As was the case for so many other therapists working with children and families, March 2020 felt overwhelming in our center for child and family therapy. From seeing clients in-person all day in our client-centered, carefully designed therapy rooms equipped with all the therapeutic tools that a child therapist might need to engage a child in the hard work of therapy, we scrambled to figure out a way to transfer our clinical tools to the virtual realm. The transition from using toys, games, animal assisted therapy, art, music, movement, and parent-child attunement enhancing interventions to connecting through a digital screen seemed at times to be an impossible mission.
The transition was especially challenging for our very young clients and those who appeared to have significant struggles with the adjustment to virtual education. Even after weeks of creating and identifying multiple virtual tools that enabled us to engage most of our clients in expressive ways to process their experiences and share their internal worlds with us, we consistently received skeptical messages from parents who were certain that their child would not be able to effectively use a virtual platform for their therapy work.
We were convinced that we would be eager to return to our carefully designed, in-person therapy rooms as soon as we possibly could safely do so. Little did we know that we would not only find the virtual therapeutic tools to be highly effective, even in some of our most challenging and complex cases, but we would also discover that there are many unexpected and valuable therapeutic benefits that come with this virtual approach to providing child and family mental health therapy services.
Logistical and Therapeutic Benefits of Virtual Therapy
The benefits of virtual therapy are both logistic and therapeutic. Parents have found that avoiding the “schlep” has been a significant help for them in their overly scheduled family-lives. In addition, the common reasons for canceling sessions have been greatly reduced, allowing for a consistent and predictable therapy schedule for children, which are significant factors in the efficacy of treatment and child-therapist relationships.
Therapeutically, we have been able to include family members (especially furry family members!) in new ways. When animals/pets are included in therapy, children feel more comfortable and open to process difficult thoughts and feelings. Connecting from the comfort (or for some, the discomfort) of their own personal environment encourages clients to share more fully and deeply about themselves and their home lives. They are able to show us their rooms, their favorite stuffed animals, and the reality of their family-life burdens. We observed this to be a clear benefit when one of our clients who had been in treatment for over a year began revealing family difficulties that they (and their parents) had kept protected until the therapist was able to “be in their home” virtually. While the treatment had been slow to progress during in-person sessions, the family dynamics were more distinctly revealed during virtual sessions, and the treatment started progressing in a more targeted way towards healing and repair.
“Being invited to our clients’ homes” also allows us to observe our clients’ experiences in their natural environments, rather than relying on reports and different perceptions. This proved to be highly valuable not only for our clinical assessments, but also for our ability to more accurately understand some of the environmental context as we witnessed some of these events and relationship dynamics first-hand. While these benefits became clear as we witnessed more and more therapeutic progress in our clients, we also had many hurdles to overcome; especially when it came to enhancing the efficacy and children’s (and parents’) willingness to engage in virtual therapy.
Challenges of Virtual Therapy
The transition to online sessions posed some significant challenges to the three main areas we consider to be crucial for the establishment of the sense of safety and trust that are at the root of the therapeutic relationship: How would a child feel connected, represented, and reflected with two screens and many miles between us?
Based on our training and previous experience, it seemed inconceivable to us that an authentic, trusting therapeutic connection could be created when the therapist and the client were not sharing the same physical space. A strong sense of connection reduces cortisol and increases dopamine, promoting client’s availability for therapeutic processing as well as resource- and skill-building. Many of the modalities we had been using for the purpose of promoting such a sense of connection (such as Theraplay®, sensory motor therapy, somatic therapy, expressive therapy, nature therapy, and animal-assisted therapy) are based on the therapist’s ability to incorporate playfulness, presence, eye contact, and touch. While we quickly found ways to be playful and engaging on a virtual platform, not sharing the same physical space made it challenging to demonstrate attuned presence, while use of eye contact and touch became impossible.
The physical distance, combined with the limited ability to notice important nervous system signals such as subtle nonverbal cues including the breath and the energy level of our clients, posed significant barriers to our ability to “accurately read” our clients’ mental state in order to effectively connect and intervene.
