Playing Together Apart


Playing Together Apart

Figuring Out Teletherapy for Kids

By Martha Straus, Kathryn O’Neil

May/June 2020


When COVID-19 hit our rural corner of New England and psychotherapists moved online en masse, those of us who work with kids started fretting. Many of our younger clients lived without computers in their homes, without good internet, without supportive parents, without privacy, maybe even without safety. And these children were already challenging enough to contain and engage in a carefully appointed playroom. What therapeutic interventions might we try online with the kids who could and should continue to have support from us through the pandemic?

I posed this question to Eli, a bright, rambunctious, eight-year-old I treat, who, like many of his peers, is amphibious in his ability to move fluidly between screen and face-to-face interaction. He stared at me a minute and then shrugged—a lot like my IT guy does when I ask a silly question. “We can FaceTime,” he replied, as if that were the most obvious solution in the world.

“But,” I persisted, “what will we do on FaceTime? Could we build with Legos and play Memory together? What do you think will be fun for us to do?” Eli wandered around my office, making a final inspection tour of the room before we stopped meeting in person for who knows how long. He smiled affectionately and reassured me, “Don’t worry, Marti, we’ll figure it out.” And, though it’s been just three weeks, here’s an account of how we’ve spent them together-apart.

Week One. Eli shows me around his grandfather’s apartment via webcam. Because of the fragility of his mother’s health, he’s hunkering down with Gramps. The tour includes private areas of the home that Gramps would prefer remain so, and I hear an exhausted voice in the background as I examine the impressive contents of their fridge say, “Eli, honey, remember how we agreed you’d have therapy in your bedroom?”

As we move through the rooms, Eli narrates what it’s been like not living with his mother and their pets, the good and bad parts of being out of school, and missing his circus-arts class. Back in his small bedroom, I get a glimpse of his bare mattress. I suspect that he’s been enuretic again since moving to his grandfather’s place. I know that’s embarrassing for him, so I file away the information to ask Gramps about at another time.

Eli then demonstrates an array of possibly dangerous leaps, tumbles, and cartwheels off the bed in a private circus performance for my viewing pleasure. At the end, when I ask him how our first teletherapy session went, he proclaims that it was “more fun than your dumb office,” before exiting our meeting. A good start.

Week Two. We decide to try to play Memory, one of his favorite games, with me struggling, tediously, to tell him which cards I’d like turned over. He’s significantly better than I am at this game anyway and invariably wins it fair and square in my office. But this is a slower, more frustrating methodology over video, and today he’s increasingly irritable. He cheats shamelessly, and I’m (mercifully) trounced in record time. His gloating laugh doesn’t sound joyful across Zoom the way it does when we’re physically together. I see that this little guy is more stressed than he seemed last week, and I contemplate doing some breathing and grounding activities with him later in the hour.

Eli then says he wants to play a version of I Spy, in which I have to guess what he’s looking at in his room. He changes what it is when I guess right, which subsequently makes it less fun for him too (a preemptive strategy, perhaps, to control the outcome when he’s uncertain about it). Predictably then, he loses interest and the game winds down.

As Eli casts anxiously around his room for something else to do, I comment that it’s harder for us to play together today. I ask if he wants to do some grounding with a Push the Wall relaxation exercise, which sometimes helps when he starts feeling worried like this. We can grunt and push hard against our respective walls and shake out our arms a few times; it’s a strategy he usually goes for.

I have a stockpile of other ideas we might try as well, but through the screen, I feel Eli’s nudgy mood: he’ll dig deeper into “no,” even if an idea sounds tempting, so I wait. He can’t figure out how to lean on virtual-me today. When he stops even looking in my direction, I imagine, correctly, he’s doing his Houdini emotional disappearing act, as happened more frequently back in our first couple months of therapy. He claims there’s no open wall space to push on in his room. This is patently false, but I’m here to support him and not to argue.

When we met in person, I’d learned how to reengage him when he got distressed this way, but this is really next-level challenging through the screen; I feel there-but-not-there for him today. I speak about how different things feel right now in the world; he shakes his head sadly and abruptly and says he just wants to go back to his video game. Then, before I can respond, in a flash, with a quick “bye-bye,” he slams the computer top and, poof, he’s gone.

I check in later with a call to Gramps, who affirms it’s been a long week for both of them. Eli’s circus activity was so important to him. Not being able to be with his friends makes him sad, and he’s spending hours and hours playing Minecraft. He misses his mom and the comforting routines of his life. We’ve met on Wednesdays at 3:00 p.m. for many months; seeing me is one of those routines. We’ll try again next week.

