Imagination and Play in
Teletherapy with Children•
Lynn Borenstein

The author describes how, during the COVID-19 pandemic, clinicians
embraced telehealth for vulnerable children struggling with intense feelings, learning challenges, and isolation. She suggests that generating playful
engagement, however difficult without the toys and comforts of the traditional office, remains crucial. She discusses the stresses of the telehealthexperience and the importance of identifying and mobilizing a child’s initiative and agency in this setting. She asserts that, when clinicians maintainempathy and share how they imagine children’s experiences, a joining canoccur that lessens the children’s sense of isolation and emotional hurdles.
She then conculdes that, if a clinician’s imaginative self becomes engaged
with that of a child, spontaneity and forward movement are possible evenwhen employing the medium of telehealth. Key words: clinician’s empathy;
imaginative play; sense of agency; telehealth.

Introduction

With the onset of the COVID-19 pandemic, telehealth suddenly

became the safe place to offer therapy to children, a space devoid of the requirements to mask, sanitize, and socially distance. For children previously seen in
the therapist’s office, telehealth offered to bridge physical distance and enable
continuity of care. For new patients with access to the required technology,
telehealth offered the possibility of receiving treatment during a perilous time.
Although new to many, telehealth has been used for mental health care forover twenty years, both in the United States and globally, typically for psychotherapy with those unable or unwilling to meet with a clinician in person. Veterans suffering from postraumatic stress disorder (PTSD) have used telehealthservices when they are alone, allowing them to access help (Chen 2019). Rural
families without local services have been able to access care. Even when face13

American Journal of Play, Volume 14, number 1 © 2022 by The Strong
Contact Lynn Borenstein at borneo00@comcast.net

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to-face therapy is available, some individuals in rural areas prefer teletherapy
with a distant clinician because they worry about confidentiality or encountering their therapist out of session (Nelson 2010). In both urban and rural areas,parents have found that the time and travel connected with the press of everyday
concerns have made teletherapy a desirable choice. Telehealth allows patients
access to experts when specialized diagnostic or treatment skills are required.
For example, Wade and her colleagues (Wade et al. 2020) found telehealth tobe effective in teaching problem solving and parenting skills to parents of neurologically impaired children.
For the practitioner, telehealth offers the opportunity to broaden practicegeographically without the inconvenience and expense of travel. Indeed, clinicians sometimes use both in-person and teletherapy sessions with the same
patient. Video sessions are facilitated by “residual trust and understanding when
the patient has been seen face to face” (Russell 2018, 156).
Although embraced by many, telehealth is not without its critics. Hoffnung
and colleagues (Hoffnung et al. 2020), in their study of forty thousand children
served through telehealth, noted that many of them struggled with communicating and sustaining attention in this medium. Children using e-learningfor school and then in telehealth were especially challenged. As Russell (2018)
emphasized, “What is important here is the necessity to understand exactly
what is taking place when we treat another human being via technology: what
succeeds in getting through, what gets transformed into something different,
and what is degraded or lost along the way” (154). Lemma (2017) noted that“body language, facial expression, and the pheromones [chemicals released
during in-person interactions] fundamental to establishing human relationships[are] all missing in online psychotherapy” (91). Psychodynamic practitioners
face the additional challenges of managing and monitoring transference andcountertransference issues in the virtual world. Prezant (2021) and Sayers (2021)
found that the rapid adjustment to telehealth proves particularly stressful for
psychodynamic child therapists. Given the myriad stressful aspects of telehealth,
no wonder zoom fatigue has been commonly reported and has become a focusof research (Shklarski, Abrams, and Bakst 2021; Burgoyne and Cohn 2020).
Whether in face-to-face therapy in our offices or via telehealth, play is an
essential mode of communication in working with children. Given its centrality
in the therapeutic relationship, how play is best adapted to the new environment
proves of critical importance. My purpose here is to discuss the challenges ofplay as we transition from the traditional office to telehealth and also to elaborateImagination and Play in Teletherapy with Children

and illustrate—through case examples—the use of my clinician’s imagination
to engage young patients therapeutically in the new medium. As background,I will discuss the stresses children have faced in the pandemic and the history
and role of play in the therapeutic relationship.

