Tuesday, July 7, 2020

Therapy Tips for Telehealth

Using telehealth as a therapist can have its challenges. 

Here are some telehealth therapy tips to help:

Know your platform – Whatever telehealth computer system you are using, it makes sense to practice working with it so that you understand all of the features and nuances of the platform. Learn how to share your screen for instance and also make sure you know how to use comments and screen backgrounds. A lot of these features can be very helpful, especially in group therapy

Prepare your telehealth environment – Using telehealth is not usually physically as comfortable as sitting in an actual room with your client(s). So, it makes sense to prepare your telehealth setting ahead of time to make it as comfortable as possible. For example, if you are running a group make sure you have a drink handy, as well as a pad and pen to take notes if needed and even have things like pillows and blankets for your comfort especially with longer sessions like IOP groups which can be 3 hours or longer. It may make more sense to have two devices handy in case you need the extra screen to look something up during the session. Having enough outlets and chargers nearby is also something to consider. Of course, also make sure your environment is confidential in addition to being comfortable.

Log on to sessions early – When possible try to allow some extra time to make the online telehealth connection, send links, and troubleshoot problems when clients are unsure how to connect for the session on the telehealth platform. Its best to be the first to log on so you can anticipate problems ahead of time and be ready for them and then help others to walk through technical issues on their end.

Have back up plan for technical problems – For example if the sound is not properly working, make sure you have a cell phone handy with a number that you are comfortable letting the client(s) know about. If using a personal cell phone and you don’t want the client to know your number, get a Google Voice number 

Be ready to do more listening than usual – This is especially if you are more of an active talker in session as a therapist. There may be a delay using telehealth at times, so it can be difficult to interject in sessions if that is something you are used to doing. It can be much more challenging to slip in follow up questions if the client is on a roll and for some reason the telehealth platform is not cooperating when you attempt to do so. You may find yourself having to carefully choose your moments to speak in session when telehealth issues disrupt the flow of the therapy communication.

Prepare, prepare, prepare! – Preparation is a good practice when it comes to therapy in general but during telehealth sessions preparing ahead of time has even more importance. This is especially true when using activities or other forms of media, as in group sessions. Everyone who has done telehealth so far has learned that some ideas that work well in person may at times not translate as well to telehealth – especially when the telehealth system is glitching or problematic. It is best to have back up simpler activities in case something you planned just is not working well. www.takingtheescalator.com has a lot of stuff to choose from including group activities, power points, podcasts, and some videos for therapy sessions.

Have some “go to” questions and phrases ready to keep things going when sessions are lagging or just not flowing ideally -  When using telehealth for therapy, it is important to increase your “awkwardness tolerance”  - There are bound to be more awkward and uncomfortable moments when using telehealth, as communication can at times be strained or challenging when compared to talking in person. Having some prepared questions and other ideas can help break through these moments. Some prompts to start these types of questions/statements that can break things out of a funk may be something like: “Can you give me an example of…”. “It would be great if you could show/describe/expound a little more about …”, “Do you mind if I ask you about…”, “I would be really interested to hear your thoughts/views on…” – The key point is to be ready to kick start communication when it hits a lull due to telehealth issues.

Take advantage of telehealth “letting you in” – We often never get to see our client’s homes. Why not use telehealth to allow them to show you around if they are comfortable? Let them show their pets, their children, their backyard, or anything that they want to show you that is appropriate. These types of things can enhance the engagement process and help with building the therapeutic relationship. A real-life example: A therapist was working with a challenging teenager via telehealth and the teen was preoccupied complaining of hunger. The therapist allowed the teen to go to the kitchen to make a snack while they talked. This flexible approach ended up really helping the session build momentum when otherwise it had stalled. Allowing a restless client to take the session outside can be another way to let telehealth work for you instead of against you. (Always keep confidentiality in mind by reminding the client of this when new locations chosen)

Get in the habit of being more descriptive and ready to follow up for clarity and understanding when needed  (But not too much, don’t overdo it)- Keep in mind that using telehealth doesn’t allow us as therapists to have access to nearly as many nonverbal cues in communication which can be a challenge. Therefore, it makes sense to be prepared to take the extra time to follow up and ask your client(s) about their level of understanding of whatever it is you are discussing in session. Motivational Interviewing skills such as empathetic reflection, open ended questions, and summaries are essential tools for therapists in telehealth. Lack of nonverbal cues often necessitates making sure you are connecting by following up a little more than you may be used too when compared with in person therapy when a client’s body language, gestures and facial expressions are much more clearly seen in context.