Week Three. Eli is cheerful and engaged today. His circus-arts class is doing an online juggling course, and he’s got three scarves he tosses up again and again, quite masterfully, as he chats with me. With my help, Gramps has set up a whiteboard with their day’s activities on it. Perhaps Eli is beginning to settle into the security of an established schedule there.

I ask him if he can instruct me in how to juggle, and he’s kind in his willingness to give it a go, despite some candid and accurate skepticism—he knows me well—about whether I’m teachable. Since I’m at home, I run and get some scarves from my bedroom. I never leave the office during in-person therapy, and it feels strange for me to disappear on him like that.

For the remainder of the hour, we juggle and talk about his week. We discuss the way that coronavirus has turned all of our lives upside down, making it hard to imagine “juggling” with what comes next. I’m glad not to lose the connection with Eli through this time of transition and uncertainty. The jury is still out, but maybe teleplay therapy with kids could be a thing?

Teleplay Therapy and COVID-19

Back before COVID-19, in what seems like another lifetime, a growing body of research considered the promising world of teletherapy and touted the social-justice implications of providing access to psychotherapy for rural, disabled, and housebound clients. Most of the best-practice exploration has involved teletherapy with adults; some studies suggest that certain kids can benefit from focused CBT online. There are surely also some teleplay therapists out there, connecting virtually with sick and isolated kids. This foray into play therapy online may not be as much of a brave new world for them as for the rest of us. But there isn’t a well-researched paradigm for reaching young children who might need teleplay therapy in an uncertain time like this, or under such confusing circumstances.

And yet here we are, working on the fly at the start of a scary and unpredictable journey. We know well that scary and unpredictable is really tough on fragile kids like Eli. All of New England, now just three weeks into the new normal of universal online treatment, is hunkering down together-apart. It’s encouraging that play therapists are already brimming with thought-provoking stories of treating young kids via teletherapy, figuring out how to make it work for us and for the children we treat.

Even children as young as six are playing out in therapy their fears about what COVID-19 means in their lives. A colleague of ours told us about a particularly fascinating recent session. Though the family didn’t have a computer, Tony’s mom had a smartphone and handed it over to him with his video session all set up. Tony first gave his therapist a whirlwind tour of his home. As she fought back motion sickness from being zipped around so quickly, she feared this session was headed for a debacle. After all, no one had ever taught her in grad school how to do therapy with a smartphone and a six-year old.

Suddenly, she realized that the phone had been dropped into a large cardboard box and she was now looking up at Tony. He glanced down at her briefly and promised to “be right back.” She waited in semidarkness, wondering if he’d simply gone onto other activities. Since his mom’s phone was now at the bottom of a box, there would probably be no way to call her to try again.

Moments later, however, Tony was back. Blankets and pillows came raining down until her screen went dark, though she could still hear his muffled breathing from above. When Tony reappeared, it became clear that he’d wriggled into the cardboard box with her/the phone; together they hid out in the dim light, draped with a blanket and cozy in his fortress. Tony held the phone up close to his face. He looked right at her, nose to nose, whispering, “Okay, now we’re in a safe place. The virus can’t find us here!” They virtually cuddled together for the rest of the session while Tony, sometimes a small fearful boy, bravely sheltered a beloved adult inside his safe place.

While children are not considered the most vulnerable of populations for this particular pandemic, they’re experiencing distress as acutely as many adults. COVID-19 is as much a crisis of mental illness as of public health; we won’t know the extent of this for a while, but we have lots of indicators already. People have to find entirely new daily routines. Many parents lucky enough to have salaried jobs are stretched to the breaking point, simultaneously homeschooling and caregiving while working from home. In this, many therapists are sharing the stressful experience with their clients. We’re all isolated, mostly indoors and, regardless of age, worrying endlessly about our well-being.

Fear is contagious. Children are bathing, without much respite, in their caregivers’ anxiety. This, in turn, increases their own worries. They, too, have lost the anchors of their daily lives. Even the children who are physically safe, with sufficient resources and loving parents—and enjoying some elements of hanging out at home—are adjusting to jarring changes to routines and the loss of their social systems. For children like Tony, living in impoverished and distressed circumstances, the experience appears to be quite traumatic. Schools provide structure, safety, reliable food, attention, and mental health services. What happens to vulnerable kids when they suddenly lose much of that support?

Several states have already noted a worrisome drop in child abuse reports—despite the great likelihood that family violence is actually increasing. Anxiety, unemployment, and financial stress invariably lead to larger numbers of abused kids. But child maltreatment will now go mostly unreported, since children are fully at home, unobserved by teachers or other community adults who’d be able to call in their concerns. Therapists working with high-risk children are worried—with good reason—about how to stay in touch with their most vulnerable young clients, especially those who require services but lack internet access or sufficient safety at home to be able to participate remotely. Unfortunately, we anticipate that, without some contact, we’ll find many kids in even rougher shape on the other side of the pandemic.

