Dimensions of Successful Telehealth Play Therapy with Young Children

Created by Heather Fairlee Denbrough, LiCSW, RPT-S, Certified Synergetic Play Therapist

With information gratefully gathered from Synergetic Play Therapy, Lisa Dion, Dan Siegel, Peter Levine, Stephan Porges, personal experience with telehealth, information from supervisees, and the input of the Certified SPT Therapist community.

Note: I come from an almost entirely non-directive perspective, and much of this guide is created specifically to allow non-directive play to be the primary focus of the session. You can easily adapt these strategies to better facilitate more directive sessions.

Overview — Dimensions of successful telehealth play therapy with young children:

  • Mindset on the “online” space
  • Conceptualization of the telehealth session as “safe container”
  • Engaging mirror neurons & social engagement circuit/ developing “Felt Sense”
  • Parent training/parental involvement
  • Person of the therapist/Attachment to Self and use of Self

Additionally in this guide you will find:

  • Trouble-shooting questions for when a child cannot engage
  • Further notes on lack of engagement
  • Specific strategies that have been successful
  • Resources for further exploration

Mindset on the “online” space:

While it is true that “being online” with someone is not the same as an in person face to face interaction, it is also true that through the medium of video, we can access the parts of our brain that allow us to safely connect with other humans. Our perceptions are what drives our internal states and ability to connect! If you find yourself thinking, “This doesn’t work,” can’t work, isn’t right for young children as a blanket statement, consider that your perceptions have a direct effect on your own ability to engage your Self in the work. Many people use video chat to make powerful and beautiful connections with family, friends, and yes, children. Check in with yourself around your perceptions of what it means to be “online.”

Engagement of mirror neurons & social engagement circuit:

Stephen Porges (creator of the Polyvagal Theory) has talked about how video chat is one of our primary tools in reducing isolation and creating warm human connection throughout the time of COVID. He talks about how video chat, despite there being less sensory information for us to use, therefore requiring more intentional presence, still is incredibly valuable for engaging our mirror neurons and our social engagement and resonance circuits in the brain.

What does that mean if you aren’t a total neuroscience nerd?

It means that the face to face we can get through telehealth still has the power and capacity to bring the child a “felt sense” of us and through that felt sense, feel safe enough in relationship to play as they need to, work on their treatment goals, and reach a place of empowerment.

Think about the moments of honest connection that you have had with friends or family via Zoom or Facetime or whatever video app you use. You can create that with children in the therapy space as well.

Conceptualizing the session: Telehealth session as Safe Container for the Child

The key to successful play therapy telehealth sessions is to create a structure/safe container around the experience for the child, so that the child understands what will happen and what is expected, creating a neuroception of safety, which allows for freely flowing play to occur. If the child does not feel safe, the space for play doesn’t open up.

You will need to go directive at first to create the safe container for the child. The directive creates the container. Then, once the container is created, you can go non-directive WITHIN the container. You can then track and reflect just as you would typically do. You can help create containment on either side of the camera (either by what you do or what you ask the child to do.)

Example of going directive to non-directive within the prompt: “I want you to get the basket of toys. I want you to show me what it feels like to be at home.”

I tend to start sessions with the child by saying, “Let’s take a look at the toys you’ve chosen and see what we want to play with.”

Once the outer structure/container is created in this way, then it becomes much easier for children to engage in non-directive play, and then I just proceed as I would normally proceed if I was in the room with the child (presence, mindfulness, reflective statements, authenticity, naming the experience.)

To set up the safe container:

  • The therapist creates a “felt sense” of themselves for the child through intentional presence
  • Parent helps set the structure
  • We offer minimal structure/directive at the beginning to support the child in being able to then go
    non-directive and move into free play
  • We support the child in regulating themselves throughout the session with the use of our nervous system (for more insight into this process, please look into Synergetic Play Therapy)

Parent training/ parental involvement – what it looks like:

Parents must be involved in creating the structure & space for the child!

A parent training session is required for successful telehealth play therapy and should include the explanation of what you need from the parent for therapy to be successful, coaching the parent on set up, and bringing the parent “alongside” so that they understand WHY you are requesting that they follow these guidelines. Remember that parents are not play therapists — they may not fully understand why we’re requesting that they do specific things, and giving them the “behind the scenes” of what purpose our requests serve is important. Additionally, follow up parent sessions may be needed to trouble shoot, problem solve, or explore barriers to success.

