Play Based Activities in Family Counseling American Journal of Family Therapy

Abstract

The field of marriage and family therapy was founded by innovators and pioneers, taking the do of individual psychotherapy and making information technology systemic. Due to the impact of COVID-19, we now need further advancement by systemic therapists for telemental health services. The purpose of this newspaper is to advise recommendations and guidelines for adapting directed family unit play therapy from the same concrete location services to telemental wellness. The article discusses recommendations for assessment, therapy structure, therapist roles, session preparation, and how to utilize virtual tools to raise treatment. Systemic play therapy in a virtual format can piece of work well if therapists make appropriate adjustments and rely on their creativity, loftier regard for ethics, and innovation.

The do of therapy has undergone a revolution due to the touch of COVID-nineteen, with therapists across the country shifting to conducting sessions virtually. However, virtually therapists had lilliputian to no feel conducting telemental health (TMH), and very few MFT training programs provided opportunities for experience grooming (Cravens et al., 2020). Until the pandemic, the literature on systemic exercise in TMH was scant (Caldwell et al., 2017), compounding the challenges marriage and family unit therapists faced in moving their practice online in a safe, upstanding, legal, and effective way. The impact of COVID-19 created a sense of hyperawareness that caused an immediate necessity for filling in the gaps in systemic TMH research. Journals across the world are commencement to answer the telephone call of therapists thirsting for TMH applications for working with families.

The field of matrimony and family unit therapy was founded by innovators and pioneers, taking individual psychotherapy and making it systemic. We at present need a similar revolution by systemic therapists in the field of telemental health. Although the pandemic has forced many therapists and clients to practise it out of necessity, TMH is not a new concept for the field of psychotherapy. Telemedicine has been practiced in the medical field for over a hundred years (Strehle & Shabde, 2006). It has been slowly gaining traction for mental health professionals over the past two decades. Yet, our field has lagged behind others. While some researchers are doing not bad work in this expanse (e.chiliad., Richard Bischoff, Jaclyn Cravens, Katherine Hertlein, Paul Springer), well-nigh enquiry, training, and exercise have been conducted by psychologists and counselors for private therapy. Just as our founders inverse the landscape of mental health through their innovation and creativity, the time is ripe for marriage and family unit therapists to bring this aforementioned spirit of innovation to the do of TMH.

In this spirit, the purpose of this paper is to propose recommendations and guidance for how to suit directive family play therapy to TMH. We believe that directive family play therapy (DFPT) is an excellent arroyo to relational telemental health considering of its ease of apply and straight approach. However, information technology is as well 1 that has inherent challenges to suit. While most clinical models tin can be easily adapted using a telemental health platform (Grady et al., 2011), those that require interaction between the therapist and clients, such as play therapy, tin can be much more challenging to accommodate. No published refereed scholarship currently recommends or proposes methods and interventions for adapting systemic family play therapy to TMH. We believe that therapists tin can suit directed family play therapy to be just every bit effective through virtual services as it is through in-person services.

Before researchers tin test new methods, those methods must first be developed and proposed. We aim to be among those who take this start stride and advise those methods in this paper. The methods, interventions, and recommendations suggested herein come not but from our own experience every bit systemic TMH practitioners simply also from the wider field of systemic TMH therapists. Nosotros thank all those who consulted with us throughout the years, sharing their knowledge, experience, and ideas. I of this manuscript'southward chief purposes is to requite systemic therapists a starting identify to begin adapting TMH to play therapy, open a greater dialogue in the scholarship for methods and techniques to conducting systemic TMH, and give researchers a base to do systemic TMH inquiry. We encounter this paper as a first step into systemic play therapy in TMH. We invite other family unit therapy scholars to add together to the literature and give a greater collective knowledge base to explore this new medium for delivering systemic services to families and children.

Directed Versus Non-Directed Family Play Therapy

Children may have difficulty expressing feelings verbally in family psychotherapy due to a lack of comprehension of emotions, emotional disharmonize, or emotional avoidance (Fromberg & Bergen, 1988; Harter, 1977). In add-on, many models of family psychotherapy are not designed for active immature children (Botkin, 2000). Thus, integrating play into family psychotherapy becomes a powerful approach allowing children and adults to build and heal relationships (Botkin, 2000; Drewes et al., 2011).

