If anyone asked me what my practice was going to look like for Play Therapy and EMDR in 2020 this wasn’t exactly what I had envisioned. By this I mean – not in my wildest dreams did I imagine that I would be doing therapy 100% online with clients and spending a good chunk of that time in a makeshift office in my garage. If you know my story you know that telehealth was part of my practice before COVID-19, BUT nowhere near all of it, and the shift to all the activities, consents, procedures, and paperwork all at once was difficult!
As we are all settling in to Tele-Play for some of us this will be the platform that we use for the foreseeable future. For others integration back into the office and sanitizing toys, ohhhh ALL the sanitizing, is the next chapter. I think we can all agree that Tele-Play is here to stay in one form or another – either for clients who aren’t comfortable and/or have a pre-existing condition where they do not want to risk being in the office or *the way I hope it will be* integrated into normal practice as a way to increase consistency when life happens. Sibling sick and can’t be left at home? Tele-play! Unable to make it into the office because of work schedule? Tele-play! AND if you are from a snowy state like me – blizzard? Tele-play!
So inevitably you have run into some of the difficulties, mishaps, and frustrations that can happen with Tele-Play. Maybe you have gone on a bike ride with your client, jumped on the trampoline, had a tour of their whole house, or had to set a limit about not taking you into the bathroom.
A recent blog comment by Ashley reads “What if they run out of the room? What if they turn off the camera/program? What if they take the device and go on other programs? What if they don’t listen to what I say? [When a client leaves the room with permission] will she come back?” These are all great questions and I felt they deserved some more thorough attention!
Okay let’s break it down!
What if they run out of the room? What if they leave with permission but don’t come back?
This is where policies and procedures are key! All of these procedures are discussed in detail with clients and parents before starting sessions. Did this sentence just make you anxious because you have no idea what I am talking about? No worries – you can introduce and orient to these at any time!
So one of my rules is I always have my business cell phone within arms reach. I have whatever parent/guardian is with the child at the time of the session’s phone number. We have agreement that they will be able to be reached immediately at any point in the session. I also have an agreement that if a session gets interrupted for any reason (tech down, the kid running out of the room) and cannot resume within two minutes (longer for things like going to the bathroom) I call the parents and have them support re-engagement.
What does re-engagement look like? It depends! One of the biggest things to consider is, if this were your office how would you handle these behaviors? Some therapists might meet the child where they are and just be present in the waiting room. Other therapists would give the child space. Still others would set a limit stating that choosing to leave the playroom is choosing to end the session and engage with the parent for the last portion.
The key is to work within your theory or framework and identify the function of leaving. For kids that just get excited and distracted sometimes it might work to have a parent camp out outside the door and issue gentle reminders for the child to stay in the room. For others who are dysregulated or have some apprehensions or anxieties about engaging then there are more complex elements to consider. You need to pair with parents and work to have the parent as an external co-regulator for the child.
What if they turn off the camera/program? What if they take the device and go on other programs? What if they don’t listen to what I say?
Now the questions above were about keeping the child in the room, this next set of questions is how to engage with the child when these problems come up during session. I promise you these things will happen – the camera gets turned off, they exit out a program, or they are just plain old playing video games or Minecraft during your session. Ugh.
The first lens I look at is “Is this behavior therapeutic”? Take the example of the child who wants to feel in control, a child who feels distant from you, or a child who feels abandoned. Could play themes come out of turning the camera on and off? You bet! Your theory depends on what you do next – tracking, creating an activity around this dynamic, etc.
Now, this may or may not be different if the child is turning off the camera to hide something. Could this be similar to a client who goes into a tent in your play room and doesn’t want you to see what they are doing? Yes! However, sometime it means a client is doing something they should not be doing both in the playroom and in the context of their home environment. For this type of behavior a limit would need to be set. This might include those policies and procedures of contacting parents and having them create the structure to enforce limits within the session.
Now, there are some ways you can tell if a client could be going on another program. If there are different lights flashing on their face, if their face is close to the screen but they are distracted, their eyes are going back and forth and are not set at a steady gaze that we would expect if they were paying attention to you on the screen, their affect (excitement or defeat) does not match the context of the therapy setting, or if you hear rapid typing. For teens old enough to have a cell phone, this could be looking at their lap frequently. Does this always mean they are on another program? No – unfortunately there is no fool proof way to call out this behavior.
With this, I usually start with a wondering or noticing of what I am observing. Then you can create some tweaks – such as having them sit far enough back where you can see their hands OR having a parent come in to ensure that all other programs are off. I am told that there is a way that a parent can lock the child onto one screen, but honestly I haven’t ever used this method so that might be some digging on your own if you have a client where this is an issue.
Lastly – what if a client just refuses to do what you say? Well…..doesn’t that happen in our offices too? I hope it’s not just me! So - how you handle it depends on your theory! Sometimes this behavior comes from a hypoarousal state where the client doesn’t want to do anything OR sometimes it comes from hyperarousal state and they are having behaviors from a flight/fight response. These behaviors typically may need limits at some point. I tend to pull limits in a bit sooner in Tele-Play due to the potential if there is escalation to need to call parents into the room and the lag that it may take from calling to parents present. This is different from in your office when you can immediately and physically be present with the limit.
Limits might look like “One of the things we cannot do during our time together is break your toys, but you can do almost anything else that you would like!”. I like the limit setting process from the book Child Centered Play Therapy by VanFleet, Sywulak, and Sniscak where after stating the limit (in the example), if the child is not able to comply you state the limit with a warning. If the child still does not comply then you enforce the consequence from the step prior. In Tele-Play this might look like the child’s time during the session ends and you continue the rest of the session as a parenting session.
Wheew! That was a lot AND I hope it got you thinking about how in office troubleshooting of problems can be translated to your Tele-Play sessions! Let me know in the comments what the biggest Tele-Play obstacles you have overcome (without any client information of course!) and how did you do it?
Want to learn more about specific Tele-Play Therapy techniques? Check out this training HERE!
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I'm Ann Meehan, an LPCC,