Be flexible and positive (even when you don’t feel like it) If clients complain about telehealth, it can be helpful to show empathy by validating their concerns and even sharing that you too would prefer to be in person. However, the overall attitude about telehealth that you express is one of the most important factors in its success in your therapy sessions. Even if you do not like telehealth, embrace the challenge with as much positive energy and enthusiasm as you can. By contrast, if you go into telehealth sessions with dread and apprehension, it will likely show to your clients. It can help internally to remember to be grateful that telehealth is allowing you to keep working when otherwise you may not have been able too. Always try to look at the bright side of things even when telehealth can feel like an emotional grind as well as a technological nightmare at times. Telehealth, with all its flaws is still a much better reality than a world with no telehealth in times of need, so it is important to keep that in mind. “Let’s all do what we can to make the best of this” is a great way to look at telehealth challenges both with yourself and with your clients especially when things may not be going as smoothly as planned in telehealth sessions.

Practice self-care – We tell our clients all of the time to use coping skills and to establish healthy outlets to get through challenging times. We, as therapists need to practice what we preach for ourselves, especially when using telehealth which can be stressful. Have a plan for mini “doses” of self-care throughout the day by taking “two minute vacations” and giving yourself time to refresh by breathing, getting up for a minute to walk around, having a healthy snack, or doing whatever you know how to do to relax and refresh your mind, body and spirit. Also, at the end of the day a routine of healthy self-care, fresh air, exercise as well as positive outlets to disconnect and detach so you can “recharge” can make such a difference in a telehealth therapy environment.

Taking the Escalator Tools for Therapists (Click to view)

Wednesday, July 1, 2020

Describe, Draw and Describe

Describe, Draw and Describe

Intro – This is another activity that translates well to telehealth but also works face to face. The process of this activity directly corresponds to the title, which is self-explanatory:

Describe: The counselor or group leader should read one of the picture descriptions provided or use one of their own. When reading the description, try to use feeling and read the description in a slow, expressive manner so as to give the listeners time to think, feel and use their imagination

Draw: While the counselor is reading the selected picture description, each person in group should draw what they are hearing and feeling. There is not wrong way to do this as the focus of this activity is using art for self-expression, and this is in no way an art contest.  If someone feels that they are terrible at drawing, it is okay as the group has to agree that art is not to be judged on appearance but again the art is more of a means helping identification and articulation of one’s personal thoughts and feelings

Describe: When everyone is done drawing, the group should take turns showing their picture to the rest of the group. On telehealth, this can be done by holding up the picture in front of the camera so others in the group can see it*. While showing the picture to the group, the person who drew the picture should describe what they drew while expressing what they were thinking and feeling when drawing various aspects of the picture. At the end, the person who drew the picture should give a final explanation about what the picture means to them and how they felt overall about the picture. The counselor should be prepared to draw out the group participants thoughts and feelings with open ended questions to stimulate discussion *If anyone is really resistant to showing their picture, the counselor can provide the option for the picture to be explained without showing it. However, people in group are encouraged to take a chance and be willing to share without fear of judgement.

Take turns and allow everyone to show and share about their picture. If there is time the group can try more than one of the descriptions

Sample Picture Descriptions:

Thought/Feeling - Based Narrations for Drawings (Imaginative – free form)

“The Future I Hope For”
(Read title first) - ”The Future I Hope For”….What is that to you?...Think about where you want to be one day…when you are where you want to be…Think about why you are here today…and where you will be when you know that you have achieved your goals…You have the life you want…You have the people around you that you want to have in your life…You feel the way you want to feel when you have finally achieved your goals one day…Think about what your life will really be like…Keep it real and not just a fantasy…What will you be doing…What will you be thinking?…What will you be feeling?…What will the people you care about be thinking and feeling…What will this new life that you want so badly be all about to you?