Stressed Children and Diminished Play in the Pandemic
With the COVID-19 pandemic, everyday reality changed dramatically inways hazardous to child development. Children experienced—and tried tointegrate—a seriousness brought by the pandemic that often surrounded themboth at home and in e-learning at school. Families grew weary, worried, and
impatient. Parents became more anxious and introduced new rules: wearing
masks, avoiding group activities, and the like. Children were often exposed totalk of illness and death beyond their capacities to understand and integrate.
Routines changed: many children no longer shopped with a parent, met playmates at the park, took the bus to school, or stopped at a grandparent’s housefor a hug and a snack.
Even as children faced increased stress with the pandemic (Fergert et al.
2020), opportunities to play and connect with peers declined with mandates
to maintain social distance (Loades et al. 2020). Free play in recess became
restricted. For younger children in nursery school and day care, toys were frequently removed and cleaned and no longer spontaneously shared. For older
children, sports teams and after school clubs were suspended. When parents
worked from home or looked for work online, children were asked to be quiet,
further dampening their play lives. A floating seriousness covered the family
landscape. For vast numbers of children, the opportunities for active physicalplay diminished—and so did the sense of playfulness and the ability to play.
Changes in the family and social environment that constrict play have significant consequences. As Panksepp (2008) emphasizes, “Physical play shouldbe part of the daily social diet of all children throughout grade school.… The
playfulness intrinsic to childhood should especially help us promote the growthand maturation of the social brain” (55). Panksepp underscores the need for
ample rough and tumble play.
Pandemic stressors added to the emotional burdens children already carried. The distress children experienced, coupled with the diminished opportunities to play, required those of us who are clinicians to find creative ways to foster

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to play was central to this task.

The Importance of Play and Playfulness
in the Clinical Setting
The belief in the primacy of play in therapy with children has a long tradition inboth theory and practice. Early psychoanalytic thinking established the centrality of play in the lives of children (S. Freud 1908; A. Freud 1965; Klein 1955).
Sigmund Freud (1908) writes,“Might we not say every child at play behaves
like a creative writer, in that he creates a world of his own, or rather rearranges
the things of his world in a new way which pleases him? It would be wrong
to think he does not take that world seriously; on the contrary, he takes hisplay very seriously and he expends large amounts of energy on it.” (143). Klein(1955) pioneers the use of play to illuminate children’s anxieties, defenses, andinternal struggles both conscious and unconscious. Anna Freud, lifelong childadvocate and founder of child psychoanalysis, underscores the importance ofplay, therapeutic alliance, child development, and work with parents and educators (Goldstein et al. 1973).
According to Winnicott (1971), psychotherapy with children “takes placein the overlap of two areas of playing, that of the patient and that of the therapist.
Psychotherapy has to do with two people playing together. . . . Where playing is
not possible, the work done by the therapist is directed toward bringing the patientfrom a state of not being able to play into a state of being able to play” (38). He
proposes that playing is “inherently exciting and precarious. The precariousness
results from the interplay in the child’s mind of that which is subjective and thatwhich is objectively perceived” (50). Ruth (2006) expands on Winnicott’s notionof precariousness in play, writing, “Precariousness also belongs to the creative,
improvisational process that occurs between two play partners as they negotiate
the shared creation of joint meaning and joint direction” (143).
Solnit (1987) coins the term “play state” to describe when children areavailable in play mode. He writes, “Play is pretend, another way of using themind and body, in an indirect approach to seeking an adaptive, defensive, skillacquiring and creative expression. . . . Play enlarges the child’s sense of himself,
his capacities and his effectiveness in altering the reality in which he lives. In
that sense, play enables the child to explore safely how he can become active inImagination and Play in Teletherapy with Children