Furthermore, the materials we had selected to share with clients in our office had been carefully selected and designed to demonstrate positive representations of our clients, their unique attributes, cultural diversity, different abilities, mobilities, areas of strengths and needs, and areas of interests. Research shows that self-representation leads to an increase in:
- Sense of belonging and comfort in social settings;
- Understanding of self and others;
- Pride in your own identity; and
- Capacity for learning.
We wondered if seeing our clients virtually would allow them to feel welcomed and represented in the same ways. Infusing diverse representation requires a level of attention to details that did not seem to be as widely available in the commonly used online therapy tools. According to NAEYC.org, a social setting that doesn’t reflect and validate children’s diverse identity may lead children to feel invisible, unimportant, incompetent, and ashamed of who they are. These feelings stand in complete contrast to what we work so hard to foster in our safe, affirming, and normalizing therapy settings.
Techniques such as reflective statements, head nods, eye movement, and synchronized breathing are widely used in therapy to foster a sense of security and safety between a therapist and a client. This careful and intentional reflection by the therapist will provide them with the supportive messages of, “my feelings make sense and are ok to feel.” By paying close attention to both their nonverbal and verbal communication and attempting to reflect it back, we can co-regulate our client’s nervous system and help them feel seen, heard, understood, and contained, which enables children to form an organized and integrated framework for processing and articulating their experiences and internal worlds.
This response to reflections can be explained by mirror neurons, which are a group of neurons that activate in our brain when we perform an action that mirrors another person’s action, or when we see our own action being performed by others. These neurons are active in human babies from birth and are considered crucial for our species’ survival. As Dan Siegel explains, a predictable sequence of motor actions being perceived by a series of sensory inputs creates a clear neuro-mapping of behavioral intentions that will determine the level of safety and security that a person can feel during an interaction with another person. Since virtual platforms limit our view of each other’s body language, and with connection through mirror neurons being necessary in order to build empathy, reciprocity, theory of mind, and other skills that are foundational for our capacity to form human connections and foster a sense of security in relationships, it was clear that we would need to find ways to “fire up” our mirror neurons within the limitations of the square screen.
Once we were able to identify these possible barriers in using virtual platforms for therapy with children, we were determined to find tools that would enable us to continue practicing in ways that address what we consider to be at the root of the therapeutic relationship: connection, reflection, and representation. Here is a list of some of the tools we found to be highly effective in overcoming these barriers.
Activities for Connection and Reflection While Apart
Theraplay© activities focus on four different dimensions of the parent-child relationships: engagement, challenge, structure, and nurture. These activities allow us to work with clients of all ages from prenatal to adolescents, along with siblings and caregivers by targeting the areas of needs in their relationships and enhancing the areas of strengths. Since we know that in-person Theraplay® activities are designed to activate our mirror neurons in order to facilitate deep connections and enhance attachments, we turned to these activities for our virtual sessions. In fact, in the spring of 2020 the Theraplay® Institute quickly rolled out modified virtual versions of attachment and connection enhancement activities which also included synchronicity as a newly discussed key element of connection.
One especially effective activity is the mirror game, where the therapist and client take turns moving their hands, head, and even facial expression as the “leader” while the other follows as the “mirror.” We also built special handshakes by bumping our fists, noses or elbows to the camera. These, along with other Theraplay© activities, are now part of our routines for opening and closing virtual sessions in order to establish and maintain reflection and connection with our clients. For example, a 6-year-old who had difficulty feeling connected on the virtual platform kept her camera off and stayed muted during school. She was enrolled in our virtual connection therapy group due to her severe anxiety about participating on screen. After observing her group peers creating their special handshake, each adding a new move to make it longer and more challenging, the screen came on with a monkey stuffed animal face, rather than the client’s face. The “monkey” joined in the handshake!