“My Positive Escape”  
(Read title first) – “My Positive Escape” – Now that you are working on recovery from whatever issues you are facing, what do you do for a positive escape…Where do you go?...Who, if anyone is there with you?...What are you doing with yourself?….What is it like to feel the peace and satisfaction of taking a break from stress?....What’s it like to get away from your problems for a little while?…What are you thinking about when you are in your happy place, doing your happy thing?…What are you feeling?...What is happiness for you…

“The World I Want”
(Read title first) – “The World I Want” – This world has a lot in it that needs to be fixed, but for a few minutes think about the world you would want…What is it like there?...What are people like in your world?...What are some of the laws and rules…Who is there with you in your world?...What do you do in your world?...What are you thinking about it your world?...What does it feel like to live in your world?

“Rising from the Chaos Toward a Life of Peace”
(Read title first) - “Rising from the Chaos Toward a Life of Peace” – What was the chaos in your life that you want to leave behind…What specific things are in that chaotic life that you are letting go of…How do you feel as you are letting go of the things you don’t want or need in your life any longer?…Now what is it like to move forward toward a more peaceful life?...What is included in this new peaceful existence?...Who are you bringing with you into your new life?...How does it feel to move toward a better life and to feel inner peace?...What is this new life like?...

“What’s Up with You Right Now?”
(Read title first) - “What’s Up with You Right Now?” – How are you doing?...What’s been on your mind?...How have you been feeling?...Let these thoughts and feelings guide your hand as you draw…Draw whatever comes to mind when you think about how you are doing right now…What do you want right now?…What do you feel right now?…What is it like to be you right now at this point in your life?...Let your hand just draw whatever it wants, there is no right or wrong…

“My Future Goals”
(Read title first) – “My Future Goals” – Start thinking about some of your goals and how you want to draw them…Use your imagination when choosing pictures or symbols to represent your goals…There are no right or wrong answers here, just let the pen draw your goals in a way that feels right to you…Try make sure goals from different life areas are represented…Recovery goals…Career goals…Family Goals….Relationships Goals…Health and Physical Goals…Financial Goals…Spiritual Goals about meaning and purpose regardless of what you believe in…Include any other goals on your mind that are meaningful and important to you

“Values and Priorities: What Means the Most to Me”
(Read title first) - “Values and Priorities: What Means the Most to Me” – Think about what is important to you…Think about the people…the things…and the ideas that mean a lot to you (like freedom, love, respect and any others that mean a lot to you)…Use different pictures and symbols to represent your values….Place things in important places in your picture to show your priorities if you would like to…Think about how these important values make you feel as you draw…

Descriptive Narrations:

“The Field” – Draw a field, anywhere and anyway you want...Draw yourself in the field doing anything you want…Put some animals in the field with you…Now add some people…Add trees, mountains and parts of the landscape…Add some water: a river or a lake or a waterfall…Make sure to add some flowers and other plants…How does it feel to be in this field you are drawing…What is going on in this field?

“The Movie” – Create a scene from a fictional movie of your own imagination…Think about your setting and start drawing…Is this an action movie or a drama or a fantasy or sci-fi or perhaps a love story?...Make sure to put in your movie characters…Fill in the background with details…Think about what is going on in your movie scene and let yourself draw…How are the characters feeling?. How do you feel creating and then watching this scene?

“The Group” – Draw a scene with a bunch of people in group therapy…It should not be this group but a group from you own mind… What kind of group is it and what is being achieved in the group by its members? …
Think about the different kinds of characters and personalities you are putting in the group…What is everyone doing?...What kinds of behaviors are going on in the group?...What is the counselor or group leader doing?...What is he or she feeling while running that group?...What are different feelings people in the group are experiencing?...

For additional ideas for drawings see Suggested Topics for Artistic Expression or Journaling

Sunday, June 14, 2020

Declare, Disclose, Display

Declare – Disclose – Display

This activity can work well over telehealth but can also be done in person. The rules are simple: Each person should take a turn and on their turn, they can choose one of the following:

Declare: v. say something in a solemn and emphatic manner. In other words, tell us how you really feel

Disclose: v. to make new information known, reveal. In other words, tell everyone the truth

Display: v. to exhibit or make visible. In other words, show us

The counselors running this group are encouraged to come up with their own ideas but below are some suggestions that you can use after the client chooses Declare, Disclose or Display:

How do you really feel right now about where you are in life?