shaping his world and not feel helpless or dependent on it more than he prefers
or can tolerate” (214–15).
According to Slade (1999), play is of “enormous value clinically and developmentally with children who cannot play coherently or meaningfully, who
cannot use symbols of play and language to make sense of their emotional experiences, who cannot create narratives for their experiences” (89). When children
have difficulty making meaning on any level, play offers the possibility of a
psychologically organizing experience.
Yanof (2013) describes play as the cocreation of “new lived experience thatcan be reorganized and reintegrated into a different narrative. Rather than finding a definitive meaning in a particular piece of play, it is often the ability of thetherapist to help the child to elaborate different meanings that is the most useful”(261). In considering the role of transference, she explains, “when children feelsomething about the therapist, they feel it in the present moment, and it seems
very real to them and very big. Rarely do they understand that the strength oftheir feelings exists because the therapeutic relationship has triggered something from their past or from their current family lives. Because it is difficult forchildren to comprehend the paradoxical nature of transference, it makes senseto address what is happening between child and therapist in the present and tounderstand the moment” (270). Such “moments” often occur in play.
Play and imagination are inseparable. Agnati and colleagues (Agnati et al.
2013) define imagination as “the act or power of forming mental images of what
is not actually present or has never been actually experienced. . . . Imagination
not only has the potential to enrich the meaning of an experience and deepening understanding, multiplying and expanding the perspectives, it also allows
anticipating the outcome of action without actually performing it via a simulation. At its peak, imagination is the very mental faculty underlying visionary andcreative thought” (2). As described by Brown (2010) our imaginations allow us
to “create simulated realities that we can explore without giving up access to thereal world. . . . Imagination remains a key to emotional resilience and creativity”(83−87). Schaefer (1993) points out that play enhances problem-solving skills
and encourages creativity and flexibility because it provides opportunities to“experiment without fear of negative consequences” (7).
Children without imaginative, physical, and pretend play lose their ability
to unwind, to recharge their psychological battery, to feel a sense of alivenessand purpose—all capacities sorely needed during the pandemic.
According to Hobson (2002), through imaginative play, pathways to inti-

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P L AYmacy and understanding are jointly created. It is in the realm and space of play,suspended from everyday reality, that a child finds the freedom to have flights
of imagination and try on new ways of being. Imagination calls on memory
without the constraints of reality. “You weren’t supposed to win!” “I wanted tobe blue today.” “You are not the mom; you have to be the little sister” (76). Singer
and Singer (1992) describe the importance of possibility in imagination, “whatmight be, being able to move in perception and thought away from the concrete
given of what is, what could have been, what one can try for, what might happen,
and ultimately to the purest realms of fantasy . . . a touchstone of that miracle ofhuman experience, the imagination” (19).
Play serves a myriad of functions for children, helping them heal, engage
with the therapist, and even develop neurologically. Erikson (1976) emphasizes
that “‘to play it out’ is the most natural self-healing measure childhood affords”(475). A primary goal of play is engagement with the clinician. The Boston
Change Process Study Group (BSPSG) (2018) notes that engagement and thesense of the therapist being a “charged other” propels psychological growth evenas the content of play changes (550).
Marks-Tarlow (2012) points out, “Across all descriptive levels—neurological, psychological, sociological, and anthropological—investigations have identified a host of affective, cognitive, social, and motor capacities that accompany
child’s play. . . . These include brain growth, self-regulation of behavior and emotions, the development of imagination and symbolic representation, the makingof meaning, the development of language and narrative, meta-communication(i.e., communication about communication), creativity, divergent thinking, selftransformation, social competence, gender identification, community membership, and cultural awareness and creation” (354).
The efficacy of child treatment, of which play is an essential component,
has been supported by extensive case studies in the Psychoanalytic Study of theChild, a review of research (Midgley, Hayes, and Cooper 2017), and research on
positive neurological changes with treatment (Badenoch 2008; Cozolino 2016,2017; Schaefer and Drewes 2014).

The Altered Physical and Psychological Environment
The traditional office with all it contains has been a place of safety and comfort
for both our patients and ourselves, a place where imagination and play canImagination and Play in Teletherapy with Children