Play therapy allows children to project feelings through a medium of particularly selected symbolic play toys (Landreth, 2012). Play for children is a natural language of symbolic representation in that information technology allows children to work out experiences that have been perplexing or pitiful (Landreth, 2012). Symbolic play for children "bridges the gap between concrete experience and abstract thought" (Landreth, 2012, p. xvi; Piaget, 1962). Through play, children's emotional expression allows for deep meanings within their subconscious to be expressed without attempting to please the adults in their adult linguistic communication (Axline, 1950; Landreth, 2012; Piaget, 1962). In Non-directed play therapy, the therapist's role is to create a safe environment for self-expression, take the child fully where they are, and allow the child to lead the sessions (VanFleet et al., 2010). The kid obtains insight from the therapist's tracking and reflection interventions. The "kid leads and the therapist follows" (VanFleet et al., 2010, p. 21).

In Directed Family Play Therapy, handling focuses on directing the family to change through play (Ariel, 1992). The therapist directs the play communication through treatment planning and developmentally appropriate play directives that accost family functioning and problems. This approach varies significantly from non-directive play therapy theory, where the focus is the kid leading the sessions (Landreth, 2012). Rather than just relying on the parent perspective alone, DFPT allows the therapist to find the parent–child human relationship'southward communication and interactions. Additionally, it allows parents and children to practise communication and coping skills during treatment, which results in meliorate outcomes than parent-preparation programs alone (Kaminski & Claussen, 2017; Kaminski et al., 2008). The goal of DFPT is to create a safety environs whereby therapists can develop play therapy scenarios within the child'southward zone of proximal evolution that challenges both the parents and the child's unconscious procedure and defense mechanisms (Rasmussen & Cunningham, 1995). This and then leads to triggering the family roles and interaction patterns to manifest in session. Fleming and colleagues found that parents who provided negative attention during child-directed play interventions had children with college conduct problems at home and schoolhouse during middle childhood. Therapists can utilize the DFPT model to assist children whose parents report behavioral problems at home and schoolhouse (Fleming et al., 2017).

This model posits that the presenting trouble is a symptom of the family system (Ariel, 1996; Eaker, 1986). Therefore, an additional component of DFPT is that when therapists piece of work with the entire family, the therapist must align with each family member to understand the problem better and go part of the system (Haley & Richeport-Haley, 2003). Therapeutic brotherhood and joining build trust among the family members and is crucial for systemic change. When working with immature children using DFPT, therapists bring together and express understanding of the family unit arrangement through play.

The DFPT therapist creates, directs, and is active throughout family play sessions. The therapist volition phase "possible worlds" of imaginative play to allow the parents and kid to communicate their perceived and ideal realities (Ariel, 1992, p. 19). The therapist continually observes all family members' behaviors and advice to decide the next steps to have (Ariel, 1992). Family play is a source of gathering information virtually the family'south advice and relationships, followed by the utilize of play as an instrument for facilitating change (Ariel, 1996). The directive play method focuses on using parent–child relationship grooming and skill-building using a prescriptive arroyo to play-based interventions (Drewes et al., 2011). For children who do not yet have the cognitive skills necessary to implement coping behaviors, the therapist coaches them to develop and practice new trouble-solving skills inside the playroom (O'Connor, 2001). When using DFPT, the therapist coaches the parents and the child(ren) to develop these skills within the playroom. Considering of the model's flexible and directive nature, DFPT can easily be adjusted to an online platform.

Benefits of Telemental Health & Family Therapy

There are many benefits for therapists to utilize TMH for DFPT (run across Table 1). While the purpose of this article is not to provide an exhaustive review of the benefits of TMH, we review the almost of import benefits hither. First, TMH provides a unique opportunity for therapists to gather information by viewing families in their homes, similar to abode-based family counseling (Tate et al., 2014). Therapists tin witness the family communication and interaction within their habitation environs as one child jumps on the couch, i child colors silently on the floor, and the reactions of the parents and the family unit dog.

Table 1 Summary chart of benefits, challenges, and contraindication of directive family play teletherapy

Total size table

Second, TMH can potentially reduce barriers to systemic treatment. With greater accessibility and ease of use, families take more than immediate access to telemental health services (Campos, 2009). Underserved populations and those living in rural areas can apply telemental health services and reach a broader range of therapists who may specialize in their needs (Nelson & Patton, 2016). Considering of engineering's continued advancement, younger populations are more open and comfortable using TMH for treatment (Boydell et al., 2014). Families studied using video platform sessions reported feeling comfortable and safe in their own abode, less stigmatized nearly receiving treatment, and that handling is more than convenient (Lingley-Pottie & McGrath, 2008). Families report increased satisfaction with telemental health due to the convenience of meeting in their own homes (Wade et al., 2004).