What do parents need to agree to provide to make therapy successful?

Parent needs to create a safe, quiet, and confidential space for therapy so that their child is able to feel comfortable participating.

Parent needs to help set the expectation/understanding for their child about their playtime. A brilliant child used the words, “Heather, let me show you how I play at home.” I have used this wise phrasing to create the invitation for children to play, and it has been very successful.

Parent needs to manage the set up and technology for the child – so at the beginning of each session, the parent logs on, adjusts video/audio, and sets up the camera where the therapist can see both the child and what they are playing with. I require that parents do this for all the children I see.

The parent helps the child choose 3-5 items/toys to put in a bin for therapy. “What would you like to choose to play with and show Miss Heather today? Let’s pick some toys for you two to play with together.”

Suggestions for parents if they need additional guidance:
● Art materials
● Pretend play/dress up items
● Animals
● Puppets
● Instruments

The bin with the toys goes next to the space for therapy so the child can easily and immediately access what they want.

If the child struggles with staying in front of the camera, the parent needs to put down a small towel or folded blanket and tell the child “When you stay here on the blanket, Miss Heather can see you to play with you. When you move off the blanket, she can’t see you anymore.”

Parent needs to be accessible to the therapist by phone as if they are “in the waiting room,” so that if support from the parent is needed they can easily intervene, for example, if the child needs in person support regulating, the camera falls down or audio goes out, etc.

If the parent needs to be in the room to keep child safe, their role should be either 1) to play with the child with coaching from the therapist OR 2) to “sit back” off behind the camera and “do their own thing” like read a magazine so that the child has 1:1 time with the therapist.

Some children that I am working with also participate very well if they can “direct” the parent to use the camera to specifically show me certain things they are playing that they want me to see.

Person of the therapist/Attachment to Self and use of Self:

It is also important for you to prepare yourself for the session in a way that serves to set up your own “safe container” around the experience. You cannot provide a container to the child if you yourself feel uncontained. Here are some ways that I have found to do this.

Have a dedicated space of play for yourself. Mine is a purple yoga mat folded over, as I almost always sit on the floor with children. My shelf of toys, instruments, and art materials is next to it. In the background where the child can see them on camera I have a huge stuffie and some puppets to recreate the feel of my playroom.

Breathe and offer the child a felt sense of YOU. I do this energetically – I think about the online “shared space” that the child and I are occupying together as a special “playroom” of its own. I imagine the “safe container” for therapy to extend in a wide circle around me and the child, and hold that space with my breath and regulation, just as I would in the physical playroom, but creating the “shared space” in my mind. You are with the child and the child is with you. Through the interplay of our social nervous systems, we are functionally together even when physically separated. I am with the child despite the distance.

Evoke the child in your mind to feel closer to them. Engage your mirror neurons, and theirs too. Remember your felt sense of the child when they’re in the room with you. Bring that sense up in your body, and respond to it. If it’s a child you don’t know yet, evoke your sense of what it feels like in the room when you meet a new child there, or what it feels like to be with a friend’s child or your own child, and hinge your somatic experience there. Bring in the sensation of meeting a child where they are, and meet them in the “shared space.”

Give yourself transitional space after sessions as well so that you can move into your next “shared space” feeling open and refreshed. Just like we need to tend to ourselves in between physical sessions, we must do the same when using telehealth. Don’t just go do a load of your laundry — get a cup of tea, massage your neck or hands, stand in your backyard and breathe. Be aware that telehealth sessions may tire you more easily due to the increased energy it takes to stay present with fewer sensory cues being offered. Tend to your Self and attach to your Self so that you can continue to be present.

Trouble-shooting questions for when kiddos are struggling to stay engaged:

Review the steps to create the safe container. Are there areas where the parent needs to step back in and create more structure? Do they have the blanket to help the child visualize their space? Are they making sure to have the child choose their toys and have them in the bin?

Think about the space that the child is in. Is it busy, visually cluttered? Are other people walking in and out? Are there electronics on or within reach of the child that seem to be distracting? Is it quiet? Are there ways to pare down the space to make it easier for the child to access their flow in play?