flourish. My now unused office is arranged to offer children freedom of movement and opportunities for self-discovery and agency. They can reach the hooks
to hang up their coats even if they have to stretch on tiptoes. They can open
a drawer full of Play-Doh cans or rearrange the dollhouse without help. Toys
are available: a baby bottle, soft blankets, dolls, action figures, dollhouses withbabies, moms, dads, grandparents, and siblings, and games of luck, chance, andskill. I often volunteer to save a child’s artwork or special items in a secure andconfidential location. For children I see after school, who need to shake off along day of concentration and physical constraint, my office offers a space where
they can be active. I can follow my patients with my eyes as they explore thespace, chooses toys, and show me how they want to use them. In the course ofa week, my office may serve as a stage for performance, an obstacle course, anda venue for playing hide and seek.
Both my patients and I know the sounds from down the hall or from outside. We consider the locks on the bathroom door together. We use the old sink
across the hall to clean paint brushes and wash off gluey hands. In the physicaland psychological space of my office, I take our psychological temperaturesduring a session, noting how we feel and move and interact. Most importantly,
the patient and I are a playful “we” in this space, my familiar office reinforcing
the connection we create over time, albeit sometimes “precarious” (Winnicott1971) and in need of repair. In the shared office setting, movement and ideas
morph into creativity and a joint experience of growth, a pattern not easily
replicated in telehealth.
With the arrival of the pandemic, this familiar and comforting environment abruptly disappeared from my life and the lives of my patients. I came torelate to my patients via telehealth and from a different physical space. Fromthe child’s perspective, the shift was huge and occurred at a time of heightened
vulnerability. I had become two dimensional to my patient and without context.
My office, with its opportunities for movement and exploration, had become
an abstraction and there was no longer a comfortable place to flop down after
a hard day of school. Along with what is now gone went what’s new; in the new
virtual world we cope with technological glitches, garbled voices, and parts ofour bodies missing from the screen.
The shift to telehealth is not without novel opportunities. Children bring
not only themselves to the screen but also their home environments, allowing
me to enter their worlds in novel ways. They choose the settings for their sessions, whether such settings be bedrooms or forts the children have made of

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blankets or on hammocks in a yard. I am a guest, sometimes welcome, at othertimes overstaying my invitation. Sometimes, I sneak glances under a patient’s
bed, check out the titles of books on a shelf or the food in the refrigerator as achild rummages for a snack. I note the orderliness or chaos that constitutes achild’s bedroom or the tenor of the voices of parents working nearby.
As rich as this new access may be, it is also disconcerting, accustomed as
we are to our offices and to moving with our patients. The imaginative play at
the core of psychodynamic treatment and crucial to forward movement provea challenge to generate in an environment devoid of toys, rituals, and shared
physical space. No longer able to rely on our offices or its contents to build
connections through shared meaning and play, we are challenged to innovate.
What equips us to do so is a reliance on the fundamental therapeutic elements
I summarize next.

Mobilizing Imaginative Play
Several therapeutic elements remain important in any space, whether a physical office or a virtual one. Our therapeutic stance needs to be one of carefulattention to the patients’ experience, that is, their empathic alertness. We needto take time to stop, look, and listen—and to imagine the child’s experience,
often feelings of isolation, fear, sadness, and frustration in the two-dimensional
world. We need to be alert to the child’s needs for physical movement and findways to accommodate such needs. Most importantly, we need to do our best to
encourage and participate in imaginative play, harnessing our own imaginative
capabilities to do so.
Just as in traditional office practice, it is critical that we recognize andvalidate a child’s fragile attempts to reach out for connection. Often hidden ina vulnerable, uncooperative child patient on telehealth we find the child’s wish
to engage with the therapist. Though sometimes disguised in provocation andnegativity, the child’s imaginative use of self is an invitation for engagement withthe therapist. Some gestures may be difficult to recognize or misperceived as
antagonistic in the teletherapy context, yet the potential for forward movement
lies buried within the angst of these gestures. For example, when children turntheir screens black, mute themselves, or float emojis, these communications canbe received and appreciated by the clinician as an invitation to play, a faint signal that Tolpin (2002) describes as “restarting and reinvigorating an expectable

