Online Therapy From Behind The Screen 

Online and remote therapy has been around in UK since the mid-90’s. I’m one of many psychotherapists who moved my practice online when the recent pandemic meant I was no longer able to see children and young people in person. In this article, I’ll be sharing what I have discovered since becoming a qualified cybertherapist. I’ll be addressing some common misconceptions about online therapy as well as shedding light on how I have adapted trusted therapy concepts to practice in new ways. Hopefully, you’ll come to share my excitement and passion for the potential of using new avenues to connection through digital technology, creativity, emotional mental imagery and immersive experiences to go beyond physical spaces.

Digital technology has taken centre-stage in the lives of children and young people and has become embedded in every level of their education, social activities and work. It is now a key element to equipping them for life in the 21st century. Online therapy can provide a choice and a culturally appropriate route into their world; a way to build the therapeutic relationship around the way they choose to engage, and the chance to ‘open up’ in in a space that is not controlled by adults.  

Benefits of connecting and communicating online:

Children and young people seldom refer themselves for mental health support, so it is often left to adults to make judgements and to choose the way that they access therapy. However, it is sometimes hard to go beyond our own concerns around screen fatigue, struggles with cyber security and experiences of motivating stressed children to learn online. It’s not always clear to a see how children, who are driven by their emotions and communicate through their behaviour, can benefit from talking through a screen. Therapists can sometimes assume that a screen will limit our ability to use our senses and intuition to connect in therapy. I like to think that a screen is simply a display window and if we really want to connect online, we need to use the device, and a range of apps and tools to their full potential. This includes ensuring that we as therapists are trained, prepared and equipped to facilitate this specialist way of working, and to recognise how it differs from simply doing face-to-face work behind a screen.

Far from being a limitation, the screen can provide a window on children’s internal world; it can significantly change what we expect and what we take for granted about being seen. During the session, the therapist can help by verbalising what we would normally experience silently. I have found that children feel empowered to describe what’s happening in the parts of their bodies that I cannot fully see, and it’s a great metaphor for exploring the hidden parts of themselves. There’s an abundance of powerful ways for all ages of clients to be ‘seen’ online through mirroring, and creating emojis, avatars and characters that represent their body language, in addition to body-mapping technology which can bring awareness to unseen internal feelings in unimaginable detail.  

For some children the screen provides an essential physical distance between themselves and the therapist – this is especially important for children from some ethnic minority groups and those who experience neurodiversity, disabilities and specific learning needs. For them, being in proximity, in person can evoke a heightened sense of anxiety and feelings of powerlessness. Practicing online has enabled me to offer more flexible, accessible sessions for these children, and a choice of location which is important for children who experience disproportionate levels of exclusion from school.

In my view, working online, whether completely or as part of a hybrid model of practice, is an ethical response that helps me to reduce inefficient processes, unnecessary mileage and my carbon footprint. It’s a small but important contribution to ensure that supporting children’s mental health does not come at a cost to the planet they will inherit in the future.

Beyond the boundaries - How do we do online therapy:

The space we inhabit has a deep impact on how everyone behaves. Practicing online can often leave therapists feeling stranded and disorientated, like we’ve left the safety of the physically containing therapy room, the bedrock of many counselling and psychotherapy frameworks. As ‘digital natives’ children can feel more confident with technology than we do; it’s essential to manage this imbalance along with our anxieties so that we can stay attuned with the energy and excitement children and young people often bring to the therapy space.

There’s lots we can learn from frameworks used by therapists who work outdoors. Their experiences of managing with forces in nature can also teach us about working online. Some children’s flourishing IT skills can also feel like a force of nature and working online needs a clear therapeutic framework in order to remain client led. No matter how well we prepare, there will always occasional issues that can make a huge difference to the session. I often help children and their supporting adults to set up their devices, apps and online accounts so we can work together in the therapy session. Demonstrating good IT skills has become an important way to ‘hold’ children and adults; at the same time, it’s also vital to stay curious about ruptures and real-life mishaps.

Online therapy is not driven by speed and convenience, unlike many online options in our lives. I feel it demands a more complex and extensive list of ‘must-haves’ than face-to-face work, extending our usual list of contracts, policies and routines. I’m amazed by the specialist knowledge and skills needed to set up some of the most popular video games as a therapeutic intervention. Training and development at trainee and practitioner level is imperative to ensure that we give sufficient focus to safety, security and privacy with a wide range of online tools.

When I’m working online, children seldom sit still, and so long as I provide a variety of ways to engage their senses, they will choose or suggest ways to participate in the session. I find that younger children adapt well to smartphones and tablets that enable them to move around their space. They often project their feelings onto the device (especially if it belongs to a parent) and use their intuitive senses and a natural inclination to share their world through a camera. The therapy session can sometimes feel like an ‘All Access’ pass to their lives in the same way that children use video stories and live streaming on today’s social media sites. It’s not unusual for me to be shaken, dropped, thrown into rubbish bins and left underneath duvets; it is a particularly vivid way to share children’s experiences. For some, it’s important to use the device to project their feelings of being muted and disconnected. As a result, working online can evoke intense feelings, especially when we need to stay present, and connected despite coping with dizziness, disengagement and displacement.   

Exploring online therapy spaces, tools and interventions

Online and remote therapy comes in many shapes and formats – it’s common, but not limited to use phones, tablets, laptops and computer screens and VR viewers / head-mounted displays sharing text, emails, video-calls, images, models, films and music. It embraces many of today’s digital technologies including animation, virtual reality, augmented reality, 3D modelling, digital art, avatars to name but a few. Every client needs a dependable, bespoke format, considering the device they are using, the operating system, location of the sessions, their age and presenting behaviours. All of these have an impact on the way we work together and the online interventions we use.