Third, families' treatment goals can be accomplished using telemental health platforms (Nelson & Patton, 2016). Efficacy is not lost through telemental health sessions versus contiguous sessions (Perle & Nierenberg, 2013). One concern for therapists has been a fear of loss of the therapeutic relationship through a video platform. However, parents and children report a stiff therapeutic brotherhood with the therapist using telemental wellness (Wade et al., 2004). Results from online family psychotherapy with children who had experienced traumatic brain injury revealed similar results to those previously conducted in face-to-face sessions (Wade et al., 2004). Kid psychiatrists can provide an accurate diagnosis, and families report high satisfaction using telepsychiatry (Boydell et al., 2014). The use of Cognitive Behavioral Therapy (CBT) interventions using telemental health is as constructive as face-to-face sessions with children and adolescents (Boydell et al., 2014). A study investigating TMH versus face-to-face treatment of 233 children with Attending Deficit Hyperactivity Disorder establish that children in both groups demonstrated improvement with treatment. Additionally, the caregivers reported that children with ADHD significantly reduced behavioral issues at home with TMH handling (Myers et al., 2015).

Fourth, TMH makes information technology easier to take all family members present for family sessions, especially working parents. Due to scheduling conflicts and transportation issues, getting all available caregivers and siblings to a family can oft exist challenging. It is non uncommon when parents request therapy that one child is the identified patient, and typically one parent brings the child to sessions. Using an online platform allows for reduced scheduling conflicts. It can thereby increase all family members' omnipresence considering the therapist can schedule appointments when all caregivers and family unit members are home to nourish sessions.

Adapting Directed Family unit Play Therapy to TMH

Whether using DFPT in the exact concrete location or virtual services, the theory of alter works the aforementioned. The family meets together all in ane room and interacts in much the same mode for both delivery methods. The family engages in directed play activities developed and planned by the therapist, and the focus of handling is on the handling goals, which are developed collaboratively with family members. This collaborative effort establishes rapport with the family and reframes the bug as a family outcome, rather than one person being viewed as the trouble. The therapeutic alliance with parents is essential to the parent coaching portion of DFPT by ensuring parents follow the therapist's directive play during family unit play sessions. Nonetheless, in virtual telehealth sessions, the therapist is not physically nowadays with the family in their home environment.

In this section, we propose our recommendations for adapting family play therapy to TMH services. This paper is non intended to serve as a general overview of the practices or ethics of TMH mostly. The post-obit recommendations assume that therapists take adequate training and noesis in TMH. These guidelines predicate therapists who exercise ethically and legally and fundamentally piece of work on the logistic and clinical adaptations necessary to provide telemental health services. Consequently, these recommendations focus solely on those related to the accommodation of systemic play therapy.

The First Session

Typically, a family play therapist would accept the whole family present at the get-go session for initial assessment and then follow up with a parent consultation. In face-to-face sessions, the family comes into the therapist's space, wherein the therapist has various specific play materials to apply in each session. However, in TMH, the therapist cannot do this without advanced planning with the parents. Consequently, the first accommodation that therapists need to make is planning and preparing for the get-go session. We suggest that this begins by flipping the commencement session's structure past holding a parent consultation before the first family session.

Needs Assessment

Before the starting time family unit session, it is necessary to conduct a needs assessment during the initial parental consultation. DFPT is most effective with families with children under the historic period of 8; however, information technology has likewise been beneficial for some children up to age 11 (Lin & Bratton, 2015). Obtaining information on the child'due south play and assessing for prophylactic concerns is essential to determine appropriateness for DFPT. Providing psychoeducation to parents on DFPT and what to expect in session is necessary for the needs cess. Explaining to parents that the children may not view the problem in the same style equally adult family members. For example, explaining to parents, "Sally may not experience comfortable talking most her lying or even sympathise it. When we play, some toys may start lying. This is her way of working out through play what she cannot express verbally because she lacks agreement."

Additionally, in DFPT, children are non actively engaged in talk therapy; instead, they communicate through play. Therefore, the family will employ the kid'due south play linguistic communication to communicate with the direction and help of the therapist. Defining therapeutic boundaries, good for you feeling expression expectations, limit setting, and therapeutic goals are also essential to address in the needs cess.

Therapists need to evaluate the family unit's play, art, and technological resources during the needs cess to determine how to structure and ready for TMH sessions. Additionally, since the family play sessions are taking identify in their abode, obtaining information from the parents on their comfort level using messy play items such every bit playdough, glue, paint, and markers is essential. During this needs assessment, it is besides vital to obtain information from the parents regarding whatever family rules restricting specific toys, magic, or games in their home.

When conducting telemental wellness services, therapists need to communicate in accelerate with families to take the necessary play materials ready. This allows the therapist to plan session activities intentionally and know what kinds of activities are even possible. In the initial consultation, therapists should obtain a list of play items the parents have in the home and, if necessary, boosted items that would exist important for the parents to obtain. Therapists might need to direct parents to acquire necessary items before a session. For example, if puppets are needed for a role play for the next session, therapists volition direct parents to make a certain number of puppets using newspaper plates, paper sacks, socks, or other household items. For families that do not have the needs or ability (e.g., low SES or high-stress families) to make or buy items, it may also be necessary for the therapist to mail items to the family in advance. Without a needs assessment, the therapist would not be able to plan for sessions or assure that the family will be prepared for the session's planned activities.