Imagination and Play in Teletherapy with Children

developmental process” (189). Over time, the therapist who welcomes antics
on the screen by acknowledging the surly and often depleted child’s behavior
fosters new ways of being together and moving forward. Again, as Tolpin puts
forth, “Fragile tendrils of remaining healthy needs and expectations are notreadily apparent on the surface, we have to be primed to look further” (189).
The following case is illustrative.
Case 1Eleven-year-old Jill was referred for therapy early in the pandemic when her
parents noted that she had “lost her bounce.” She had become fretful, argumentative, and solitary. In teletherapy, Jill was initially quiet and polite. As I watched
her sit at her desk and stare at me with a dull, annoyed expression, I tried toimagine what she had been like before the pandemic when she had friends,
participated in choir, and joked at the family dinner table. That was before. Now
I found her sense of defeat contagious, and I could find no easy way to connect.
After several stilted sessions, Jill began a session with an accusatory question,“How come you always get to be the host?” Rather than viewing this as negativetransference, I paused to imagine Jill’s day, the endless hours of e-learning andthe accommodations she endured. I decided to embrace her spunk rather thanrespond to her negative feelings about my having taken the lead. “Maybe, you
would like to be the host today?” I offered. She jumped at the offer.
I turned off my camera and lowered my screen so I could not see her,ostensibly “leaving” the meeting. Then Jill pretended to call me as if the meetingwere hers. I answered by turning my camera and lifting my screen so I could
see her again. As I joined her meeting, I saw Jill sitting tall in front of an imageof a rising sun, a background that she had chosen. Now wearing fancy virtual
sunglasses and a goofy hat, she no longer looked passive and bored. “That hat
is awesome,” I said. “You are partly hidden under the rim of your hat, but I bet
you can see everything.” Jill grinned and gave me a thumbs up. Emerging fromour joint stupor, we had found a way to engage in imaginative play. I followed
her lead, and she wowed me with her creativity. We felt revitalized.
Though cloaked in negativity, Jill’s brave question was an invitation to play.
Importantly, I did not direct her toward this play gesture. Rather, I provided theconditions of safety and empathic alertness that allowed it to emerge. She had
spontaneously felt an oomph of initiative, a reemergence of the capacity to playwhich had been buried for months. I responded by suggesting a way to proceed.
As she enjoyed our new flexibility, sharing became less fraught with anxiety.

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With Jill as host, we played with the experience of teletherapy, using functions of Zoom as shared toys. Jill’s ability to draw on the screen and use filters
became the “toys” we engaged with together. As host, she was psychologicallyempowered and experienced an enhanced capacity for self-expression (Bennett
and Eberts 2014), moving around her room, bringing her stuffed animals to thescreen, teaching me what brought her comfort and what annoyed her.
From a psychological perspective, a spark of initiative in Jill was encouraged by her sense of safety and my alert and empathic stance, and she was able
to harness aspects of the virtual office in imaginative play. Together, we wereable to build a virtual space in which we both felt safe to explore. We owned theexperience together—but only because she had first asked to own the space herself and I could empathize with her need and find a way to follow her. Buildingon the foundation of our joint play, we were subsequently able to approach the
topic of her loneliness and her feeling out of step with me in our first attempts
at teletherapy.
All children begin to own their therapy in unique ways, and under pandemic conditions on telehealth, trust and a sense of safety can be slow to develop.
Without our office, toys, and familiar boundaries, we must build with ourpatients what can be possible in terms of imaginative play, attending closely toboth verbal and nonverbal messages. The teletherapy setting challenges us to be
especially resourceful. When possible, we honor the child’s urge to be physically
active in play, often at the beginning of the session. With empathic alertness,
the therapist needs to be ready to engage imaginatively and with an openness toplay whenever a patient offers even a disguised invitation. As illustrated in thenext case, this listening and following is a bumpy process, sometimes literally
as well as figuratively.
Case 2
When nine-year-old Ryan said, “I want to show you something” and carried
his iPad through the house, I recognized his need to move physically and his
willingness to treat me as a trusted companion. Even though I sat in my comfortable chair, I felt jostled as he climbed “me” upstairs to see a picture he hadin his bedroom. Even as I glimpsed the ceiling, then carpet, then floor on thisroller coaster ride, I recognized the playfulness in our exchange and pushed it
forward. I said “Ryan, I’m spinning because you are turning your iPad upside
down! Are we there yet?” I moan. He laughed raucously, “Shh! Yeah, we arealmost there.” Ryan and I were playing, we were together on an imaginary trip.