There are lots of ways to create and manage the space where we meet for regular therapy sessions online. I use an online platform with a focus on 3D to create imaginary activity rooms that can be accessed on a variety of devices. Whether therapists use a virtual room or make use of the physical room that clients see online, it’s important to provide a way to access all the apps, games, activities and interventions that we use during our sessions. Wherever we and our clients are physically located, we need to be extra careful to establish rules around privacy and confidentiality.

I find that some simple adaptations from my face-to-face work can help to make online work feel safe and contained. When we connect on a video-call I draw attention to locking the online meeting room in the same way that I would naturally close a door and use a ‘private – no entry’ sign. I encourage supporting adults to provide a private box to hold all the creations children make on their side of the screen, and we also have a secure, encrypted folder for their work online. I sometimes print a 3D model of an object we’ve created in our sessions or send children an object that represents our work together.

I like to describe the different ways of working online as a ‘spectrum’ of connection. At one end of the scale, therapists can use the screen of our devices as a 2-way window to observe what is happening in the client’s space. Children can bring their favourite toys, activities, objects (and sometimes pets) that matter to them. This is a useful way to use tactile media during online work, so long as therapists agree the clearing-up process with the supporting adult! Alternatively, the therapist might hold the objects and interventions on their side of the screen. With clever use of the video camera and additional devices controlled by the therapist, we can create the feeling of searching around the room, allowing children to select what they want to play with, just as they would if we were physically together.  

The next level of online engagement involves sharing an activity together on the screen. This allows children to select their activities and control features such as size, scale, colour and various features of animation. I find it fascinating to explore the transference and countertransference that happens in those moments when I relinquish control of my screen, especially to younger clients.  

Virtual playrooms create the feeling of being together in an imaginary space. An online playroom can be an image presented on a slide, containing links to different games and interventions or a model of a 3D environment where children can enter, tour and play. Children often enjoy using themes from their favourite games and films as backgrounds, and with the ability to record sound, images and videos within may apps, it’s not hard to combine the tools you use and take imagination to a whole new level. No matter how or where we choose to connect, there’s plenty we can do with green-screens, backgrounds, lighting, cameras/videos and sound to make the ‘windows’ of our screens into exciting, imaginative and welcoming therapy spaces.   

A further level of engagement involves being immersed in an online environment that belongs to neither the client nor the therapist; often using video games. Older children can enjoy using avatars to embody different personas and embrace life in imaginary worlds. Cameras allow us to move around these spaces and explore scenes from different angles and multiple perspectives, all of which present a powerful way to look at children’s inner world of experiences.

Although several of our ‘digital native’ clients have played and inhabited imaginary kingdoms and realms in the gaming world for many years, this is a hugely exciting development for online therapists. There are hundreds of multiplayer games and apps, some of which are designed specifically for use in therapy (eg. virtual sandtrays) and other ‘sandbox’ games which can be adapted for therapy interventions. Online versions of traditional board games also lend themselves very well to therapeutic work and interventions, the main challenge is to set up all online environments so that they support the therapeutic frame, with safety in mind always. Personally, I enjoy creating activities together with children – they are sometimes highly skilled in digital arts, animation, sculpting and 3D modelling, and game development as a result of the technology they use in school. We can explore every part of the images and objects they create and can literally put ourselves into the frame to experience what has been crafted both above and beneath the surface level. This can provide a powerful insight to sub-conscious feelings and for me, it is an exciting way to extend what we can usually do using our imagination and physical objects in face-to-face therapy. VR takes this concept one step further – the VR viewer or head-mounted display blocks out our natural surroundings leaving young people and the therapist fully immersed in the virtual space and the intervention we have chosen.

Although it is exciting to use our senses to experience online what children and young people are imagining, the impact of bringing ¬imaginations to life can sometimes become overwhelming and we need skills to help clients to feel regulated and grounded in their bodies. Both children and adults can experience physical symptoms when moving around in specific virtual environments, causing our bodies and senses to become out of synch. Even on a small screen, some children need support before their hand-eye co-ordination can work effectively with built-in controls and cameras. It is imperative to weigh up the risks and protective factors for all forms of therapeutic support, and this applies equally to online therapy. All technology-based interventions, especially with children and young people, should be used with caution and with ongoing clinical supervision.

For me, the greatest benefit of online therapy is the potential to take tried and trusted concepts to new dimensions using emotional imagery. Online therapy has come a long way over the last 30 years. It is my hope that with specialist training and tools, therapists will continue to use innovative, creative ways to work remotely with a wide range of children and young people with all levels of need.

Images have been created for illustrative purposes only, and are used under licence and/or permission from:

• ProReal World –

• Virtual Sandtray App®© –

• CoSpaces Edu

• Mycybertherapyspace VR ™


The Sunflower Network provides a platform for professional community members to publish articles on this website. The views expressed in this article are those of the article author.

Written by

I am a qualified and experienced Cyber Therapist with specialist skills using digital creative arts and emotional imagery. I hold an MA in Integrative Child Psychotherapy, and extensive training in using avatars and a wide range of VR tools for telemental health. As both a care-leaver and adoptive parent I bring a holistic view of family life and child development, and my personal experience of dyslexia and autism has informed my approach to neurodiversity. I am also qualified in Mental Health Advocacy and Therapeutic Life Story Work.

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