Any kind of continuity in this time of loss and potential loss can benefit these children. Teleplay therapy (along with parent support) might keep a stressful situation from becoming even more traumatic. At the very least, it preserves our relationship for when we meet again in person at a future time. By maintaining connections and routines with children now, we’re also mitigating the challenge of subsequent transitions when the world heads into whatever the next new normal turns out to be.

A Typical Teleplay Therapy Session


  • Say hello to the parent/caregiver who’s helped set up the chat.
  • Get oriented. Ask: Where are you? What’s behind you today? Tell me all about this space? Is this a safe place for us to talk and play? Who else is nearby today? What’s going on?
  • Check in. How are your emotions today? How does your body feel today? What was something that made you happy today? What’s something that’s worrying you today? If you have specific ongoing concerns, make space for that conversation—but keep it brief unless you’re okay with ending early.
  • Offer to do a sensory regulation activity. These might include basic breathing exercises or doing body scans together. You can stretch or do yoga poses or exercise along with a YouTube video. Challenge clients to find a nearby object of every color of the rainbow. Help find items with different textures, which the child can touch with closed eyes to see what stories or feelings come up. Share a song of the day, or come up with new signature dance moves.
  • Ask if the child would like to suggest a play activity or focus for the day, but have a few ideas of your own in your back pocket.
  • Talk about how the session worked.What was good? What was hard? How did it feel?
  • Arrange for when you’ll see them again—at the same time if possible— and sign off.
  • Keep in touch with caregivers, especially if the session ends without a checkout with them.

Anxious Kids are Likely to Be Even More Anxious

Evelyn is a talkative, socially anxious 11-year-old, who feels a high level of stress under ordinary circumstances. Managing the effects of a lifetime of traumatic exposure, she tends to keep moving—and talking—to stay ahead of anxiety and despair. We met only a handful of times before the office closed down for COVID-19, and it’s been a bit of a wild ride. She’s excited to be in therapy and ready to try anything I suggest, but regresses rapidly when activated, rolling on the floor and making frightful pterodactyl sounds when we touch on sensitive subjects.

As a result, while we were meeting in person, we developed some predictable grounding routines. We’d begin each session with an activity to help her feel more regulated right away and monitored her sensation of anxiety together throughout the sessions. Often I’d start by picking three yoga cards and asking her to choose one for us to try. Using belly breathing and mindful noticing, we were then able to stay calm and present during conversations. Before COVID-19, our connections were growing stronger and lasting longer. But at our last in-person meeting, she was again like a highly conductive and uninsulated wire. “Getting sick really, really, really, really freaks me out,” she moaned softly from the floor.

In the intervening couple weeks before going online, I felt so disappointed about losing that face-to-face therapy with Evelyn. I worried that I wouldn’t be able to sense the raw charge of her anxiety through video. I also feared that the technology would make it even harder for me to get a word in edgewise, as Evelyn didn’t leave much room for dialogue once she was fully revved. It was, I feared, RIP to coregulation.

But Evelyn is a resilient kid, and I can be a resilient therapist. Her custodial aunt, Melissa, with whom she lives, had her hands full keeping Evelyn focused and steady at home 24/7. Perhaps even more than Evelyn, Melissa felt acutely the loss of school structure and respite support on weekends from her parents, who were similarly self-quarantining and now off-limits. Melissa was at her wits’ end, worrying that Evelyn was losing developmental ground and behaving more like a miserable, demanding toddler every day. I received several increasingly desperate emails from her while I was still ironing out the details of the transition to online play therapy.

As it turns out, the biggest problem with doing teleplay therapy with Evelyn was my disparaging attitude about it. It’s hard for me to fully grasp, but I think that Evelyn experiences video chatting to be just as real—if not more so—as real life. She’s waiting for me impatiently when I arrive for our session. “Finally!” she exclaims, though I’m usually a couple minutes early for the meeting.

She wants the hour to feel like the ones that came before, so we continue to stretch and breathe together. Often I send her on sensory scavenger hunts around her room to find something fuzzy, something smooth, something that smells nice. We take turns closing our eyes to use our senses and calm ourselves down.

I’m a little more direct, perhaps, in how I ask for feedback about how her body feels. I hold up an emotional color wheel and check in for her “emotional weather report” to find out about her mood—hailstorms, hurricanes, cloudy, or sunny? She sits cross-legged on her floor, surrounded by her stuffed animals and dirty clothes and holds me near. I can’t help noticing that the screen absorbs her much more than my office did: she studies her own image closely and looks right into my eyes.