Imagination and Play in Teletherapy with Children

As the driver, the tour guide, he had a bounce in his step and was leading theway with his own agency.
My spontaneous trip through Ryan’s house brings to mind Lyon-Ruth’s(2006) description of the therapeutic voyage, “The meaning of this voyage isbeing co-created between interacting partners rather than a meaning that ispre-existing within the child and unilaterally introduced into the play” (157).
In teletherapy, as in my office, my goal is to create with my child patients what
Panksepp (2008) aptly termed a “play sanctuary.” In teletherapy, through a computer screen, we do our best to coconstruct a psychologically safe sanctuary
where we engage in virtual play.
The next two cases illustrate the use of therapist memory and imagination
to help young patients transition to a virtual play space after losing the sanctuary of the therapist’s office.
Case 3
John, age ten, experienced both e-learning and telehealth as intensely uncomfortable; he had nowhere to hide on the screen and felt utterly self-conscious.
During free time at home, he retreated to his bedroom to play video games,
emerging only for meals. Although he had been animated and cheerful in myoffice, his quick smile and spontaneity had disappeared online, and his negativity
permeated our sessions: “This is boring,” he said, “I have nothing to talk about.
I’m fine.” I sensed John’s wilting spirit and worried that I was asking him too
many questions, like a distant relative visiting from another state. The rituals of
beginning a session that had evolved in the physical environment of my office
were no longer available to us.
This particular day, another session with John began with a long painful
silence. As I listened to the quiet, I remembered how our therapy sessions had
usually begun in my office, and I was filled with longing and frustration. I spontaneously began to share what I was remembering with John.
Me: John, you know this feels so different, doesn’t it, from when I could hear
your car from my office window? Your dad always seemed to slam on thebrakes at the last minute. I sometimes thought he might whack into the sideof the building with your car.

John grinned broadly, so I went on.
Me: I could hear you guys get out of the car, two door slams and then a pause,

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another slam a few minutes later. I guessed you had forgotten your phone.
John: Not fair, sometimes it was my dad forgetting stuff.
Me: I correct. Yep, your dad would forget where he put his phone, and you
both searched the car. Then, a few minutes later I would hear the candy jar
open and close very softly.
John: No way can you hear that!

He was right. It was his bulging candy-filled pockets that tipped me off.
I noticed that he had shifted to the present tense, becoming more engaged. I
followed his lead, staying in present tense.
Me: Then you guys come up the stairs. I don’t know how you do it, but you
are able to sneak up on me all the time. I’ll look down for two seconds to dosomething on my desk, and the next thing I look up and you are sitting in
the blue chair. It always feels like a boo-yikes moment!
John: Sometimes you jump!
Me: I know. Ridiculous, right?

I hesitated.
Me: John, this is a “what if ” kind of idea, ok?

There was a pause in the conversation.
Me: I wonder if it feels weird that I call you on telehealth . . . cuz you never
get to walk into my office anymore. I just pop up on your screen. It feels off
to me. I am wondering, what if we changed this and you call me?

John did not hesitate. He jumped up from his chair.
John: Yeah!
Me: Should I call you first, so you have my number?
John: No, I know your number.

Before I could reply John slammed down the phone. He called back immediately.
Me: Hello?
John: Oops, wrong number!

Imagination and Play in Teletherapy with Children

He started to laugh and banged down the phone. He called back again,
still laughing. I smiled.
Me: That was a tiny bit evil!

Our playful exchange felt like a teletherapy version of John sneaking up to
my office and surprising me. We were both infused with energy as we restored
and advanced our psychological connection.
In this session, as I shared my memories and playfully imagined, John
joined me, feeling our connection. We expanded the play to try out a new version of how to begin a session. By being first scaffolded in his play, his ability
to reframe our connection in the present was enhanced, and he regained asense of agency. He could decide when and how to begin and how he wanted
to engage or disengage. Using our imaginations in play enabled us to reengage
comfortably. Then we could jointly shift to the reality of our impasse and talkabout possible solutions. How clinicians can use memory and imagination finds
further illustration in the next case.
Case 4Eight-year-old Sarah was having a miserable time with e-learning. Bored, frustrated, and angry, she muted her computer during class, took frequent bathroom breaks, and got further and further behind in assignments. She madelame excuses and belligerent demands of both her teachers and parents. WhileI understood her fears, I struggled to understand her total shutdown. Tension
at school and home escalated. Her parents—both working from home—were
defeated and exhausted.
Sarah: I want my mom to homeschool me. We could have a Pod with myfriend Emily. My laptop never works. I really do have stomach aches. Why
don’t you just tell my mom I can’t do e-learning?