Tell us about something that makes you happy even if it may not seem to be that important
What is one thing that makes you-you?
How do you feel about feelings?
What is something that you believe in strongly, even if you don’t always tell everyone
If you were in charge what is one thing that you would make a priority?
What is one thing that you feel is an injustice in the world that you wish you could change?
Tell us about someone or something that you truly love and why
What is a source of hope for you?
What is something unbelievable that happened in your life?
Beside the obvious materialistic or pleasurable things you may do, if you had a billion dollars what is one meaningful thing you would do?
What is one positive thing that someone has done for you that you will never forget?
What is something you have done that took courage?
What is something about you that shows you have inner strength or the ability to keep going without giving up?
Who or what do you feel a lot of compassion for and why?

When is one of the last times you can remember making a fool out of yourself?
Have you lied or hid something in this program, if yes tell us about one time
Tell us about a time when you disagreed with your counselor or someone in this group, but they ended up being right
What is a fear you have that you may at times try to hide?
What is something that you sometimes feel insecure about?
Fill in the blanks: If ____ knew about _____ then I would be _____
What is one thing that you sometimes think about more than you should
What is something that your family doesn’t know about you?
What is something strange or unusual about you?
How long ago was the last time you thought about running from your problems and what kept you from going?
Tell us about the last time you cried or got choked up emotionally
What is something embarrassing or that you may not be proud of that makes you laugh?
Is there a song or movie that many people hate or make fun of, but you love?
If you were an onion and someone peeled all the layers, what’s inside?
Fill in the blank: My least favorite thing about ____ is ______


Show us a tattoo, birthmark or scar and tell us about it (Appropriate places only, no private parts please)
Do an impersonation of anyone that the group may know (Please do not be mean or insulting)
Try to rap or speak in poetry about a topic for the group and then explain what you meant
Show the group something that you have in your pockets or in your wallet and explain what it means to you
Show the group something in your phone and tell what it meant to you
Do some chair dance moves for 20 seconds (See if someone in group will make a beat)
Show the group one of your best strange faces
Keeping it appropriate what is a unique body part that you can show
Sing (or if you can’t at least recite) a few bars of one of your favorite songs
Grab something within reach and try to sell it like a commercial
While the rest of the group is silent, see if you can make weird noises by yourself for 20 second while everyone listens
Act something out (charades-style) and see if everyone can guess it
See how long you can stare forward without blinking
Fake laugh for 20 seconds and see if it turns real
Sing, or at least recite a show’s theme song that you memorized

Monday, June 1, 2020

Duplicity: The Story of Addy

The COVID-19 Pandemic has increased the use of telehealth instead of face to face treatment. Due to the decrease in social contact, many treatment providers have found it to be increasingly difficult to know what is really going on with group members when they do not honestly disclose the truth about substance use. This story and follow up questions are designed for group members who may be concealing their substance use (or considering doing so) to honestly self examine the choice to be up front and honest as opposed to trying to live a "double life"

Introduction – The following story is an allegory. An allegory is a story with a greater meaning. You will probably soon figure out the meaning behind the story. As the story is discuss, please keep in mind, the purpose of this exercise is for self-inspection and insight.
This story is not meant to open the doorway to finger pointing, accusing, blaming or judging of others in the group. It is for learning about and looking at yourself. Also, there is no expectation that anyone make any confessions, and no one should feel judged or expected to say anything that they do not want too. Now please focus for a few minutes and listen to the story of Addy the Caterpillar:

Addy –
All the caterpillars were eating leaves and their lives got out of control. Eating leaves was fun at first but soon it became an obsession and all the caterpillars did was eat and eat and eat and eventually eating leaves took over their lives. Finally, an instinct kicked in with all of the caterpillars which told them it was time to change and grow. All of the caterpillars made their cocoons and started their transformation. All except one
One caterpillar who we shall call Addy was very smart. In fact, he may have been too smart for his own good. Addy knew that going into the cocoon was hard work and doing all of that changing was going to be a long process and at times painful struggle. Another problem that Addy had was that he didn’t want to stop eating leaves. He knew he was out of control, but he wasn’t ready to stop his leaf eating habit just yet. Addy, being very clever, came up with a plan.
When all of the other caterpillars when into their cocoons, Addy pretended to make a cocoon. He just worked on the outside so it would look like a cocoon, but it was just the mere shell and no real change could happen inside of it. As the other caterpillars went into their cocoons, Addy pretended to go in his, but as soon as the others were all gone, Addy came right back out and started eating leaves again with no one to bother him.
After a few weeks of enjoying his leaves Addy could hear the other caterpillars coming out of their cocoons. Addy had to come up with a new plan so the others couldn’t figure out what he was doing. Addy, being as clever as he was, got two colorful leaves and glued them to his back to appear to be a butterfly like the others.