Is the child starting off engaged, but then tending to drift as the session continues? Is the length of the session actually too long for this particular child? I have had success with doing 20-30 minute sessions with the youngest of my kids, letting them know exactly how long we have, and giving them a timed transition out at the end. With this additional structure, even the youngest children I see have been able to engage throughout the session.

Are you yourself distracted, tired, thinking about other things, tempted to check your email? Are you feeling distraught, like it “isn’t working?” Are you telling yourself that you “should” be doing therapy another way or better or more successfully? Tend to your own sensations and perceptions, as the child “feels” you, just as you “feel” them. Just be with the child and follow their lead.

Is the child indicating that they want or need their parent to be more present throughout the session? Are they seeking for relationship?

Is the parent attempting to “make” the child participate by telling them to sit still or talk more or pay attention? If this is the case, a follow up conversation with the parent is needed to review why we allow children to titrate their own experience of therapy, so that they don’t become emotionally flooded and unable to engage. Problem solving with the parent can help with this, as well as talking explicitly about how a child does not “have to” do anything specific in therapy – they are here to engage with themselves and figure themselves out.

When in doubt — return to the most seminal of ideas in play therapy, and …

… Follow the child.

Further notes on lack of engagement:

If a child is struggling to engage fully, dedicating more time/energy to figuring out the set up/structure of the session and how it is talked about has been the most helpful in successfully getting re-engagement.

Also: Sometimes children, just like adults, just don’t want to do therapy. They may be tired, unhappy, distracted, getting sick, or any number of other things that might get in the way of engagement. Remember that therapy, even play therapy, is WORK for children — and sometimes we are too exhausted to work.

Additionally, children who have been doing school on Zoom or other video media are also hitting a point of screen-exhaustion, but, as they are little, often don’t know how to put that feeling into words.

Specific strategies that have been successful:

Reaching through the screen to offer toys or “share” things with the child, passing them “back and forth” as you would in the playroom

Using Zoom virtual backgrounds to initiate or enhance imaginative play (you can save pictures to your computer and then use them as backgrounds.) Use these to show location (a flower field, an old abandoned house, a comfy living room, etc.) and sharing what emotion it evokes. You can build on it by describing the body sensations and working on interoception, or using it as a jumping off point for moving into imaginative non-directive play. You can also bring in characters like Elsa or Hulk that kids connect with and use them as the prompt for non-directive.

“Share” food, passing snacks to one another and eating them

Mirror — if the child is playing with makeup, I take out my own makeup bag and join her and we “share” makeup

High-fiving/touching hands, touching noses “through” the screen (gets those mirror neurons going)

Pay attention to any toys that show up as the self-object and interact with them

Rock babies and soothe them together

Reintroduce toys from your playroom that the child likes and wants to see again “Look who’s here today! It’s your fave little giraffe!”

Resources for further exploration:

Synergetic Play Therapy Institute

Dr. Stephen Porges on the “shared space” in online work

Lessons from the Playroom podcast: Does Telehealth Work in Play Therapy?

Lessons from the Playroom podcast: Online Therapy and Therapist Fatigue

SPT Blog: Overcoming Fatigue in Teletherapy

How to Locate Your Felt Sense

Dr. Peter Levine Describes the “Felt Sense”

Dan Siegel Explains Mirror Neurons video

Stephen Porges on COVID & social engagement

Harnessing a Neuroception of Safety in a Fearful World with Dr. Stephen Porges

The Neurobiology of We – Patty de Llosa

About Heather Fairlee Denbrough:
Heather is a Licensed Clinical Social Worker, Registered Play Therapist Supervisor, and Certified Synergetic Play Therapist. She has worked in community mental health for 11 years and counting. Heather’s specialty areas are: children ages 2-9 years, early childhood trauma, attachment, parent-child relational issues, and parent training/coaching/inner work. Heather also practices reflective play supervision. Heather has created and led trainings for therapists on topics such as: Introduction to the Nervous System, Authenticity in Parent Work/ Supporting Parent Shadow Work, Working with Families of Faith, Unusual Presentations of PTSD in Young Children, Respecting Young Children in Therapy, and more. She currently facilitates an ongoing curriculum-based group for therapists on Interpersonal Neurobiology in the Therapy Room. She comes from a Synergetic and non-directive perspective.

Contact:
Heather Fairlee Denbrough, LiCSW, RPT-S, Certified Synergetic Play Therapist – heatherfairlee@gmail.com