Reasoning and strategies got us nowhere, though I could remember ourdoing well together before the pandemic. Then she was engaged in accelerated classes at school and had friendships and hobbies. Now—and for several
weeks—she was defensive, angry, and unreachable.
I recalled Sarah when we first met, two years ago after she was first referred
for therapy by her day care teachers who had exhausted their ideas about how toengage her. She had been enrolled in after-school day care but was determined

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clear there was no “we” joining together in play and learning; rather, it was theteacher and Sarah in a battle of wills, both losing. Over time and through sharedplay, Sarah and I had become a “we” and worked hard together to find meaning
in day care, a connection to the teachers, and a feeling of having a voice to beheard, but in a reasonable way. Resparking her sense of agency had been crucial
in enabling her to engage more productively at school.
My imagining the Sarah that I had known prior to the pandemic allowed
me to wonder about her subsequent regression at school and shutdown in our
virtual meetings. Then, Sarah had felt invisible, enraged that life was not going
her way. She would fly off the handle if she was not the snack helper or if her
friend refused to sit with her at rug time. Perhaps her problems now stemmed
not from endless e-learning or fear of the future but rather her sense of diminished agency with the changes. I decided to share with Sarah how I imagined
she had felt when she first came to my office.
Me: You know Sarah, I was thinking about the time you first came to my old
office. You told me I needed to get rid of my chairs and get bean bag chairs
instead. And you told me I should buy a new dollhouse. Remember that?
You weren’t so sure I had the right stuff to help you. Maybe you were feelingworried or disappointed. You were not in a good place. And you didn’t evenknow me at all. I probably was nothing like you thought I might be. Do you
remember that too?
Sarah: Yeah. I miss your office. We can’t really play hide-and-seek anymore.
And I could dance in your office.
Me: I miss us there too.
Sarah: Will you tell my parents that I can’t do e-learning and she has tohomeschool me? Where are all my pictures now (from sessions in my office)?
Me: I have them right here in my private drawer. Do you want to see them? I
remember the picture you drew of the little girl; she was so tiny in the rain. It
was raining so hard, and she didn’t even have an umbrella to help her stay dry.
It made me so sad. I remember looking at the tiny girl and wanting to takeout a pretty light purple marker and draw a fancy umbrella for her to hold.

She nodded.
Sarah: I would have gotten so mad! And you can’t draw either! I remember
drawing a lot of rain.
Me: I know. That little girl in the picture was soaked. For sure she neededImagination and Play in Teletherapy with Children

help. So, what if some of these old feelings of being alone and unhappy arepeeking around the corner? (We sometimes played the “What if?” game
together.)

Sarah’s body relaxed. She made eye contact. Once we had found connection
through imagining her earlier self and the picture she had created, Sarah could
begin to acknowledge her currently messy situation at school.
I believe that our earlier work had offered her a bit of protection andscaffolding. She had brashly and impulsively walked where she wanted to andstepped in a lot of puddles along the way. In therapy she had turned to me
for a bit of shelter and safety as she learned to move forward and conform to
expectations for her behavior at school. As Geist (2016) writes, “The depth andcurative potential of any treatment is contingent on a sensibility in which patient
and therapist allow themselves to be a presence in each other’s experiential
world. . . . It is only through reestablishing connectedness developmentally or
therapeutically, that hope is preserved. The protective part of connectedness
is particularly important as it affects the modification of defensive structures”(370–73).
When Sarah’s hard-won progress eroded under the stress of the pandemic
and virtual therapy, I offered shared memory to reestablish connection andforward movement. As we reimagined six-year-old Sarah, we felt that we knew
the map of how to feel frustration and move forward anyway. Together we could
feel sad about not being in our old office, playing and hanging out. Although
we did not want to “grow up” and find solutions to all the new messes, our
imaginative joining was emboldening. Allowing myself to imagine playing withthe six-year-old Sarah and inviting her to join me enabled Sarah to give voice
to her complaints. A shift in her behavior at day care affirmed the value of thetherapy; she began to talk with her teacher about what she needed—which wasmore advanced reading and occasional time out from the video screen—putting
into words what she had previously expressed in defiant actions.

Discussion and Personal Reflection
As the cases have illustrated, even in the virtual environment of telehealth, theimaginative potential of therapist and child can be harnessed in a “we” of creative play. Through playful engagement, the child can transition from feelings ofisolation, anger, sadness, and hopelessness to feeling a renewed sense of agency.