Last week, I was able to be present in real time for a conflict between Evelyn and Melissa, and I got to help Evelyn sort out what had happened immediately afterward. I’m over my consternation about teletherapy with her. Indeed, I see some new opportunities in our work. We can more easily share music and dance together. I’m an enthusiastic witness to the creative redecoration of her room—a transformation that feels surprisingly intimate to me. And I’m now able to experience a small, novel immersion in her home life.

This format might be a boon for socially anxious digital natives like Evelyn. Indeed, she actually seems more comfortable and relaxed talking to me on a screen from her own familiar space. It’s turning out to be a gift for both of us.

- - - -

A few days ago, Eli’s mother, who has numerous health challenges because of an autoimmune disorder, started feeling unwell and got tested for COVID-19. Very few people in our town have been diagnosed so far, but we’re preparing for the tsunami ahead and know it could be soon. We all went through a frightening time waiting for the results. It was such a relief to learn that, so far at least, she’s in the clear. Although Gramps determined it would be best not to tell Eli, the apartment is small and Eli heard just enough to flip out. I helped Gramps find the words to reassure and comfort the boy, all the while feeling quite frantic himself.

This incident raises the specter of the millions of children whose lives have been and may be forever altered by this virus. And though teleplay therapy is sometimes unwieldy and strange, different from therapy in person, inequitably available, and of unproven outcome, for now, we’re going to stand by it. It’s true that Eli banged the laptop lid shut when he’d had enough; it’s also true that the following week he was delighted to have therapy at the appointed hour, as always, corona­virus be damned.

Teleplay Therapy Activity Ideas


Sensory Scavenger Hunts

  • Find items with different colors of the rainbow.
  • Find items that are soft, smooth, fuzzy, hard, slippery.
  • Find items for each of the senses: something to hear, smell, taste, see, touch.

Change One Thing

  • Have the child study the area visible around you. Turn off your camera and change one thing behind you in the room. Turn your camera back on and ask the child to guess what thing (or two or three things) is different. If you’re using Zoom, the virtual background option can be fun and funny in this game.

Interactive Games

  • Play Rock-Paper-Scissors, Simon Says, I Spy, and other interactive games that don’t require physical proximity.
  • Play “I Beg to Differ” to practice safe, playful conflict with older elementary kids. Just find an object and take turns thinking of creative uses for it via pretend arguing. For example: “I beg to differ. That’s not a pencil: it’s a tree for an ant.”
  • Play board games together; the child moves the therapist’s game pieces as the therapist indicates.
  • For kids who like to be in charge, use a whiteboard and try to draw exactly as they instruct you.

Juggling

  • Rhythmic, repetitive, and grounding, juggling helps with frustration tolerance. It can be a great activity to do while talking. Plus, it can be used as a metaphor for our lives right now.
  • Juggle with tennis balls, balled-up socks, washcloths, or handkerchiefs.

Internet-based Activities

  • Use Google to search for images and explanations to answer pressing questions of the day, like: What’s your dream vacation? Can a dog make friends with a tiger or a bear? What animal best represents your personality?
  • Search YouTube for a song that represents a current feeling (or perhaps gives your young client the chance to share a Disney-fueled obsession). Some examples of songs about moods: “Happy” by Pharrell Williams, “Brave” by Sara Bareilles, “Mean” by Taylor Swift, “Firework” by Katy Perry, “Count on Me” by Bruno Mars. Many preadolescents have songs and performers that really speak to them—so it’s good to ask.
  • Try out new apps together, like Calm or Shine, for stress management.

Toys

  • Use Play-Doh to depict feelings or events, or as a sensory support while talking.
  • Puppets, stuffed animals, Legos, and other representational toys available in the child’s room can be part of online play. The therapist can engage in the play, both as witness and collaborator.

***

Martha Straus, PhD, a professor in the Department of Clinical Psychology at Antioch University New England, is the author of No-Talk Therapy for Children and Adolescents, Adolescent Girls in Crisis, and Treating Traumatized Adolescents: Development, Attachment, and the Therapeutic Relationship.

Kathryn O’Neil, MSEd, a doctoral candidate in clinical psychology at Antioch University New England, has a background in special education for children with emotional disturbances. She has focused her training on therapeutic assessment and intervention for children and adolescents with complex trauma.

***

PHOTO © ISTOCK.MONKEYBUSINESSIMAGES

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2 Comments

Friday, July 3, 2020 1:13:06 PM | posted by Margarita Hernandez
Very helpful, informative, and reassuring. Will definitely use some of the suggested strategies. I, too,was initially skeptical and reluctant about play teletherapy, however the past two months, have shown that it can be and is of value. Thank you both. Great article.

Tuesday, May 5, 2020 3:35:00 PM | posted by Denise Buckingham
Excellent read! Thank you for sharing your personal experience. Appreciated.