How to Make Virtual Therapy Work for the Child that: “Can’t Do Virtual!”
This year, I've felt unsure, confused and defeated as an individual and a clinician. I’ve also had the opportunity to: be creative, foster connections, and adapt, which we often encourage our clients to do.
We have faced many hardships and challenges in the last year. Initially, I felt that virtual sessions would not be possible for many child clients I worked with. When beginning this adventure into virtual therapy, I often found myself discouraged, frustrated, and yet determined. As a clinician, I knew the importance of our work (especially in a time of difficulty) and felt committed to finding an effective way to support my clients. By relying on my core therapeutic skills: creating a safe space, building rapport, and a precise treatment plan, I quickly found glimpses of success I knew could grow. Theraplay® became stable in my virtual sessions, providing therapeutic beneficial activities and creating an atmosphere of joy for families.
I hope this case summary provides some encouragement and ideas for those situations when we meet parents torn between physical safety for their children and accessing support for their emotional well-being. Many times over the last year, I met with parents who explained their desperation to connect their child with therapeutic support while exhaustedly sighing, “They just can’t do it virtually!”. I want to provide a case illustration that helps the clinician feel energized in these moments and confidently share an option for parents.
In mid-fall, a family with a 4-year-old son, David*, reached out to discuss service options. This family had previously participated in play therapy, specifically Theraplay®, two years before supporting the adoption process. In-person, David began Kindergarten in September of 2020 and was struggling. It was reported that David could not follow instructions in class and displayed moments of intense dysregulation. The parents knew he displayed fight-or-flight responses, including throwing items and running from the classroom. Additionally, at home, he could not follow any routines the parents attempted to implement, often becoming destructive and would break items, including his toys.
My initial step was to have a virtual parent meeting. They shared that overall they were concerned for their child’s happiness, sharing he typically presented as angry and displayed negative self-talk. The parents were very clear about their desire for therapeutic support. And then the “BUT” came. The parents shared that due to Covid-19, they did not feel comfortable returning to ‘in person’ sessions, “BUT” David could not participate in any virtual calls, with friends or family, for more than a minute. The parents shared that these calls often produced an increase in dysregulated behaviours. During this meeting, I focused on helping the parents feel heard and gaining as many observations as possible about David’s previous virtual experiences.
I then had a second parent meeting. In this meeting, we aimed to create a plan for a successful virtual session. Which would involve two pieces: 1) the therapeutic activities we will use and 2) the definition of success. I shared with the parents that therapeutically, I wanted to begin with including the Safe and Sound Protocol and Theraplay®. Providing psychoeducation for the parents is crucial in a successful virtual experience. This knowledge gives parents an understanding of their role and confidence in the integrity of the modalities we use. This nonverbal confidence and belief in the possibility of success impact the child’s perceptions and capacity to participate before entering the virtual session. I then suggested we define “success” initially, as David reported: to have fun, be willing to be engaged, and want to meet again. At the end of this meeting, the parents shared that this plan was “too good to be true” but acknowledged the growing feeling of hope.
I decided on a blended approach of Theraplay® and the Safe and Sound Protocol for this treatment plan. The goal of Theraplay® was to focus on creating playful, attuned, and co-regulated interactions. The Safe and Sound Protocol (SSP), as developed by Dr. Stephen Porges, aims to support the nervous system in reaching a regulated state through listening to music specifically designed to strengthen the vulnerable polyvagal system, which supports social engagement experiences. (For more details on the Safe and Sound Protocol, please see https://integratedlistening.com/ssp-safe-sound- protocol/).
The parents shared that David was often resistant to entering the camera area of the screen and did not believe playing with someone on the computer could be fun. Therefore, I felt it was unrealistic to expect David to sit and engage in the SSP at the start of the session. Therefore, I planned to engage him first with fun, playful Theraplay® activities. Additionally, I assured the parents it was okay if I couldn’t always physically see David on the screen. I would ask my parents to be my eyes, ears, and hands as needed.
Our first meeting was 15 minutes, with Structure activities involving physical movements, such as Funny Ways to Cross the Room, Balloon Pass, and Bean Bag Drop. We began with more physically active activities, meeting David at his level and slowly decreasing the pacing, such as: Mirroring with a twist. I had Mom lead the mirroring as typical, and then I instructed “fast forward” or “slow motion” to lead the game's tempo. During this session, David participated fully and often interacted happily on the camera screen. Ultimately, he asked, “When will we play again.” Although David was having fun and could have extended the session, we did not. I felt it was important to end while he was still feeling it was fun and was wanting more.
In the subsequent sessions, we began incorporating the SSP with Theraplay® activities. We would always begin with Theraplay® activities, initially a Structure or Engagement activity with some physical movement, moving to slower-paced activities and ending with a Nurture activity (usually a sequence of four activities). The reasons for implementing these activities in this order are to help establish synchronicity within the dyad and to instill some endorphin-like moments to counteract his physiologically triggered cortisol surges of flight, fight and, at times, freeze responses. I then would lead the transition to the Safe and Sound Protocol. We decided both David and his parent would listen to the music together (each with headphones). This helped increase David’s comfort level and foster further connection in the experience.
David’s earlier blueprint of trauma contributed to his ongoing difficulties in achieving a regulated state of calm or safety, which in SSP terms, means he has been unable to reach a ventral vagal state of social engagement. For David, when beginning the SSP, it was difficult to remain in this ventral vagal state, and thus it was important to have attunement and co-regulating strategies. Initially, during the SSP, we only began with five-minute chunks to provide an experience that could end successfully and not create future resistance from David. During this time, I would lead drawing activities in order to help him focus on something while listening, such as “Let’s all draw three animals playing with each other and share them at the end of the music.” After listening, we would then play another sequence of Theraplay® activities. I would include more Nurture Theraplay® activities during this portion to help co-regulate and calm his internally dysregulated states of arousal.
The subsequent sessions followed the same routine and worked to extend the length of the session time bit by bit. First, we added two chunks of SSP. Then slowly worked to increase the length of the time spent listening to the SSP. During this time, I also introduced the “stop” sign strategy. The goal of the strategy was to support David in noticing when his body felt “calm” or “safe.” For this strategy, David, his parent, and myself would each have a stop sign. We could hold the stop sign up when we noticed David’s body felt “uncomfortable,” “wiggly,” “tingly,” etc. We connected the stop sign to needing a break. Although my goal was to pause the SSP before David needing a break, I also wanted him to have a safe way to communicate when he was no longer feeling comfortable.
We continued moving through sessions in this way. David made many gains throughout these sessions. He could participate in the SSP for up to 15 minutes and eventually could select his activity from some options his parent would provide (ex, colouring, playdoh). David also spontaneously started using the stop sign strategy throughout his daily routine. It surprised me and his parents when David struggled to complete his morning routine and ran to get his stop sign, saying his body needed a break. His parent responded by doing some ‘calming touch’ through Theraplay activities such as doing the “weather report” on his back. David then felt ready to complete his routine. This was a HUGE success for the family.
These sessions provided the family with the support they needed immediately. It also provided the family with a framework for how they could help their child. The family expressed they were most grateful for the moments of laughter, connectedness, and love that filled these sessions. These sessions quickly became a highlight in their week and offered hope when they could have joyous and playful moments, protected from external stresses.
Children are resilient and, in my experience, much quicker to adapt than adults. If we provide them with the framework for success, they can follow. I’m continuously grateful that I had the foundation of Theraplay® to be able to adapt therapeutic activities to continue to support children and their families in healing, even through a virtual platform.
* To protect confidentiality, any identifying details have been removed. Additionally, some describing characteristics and the client’s name have been changed.