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Although daunting, the telehealth version of therapy nevertheless contains thepotential for rekindling affect, the sharing of ideas, and the conversion of apassive experience into one of spontaneity and play. And it is through the connection of imaginative play that forward movement becomes possible.
Working in telehealth continually presents thorny challenges for theclinician. In the case examples I have offered, the treatment benefitted fromspontaneous imaginative play that was initially evoked by a profound sense of
disconnection between me and my young patient: John, who desperately missed
being with me and the rituals of engagement in my office; Jill, who had lost her
sense of vigor and required encouragement to find her psychological well-being
and creativity; and Sarah, who lost her newly acquired problem-solving capacities but reengaged through our remembering her previous mastering of messes.
My sense of the “Zoom fatigue” of my patients—the frustration and mounting sense of defeat they experienced struggling for connection through theirscreens—is part of what propelled me to use imagination and play as a bridge.
I, too, struggled with Zoom fatigue, initially blaming technical glitches
for my dismay. The adaptive demand of transitioning to the new technology
was considerable. I missed the relative absence of bodily cues, being able tofollow a child’s gaze, and the essential connectedness that face-to-face humancontact offers. I missed the abundance of toys in my office and the office itself
with its rhythms and rituals of use. I especially missed the physicality of hellos
and good-byes, the beginnings and windups of sessions.
My patients came to learn that cleaning up the office space was a necessaryand helpful ritual, bringing closure to a session. Over the years, I have foundthis to be a tender time as we transitioned together from the therapy space toeveryday existence. As we put toys back on shelves, vacuumed the floor, andlooked around together, our ritual affirmed that moving from chaos to repair
was possible. In contrast, teletherapy endings feel more abrupt, even though we
may choose the same words for good-byes and try to establish ending rituals. As
Kashyap, Chandur, and Reddy (2020) summarized in regard to treating adults,“At the scheduled time, they (patients) had been greeted at the door, invited into
the therapy space . . . wind down with small talk and shown out by the therapist. Now (using telehealth) in a single click, we start and end the session. The
abruptness of transition between reflective space and ‘real life’ (both enteringand leaving) was experienced as jarring”(3). Zoom fatigue may be understood,at least in part, as a serious alert to review and rethink our clinical work in asession. The challenge of shifting from office rituals to saying telehealth hellosImagination and Play in Teletherapy with Children

and good-byes is but one example requiring thought and creativity.
In efforts to deal with my Zoom fatigue, I sought articles (Sayers 2021;
Russell 2015) and consulted with tech-savvy colleagues. Even with a career ofdoing and teaching child therapy, presenting workshops, and writing articles,
I struggled with whether I was a good enough therapist to adjust to the telehealth format. Ultimately, it was my experience working with young children
during the pandemic, as I have described here, that convinced me that telehealth could be effective. It requires vigilant self-reflection, consultation withcolleagues, and confidence that our training in intense listening and observingof patient process is relevant and transferable to the new medium.
Telehealth challenges will continue to require our thoughtful attention
and creativity. If we appreciate that our Zoom fatigue is a call to attention,
we can adapt. Whether beginning our career or adapting to teletherapy after
years in practice, active engagement in the learning process is essential and ongoing. And a focus on finding ways to join our patients in imaginative play—even in this medium—is essential.
Optimal use of the therapist’s imagination is built on the foundation of
empathy, and it entails active engagement with the child patient’s “what-ifs?”
Opportunities for imaginative engagement occur when the child patient feels
safe to explore in both physical and psychological space. We clinicians need toattend closely, to stop, look, and listen, staying open to the gestures our patientsuse to indicate stirrings toward agency even when disguised in what may beperceived as negative behavior.
Yesterday seven-year-old Tom carried me to his kitchen on his iPad and left
me in the refrigerator with the door barely ajar. Staring at the milk cartons, I felt
isolated and anxious, momentarily forgetting that I was actually sitting in myown cozy chair. I reminded myself that the child who shows me his room, walks
me through his house, and puts me in his refrigerator is owning his therapy,
using playfulness to define himself and claiming his place in the teletherapy
experience. Can we use our imaginations to engage such sparks of initiative? Is
it workable? On behalf of the children we serve, we need to try.

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