After three weeks of participating via the monkey, the client felt comfortable and connected enough to join the handshake, and soon after that, to join the entire group session. Not only did the client make these gains in the therapy group, but when we informed her teacher about this connection strategy, it enabled the client to increase participation and decrease anxiety during the difficult days of virtual school. One of her parents even started using the special handshake with her first thing in the morning to start the day off feeling connected!
Virtual Tool for Expression and Representation
Pixton is an online comic creator that offers children an opportunity to design their virtual characters (aka avatars) and create comics, stories, and narratives in fun and engaging ways. This type of tool allows clients the ability to explore different experiences with an enhanced sense of safety that is created by each child’s ability to choose their own comfort level with the emotional distance from their characters and the narrative they represent.
For example, some children are comfortable being direct and using their own character and experiences, while others might feel a need to create additional layers of emotional safety by writing about a different character or an imaginative experience. In addition, because it provides character templates and pre-made backgrounds, Pixton allows children to tell their stories without the artistic skills limitations that so often become a barrier to children’s self-expression.
Furthermore, Pixton offers a highly diverse and inclusive array of options for the creation of characters that enable all children to feel fully and accurately represented. Options include non-binary gender expression, assistive technology and mobility devices, culturally diverse articles of clothing, diverse religious settings and symbols, many skin tones, different body shapes, and unlimited options for family structures.
By using Pixton during virtual sessions, we quickly saw clients making choices to represent themselves as they are, as they hoped to be, or as they might fear to be perceived by others. One of our adolescent clients shared that he fears being perceived as feminine through designing his Pixton avatar to look feminine and choosing non-binary clothing. This client’s experience of representation led the way to further exploring his gender, sexuality, and self-identity as well as his social anxiety as it relates to his identity—a significant breakthrough in his treatment. One of our 5-year-old clients with significant mobility and physical limitations accurately represented herself using a wheelchair, and then created her avatar to look like a powerful superhero! Her experience of representation allowed her to process and explore both her limitations and her unique strengths and resources.
Creating Your Virtual Therapy Setting to Foster Connection, Reflection, and Representation
In many cultures “mental health is often perceived as a harmonious balance between a person’s internal and external influences. Thus, a person is intrinsically linked to their environment and vice versa.” What you surround yourself with on your virtual screen matters! Put careful thought into designing your virtual setting in a way that will be engaging to your clients and to represent their internal world. Your background will set the tone for how connected, reflected, and represented your clients feel during their virtual sessions. Ensure that your camera is not facing a door, as doors represent possibility for disruption and might decrease your clients’ sense of containment, and therefore can hinder their sense of connection.
Consider intentionally placing interactive toys like a Kimochi with a wide array of feelings that can be experienced at the same time, a Feisty Pet that shows anger, and books, posters, and toys that reflect meaningful representations of differences. Tools and toys for representation are available from stores such as Toy Like Me, Multicultural Classroom Materials & Diverse Toys for Preschool, Representation Matters in Toys, and Best Anti-Racist Toys for Kids.
Ensure that your background meets the unique needs of each of your clients by placing and even replacing items that could facilitate processing relevant experiences to each client’s individualized therapeutic goals. For a client who is working on understanding their anxiety, you might choose to place different toy models of the brain and a Worry Monster; for clients experiencing or recovering from medical trauma or anticipating an upcoming medical procedure, you can place toy models of the body or different body organs.
One of our 9-year-old clients who had been experiencing a chronic medical condition requiring continued procedures and several major surgeries, was excited to notice different models of the human body and share their experiences in detail, allowing them to explore the body with a sense of control and process their traumas.
Final Thoughts on Virtual Therapy
While it was a long and challenging journey to adjust our expressive and experiential therapeutic modalities to a virtual platform, we now advocate for its high effectiveness. In fact, it is currently often our preferred platform for treating children and families. Not only do we see the benefits of the virtual tools we are using with our clients, but when given the choice, it seems that even parents who were once the biggest skeptics are opting for virtual therapy because they appreciate the flexibility, ease of access and evidence of progress in their families. Virtual therapy is not going away, and neither is the need to foster connection, reflection, and representation in every therapeutic setting.
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