselor game play can be a way to cultivate 78 the therapeutic alliance, especially playing familiar games that can be therapeutically modified. For existing clients, playing games can help transition from in person to telemental health. We identified four types of interactive games that can be conducted online: a). board games, b). card games, c). art games, d). physical games. Board Games Interactive board games include both chance and strategy type of games that can be therapeutically modified. Battleship can also be played on a virtual medium and be made therapeutic by having each player share a certain information about themselves when they get hit. For example, each time a player “hits” the other’s ships they share something they like about themselves. Clinicians can change the topic each game dependent on the client’s goals in counseling. Other board games can be played both on a virtual medium or on a traditional set with the camera focused on the game set. For example, clinicians can prompt the client to share the classic board games they have at home and select from their existing collection. This could help the clinician tailor the activity to the client’s interest and promote engagement (Dueweke et al., 2020). Clients using games from home can be responsible for moving both the clinician and their own pieces as well as rolling the dice, if applicable. However, the client’s facial expressions may not be as visible. Clinicians may select from the client’s existing collection and modify the game to make it therapeutic (Swank 2008; Swank & Weaver, 2021). For example, for the game Sorry!, each player is prompted to say “Sorry!” when landing on the other player’s space making them return to the starting position. The player sending the other to the starting space must share a time they apologized or wish they had apologized. Clinicians can apply this same technique with other games, such as Trouble, where players can share an instance they got "in trouble” when sending the other player to the starting space. Card Games Interactive card games that can be played virtually may include shedding type card games (e.g., UNO) or matching card games (e.g., Go Fish). UNO can be made modified that each color represents an emotion (e.g., red is angry, blue is sad, yellow is happy, green is peaceful). Each time a player changes the color both players must share a time they felt the emotion associated with the color change. For example, players can share a time they felt angry when the color is being changed to red. For Go Fish, each time a player has to “go fish” they get to ask each other a question to build rapport. As therapy progresses, the clinician may wish to change this to specific topics that pertain to the client’s goals in counseling. Art Games For interactive art games, Pictionary is a game that can be played virtually and easily therapeutically modified. For the canvas, clinician may introduce the choice of using a virtual white board or a blank sheet of paper as a virtual white board may be difficult for some clients. Next, the clinician may use a virtual spinner populated with various feelings. The drawer will spin the spinner to determine the feeling then the player can be instructed to draw a). things that 79 represent the feeling, b). things that make them experience that feeling, c). the last or a time they felt that feeling, d). a coping skill related to that feeling. The clinician may select other prompts that relate to the client’s goals in therapy. Other topics may be included on the spinner such as coping skills the client has learned in previous sessions. The client may have more autonomy in this process by selecting their own feeling from another source such as an emotion wheel or their own knowledge dependent on the developmental level of the client. Physical Games Interactive physical games may include a therapeutic scavenger hunt or charades. Researchers recommend utilizing physical things in a client’s home environment (Dueweke et al., 2020). Hence, a therapeutic scavenger hunt can be an excellent means to build rapport and identify objects that can be coping skills. These scavenger hunts can have various themes. For example, a self-esteem scavenger hunt may include finding something the client feels proud of, or something that represents something they accomplished. For a mindfulness scavenger hunt, the client may identify for things that channels their senses such as five things the client sees, four things that make noise, etc. This scavenger hunt can be modified to the goals the client has in counseling. For charades, the clinician could use the spinner from the Pictionary activity, and have the client act out various feelings, coping skills, or past experiences. Considerations When conducting telemental health sessions, the clinician should also consider factors related to technology. Prior to the session, the clinician should be comfortable with accessing the virtual platform, including connecting to an internet source and troubleshooting basic technology issues that might arise (e.g., no audio). These platforms should be HIPPA compliant. For further guidance, clinicians should refer to their profession’s code of ethics. For example, counselors may refer to the American Counseling Association’s Code of Ethics (2014), specifically Section H: Distance Counseling, Technology and Social Media. When applying online games, clinician should consider the safety of the website (i.e., privacy), (American Counseling Association [ACA], 2014, Section H.2.d) and attempt to find a source that has no or minimal advisements. Clinicians should try to use sites that one has to send the other user an invitation to play or share the experience (ACA, 2014, Section H.5.c). Clinicians should limit the sites that the client could connect with other users sans invitation for safety reasons. Clinicians may use the share screen function for certain games if the child is younger or has trouble staying on task (ACA, 2014, Section H.4.c). Clinicians may need to set limits with the types of games that can be played during session as some clients may desire to show the clinician other online games that might not be therapeutic. Relationally, clinician should note these skills may differ digitally than in-person, particularly with children and adolescents (Orsolini et al., 2021). Clinicians should minimize any potential distractions in view of the camera, zoom in their camera so the client can see the clinician’s facial expressions, and maintain continuous gaze into the camera (Segar van Dyk et al., 2020). Clinician should use energetic tone of voice, exaggerated hand gestures, and facial expressions when working with younger clients (Orsolini et al., 2021). Clinicians may wish to play with 80 various telehealth backgrounds as younger clients may find that amusing (Segar van Dyk et al., 2020). Clinicians may also want to plan their instructions for game use, especially if the game is a traditional board game the client uses from their collection. In considering the counselor’s response to the client’s decision about whether to follow the rules of the game, Bellinson (2013) emphasizes the importance of remembering the purpose of integrating games within counseling. The purpose of using games differ by client; and therefore, counselors may address rule following differently for various clients. This may also differ based on the use of games in individual, group, and family sessions. Similarly, a client may cheat during a game for various reasons; therefore, the counselor may address it differently depending on the client’s goals. Bellinson (2002) cautions counselors to be careful about becoming involved in power struggles with clients related to following the rules and cheating. The counselor must also be mindful about what they are experiencing in the moment, as countertransference may also arise when using games in counseling. Counselor should reflect on their experiences with various games and what feelings arise for them when they play the games (Reid, 2001; Swank, 2008). They may choose to not have some games available due to their own reactions related to the games (Bellinson, 2002; Bellinson, 2013). Counselors also make decisions about whether they let the client win, with Reid (2001) emphasizing the importance of balance related to winning. Furthermore, when it is the counselor’s turn, it is important for the counselor to respond honestly, but for the response to also be relevant and appropriate for the client (Bellinson, 2002). When modifying board games, clinicians should be mindful of the amount of sharing required. In other words, if the players are required to share something with every turn, they may run out of responses, the game may become prolonged, and they may become disengaged (Swank 2008; Swank & Weaver, 2021). Conclusion Games are an easily transferrable tool from in person to virtual therapy. Interactive board games, card games, art games, and physical games can all be modified to be conducted virtually. Clinicians may wish to continue games played during in person sessions or introduce new games to keep virtual sessions interactive and engaging. 81 References American Counseling Association. (2014). 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