Soon as other caterpillars all came out as butterflies, Addy pretended to be one of them. The butterflies had changed and now were eating nectar, but Addy still was hooked on leaves. This time however, Addy had to eat leaves in secret when none of the other butterflies were looking
Over time the other butterflies started to notice something wasn’t right with Addy. He just didn’t look like a healthy butterfly like they did, and he wasn’t growing and learning to fly. The other butterflies would periodically check in with Addy and ask him things like “is everything OK Addy, something doesn’t look right” but Addy would always insist he was feeling fine and that he was doing great and making awesome progress as a butterfly, even though he was only pretending. With time the other butterflies couldn’t help but notice something was wrong with Addy and he was no butterfly. But Addy had spent so much time and energy trying to fool them, so they all stopped asking and just wished him the best. They all knew something was wrong with Addy, but they had their own lives to worry about as they were butterflies and it was time to move on
Eventually all of the butterflies started to fly away but Addy kept up his charade, always making excuses why he wasn’t flying like the rest them. Soon all the other butterflies were gone and by then Addy’s fake wings had fallen off and there he was again eating leaves, living the life of a caterpillar. Addy reflected on his life and he was truly disappointed as all of his butterfly friends had grown up and flown away and he was stuck alone living the same life he had been living with no progress. Addy regretted not taking the time and putting in the effort to become a butterfly because being a caterpillar for this long had become tiresome and dreadful. The leaves were no longer as enjoyable, and he was alone and afraid. Addy thought to himself “why didn’t I just speak up and ask tell the other butterflies about my struggles, they could have helped me, and I could have been a butterfly right now!”

Group Discussion

What is the meaning behind the story? – Obviously it is an allegory about addiction and duplicity

Duplicity - deceitfulness in speech or conduct, as by speaking or acting in two different ways to different people concerning the same matter; double-dealing. Another way people often describe duplicity is “living a double-life”

Again, the rules for discussing this topic is for 
No judgment
No accusations
No one is asking anyone to admit or deny anything – Just food for thought -for YOU as an individual


Can anyone identify with Addy’s story at any point in their lives? Living a double life can be common in the process of addiction.

Why do people choose to live a double life when it comes to addiction and sometimes even when a person is supposed to be changing or recovering?

Why may it be even more tempting to live a double life during a situation like the COVID-19 pandemic (Think about how it may feel like it is easier to hide things)

What is the eventual outcome of living a double life?

Sunday, May 17, 2020

Return to Normalcy

This paper is for group therapy especially made in response to the COVID-19 pandemic, however it is useful for other life situations as well. This is probably being released prematurely as any real semblance of a  "return to normalcy" looks like it is still unfortunately still a way off in many areas. Still, hopefully this can be a tool when the time is right

Keep in mind: The idea of what is “normal” is difficult if not impossible to define and it often changes as quite often there may be a “new normal”. For the purpose of this exercise, we are referring to situations when there is a serious change, and then things go back toward the way they were, even if a true sense of things being “normal” or the same again is not possible.

Situations that would be examples of a “return to normalcy”:

Return from quarantine/social isolation as in the COVID-19 pandemic

Return from incarceration or rehab

Coming back from being sick or recovering from a medical procedure for an extended period

Questions for thought and discussion:

What happened? What has been your experience with this “return to normalcy” situation for you?

What is different about you now...



Spiritually (Your beliefs, how you view the world, the future, your place and purpose in the world, etc.)

What will you take with you from the experience? (Things learned, new viewpoints, new attitude, etc.) – Consider some of the following life areas and if you have learned or gained anything in these areas:





Positive Qualities – Review this list and discuss if you have changed or grown with any of these:
  • Endurance
  • Persistence
  • Patience
  • Faith
  • Hope
  • Courage
  • Gratitude
  • Other?

What do you still need right now? Consider what you still may need in the following life areas:

Family related
Other needs?

PLAN – After reviewing all of these areas – What is the plan for the return to normalcy in the following areas:

Immediate plan- What are you going to start working on right away to adjust?

Short term plan – What are you going to focus on for the next month or two?

Longer term plan – Where do you see yourself when things are back to “normal” for you (When you are back to where you want and need to be, or at least closer to it if that is not possible)

Thursday, May 7, 2020

Due to Unforeseen Circumstances: Adapt or Collapse

Introduction – This activity was developed in response to the Covid-19 Pandemic, but the content can be used for any situation where an individual or group is forced to adapt to sudden or unexpected changing circumstances

The COVID-19 Epidemic has forced people to learn about how they handle change because this situation forced change on everyone involved, to varying degrees. Other life situations can do the same such as:

  • Suddenly losing an important job or a major financial change
  • Finding out you or someone you are close with are seriously sick or disabled
  • A serious accident or natural disaster
  • Losing a loved one unexpectedly
  • Going into or coming out of a controlled environment

(There are other examples as our lives, our circumstances, and the world changes)

Consider some stages to the process of adapting to these types of unforeseen circumstances (like the COVID-19 Pandemic)

As a group try to answer all of the questions

Shock – In the shock stage, we may feel surprised.  Believing what is going on around us can be hard. This can be normal for a while however shock can lead to denial. People who stay in shock do not adapt.

Were you in shock at first? If so, what was that like?

What would it be like to be stuck in the shock stage? (How would someone who stayed in shock and could not get past this stage act?)

How do people get stuck in the shock stage?

How do people successfully move past the shock stage?

Venting – Once shock is over and reality sets in some venting and complaining may often follow. This may feel good at first but after a while can become very counterproductive

What are some things you wanted to vent about with this situation?

What happens when people get stuck in the venting stage? How does that happen?

How do people successfully move past the venting stage?

Assess – Next comes the stage where we need to figure out what we are going to do.

What changes did you assess that you needed to make- or still need to make, in order to successfully adapt?

Why is action needed next?

Action – Assessment is not useful if we don’t do something with it by making decisions and taking action.
What is it like when people fail to act when change is happening?

What actions have you taken or still need to take to keep successfully adapting, thriving and/or surviving in spite of what is going on?

People who take well thought out action are the ones who adapt others who get stuck may collapse

Ending with what is positive – Discuss the following as a group:

Even when bad things happen, people can sometimes* experience what is called posttraumatic growth. A simple way to think about posttraumatic growth is to think about ways that your personality and lifestyle has changed for the better in spite of all the bad that happened.

*Unfortunately, posttraumatic growth is not a guarantee and does not always happen, but it is far more likely to be experienced by people who adapt to try to make the best out of bad situations and attempt to stay as positive as they can in spite of any loss or pain they may have experienced

Have you experienced any of the following aspects of growth from this experience, and if so how?

Improved existing relationships (especially with those close to you and who may have shared the experience with you, like family and friends)

Rebuilt old relationships – People from the past or who you were not as close with, who came through and connected with you or helped you during this time (Distant family or old friends who you reconnected with)

New connections and relationships – Forming new connections with resources, ideas, opportunities, or people who you can keep in your life even after the situation is over

Lessons learned that can be used again in the future (What to do, what not to do, what works and what doesn’t)

New positive habits and routines (Things that you started doing during the situation that are good for you that you may choose to continue doing in your life)

An increased feeling of inner strength and resilience (The ability to bounce back in the face of adversity)

An increased sense of gratitude


Monday, April 20, 2020

Breaking the Ice on Telehealth

So many people are using online platforms for group therapy like Zoom these days and one of the most common challenges can be engaging the group. These activities are more on the fun side and are designed to engage group to participate and share using online platforms

Some of the titles - 

  • Show and Tell
  • Pet Show
  • Picture Show
  • 10 Questions to Guess What I am Holding
  • Talent Show
  • Scavenger Hunt
  • One Minute Monologue
  • Last Person Standing Trivia Challenge
  • Juke Box
  • Two Minutes or Less
  • Chat Room
  • Hot Potato
  • Unique
  • Anonymous Feedback
  • Pulling the Strings