Conducting a needs assessment tin be made easier with documentation and premade handouts. Because families may have widely different resources, the therapist must accurately and carefully document the needs assessment results. Premade handouts can make this fifty-fifty easier. A elementary checklist of items, organized by blazon of resource (art supplies, dolls, animal toys, printer, paper, etc.), can significantly do good the therapist in documenting the family unit'southward resources and planning according to each family's resources.

Family unit Play Therapy Toolbox

After conducting a needs assessment, the therapist can then work with the family to develop an individualized family play therapy toolbox, a designated box of supplies for family play therapy sessions. The family unit needs to have play therapy resources for virtual sessions similar to those that the therapist has in their office. The therapist and family need to have a similar set of toys for imaginative play for story congruence, construction, and organisation (Dimitropoulos et al., 2017). Having a family play therapy toolbox would permit for ease of access for families during sessions, create consistency for the children, and permit easier planning for the therapist. Rather than calling the family unit before each session to have the family unit gather play resources for the session, the family can have one box of resource to exist used from session to session.

When deciding on the family unit toolbox materials, it is essential to remember that each item has a purpose in helping the family reach their therapeutic goals. In-play therapy, "toys are viewed every bit the child's words and play equally the child'due south language—a language of action which may contain more meaningful cloth than verbalized words" (Landreth, 2002, p. 529). Helping families understand the importance of play and items in the toolbox is a meaningful conversation to accept with parents to set up a meaningful toolbox for therapy.

Using the objects in the toolbox creates opportunities for families to learn, practise, and demonstrate skills during telehealth sessions. Suggested items for the family unit play therapy toolbox include a variety of miniature, real-life figurines of humans and animals, baby dolls, small vehicles (e.g., Hot Wheels), soft or squishy balls, games, and creative/expressive fine art materials. According to Landreth (2002), specific items such as handcuffs with a spring-release, two colors of soldiers, a iv-ft. rope, and a toy gun assistance children limited anger, frustration, or hostility. Toy animals (predators and prey) and farm animals, cats, dogs, spiders, and snakes tin exist used to act out experiences or scenarios directed by the therapist. For instance, the therapist can present a situation in which Milly the Goat ate Farmer Joe's tractor tire, and now Farmer Joe cannot plow the field, or Fido, the family true cat, feels sad since petty David received a puppy for his altogether. Puppets help children communicate their emotions, recreate life events, and test new behaviors (Desmond et al., 2015). According to Bromfield (1994), puppets are the well-nigh helpful tool for children and families because they are fun and tin can be made from everyday household items. Puppets can be fabricated with old socks, paper plates, or newspaper sacks. Legos are some other must-have in the toolbox. There are many means to employ Legos that require the family to accept common goals, constructive communication, and shared attention. For example, family members have to complete the task of creating a Lego structure and are given roles, including a planner who reads the Lego set'south instructions, a searcher who finds the pieces, and the builder who constructs (Peckett et al., 2016).

Fine art provides a way for family members to convey thoughts and feelings while being creative, so the following listing of items are essential to have in the toolbox: paper, a pencil, Crayons (8-count to avert likewise many choices), paint, blunt scissors, non-toxic glue, and Play-doh (Landreth, 2002). Other imaginative supplies such equally pipage cleaners, popsicle sticks, colored paper, notebook paper, and transparent record can too be added to the toolbox (Landreth, 2002). Paper plates are also an excellent substitute for eraser boards. Clients can depict their feelings on a paper plate and concord it upwardly equally a mask to communicate with family unit members or write on the plate; still, they might opt for using a small dry erase board during games. Families can too take advantage of their natural surroundings by adding sticks, rocks, and leaves to their toolbox. Children can use their imagination with rocks and often requite them healing or magical powers (Linn, 2010). Soft, squishy balls can assistance children remember whose turn information technology is to speak by tossing the ball to the family member who "has the floor." Playing cards have many uses and tin exist a smashing improver to the toolbox. For example, families can be instructed to play Go Fish. If a eye is fatigued, they share a feeling they are experiencing; if a spade, the player talks most their favorite family retentivity. If a diamond, they say something overnice about the person sitting to their left. If a club, they name something for which they are thankful. Therapists and families should also consider adding a kitchen timer to the toolbox for timed activities and boundary setting.

Therapists and families need to hash out appropriate and bachelor toys to choose the best toys for each family's toolbox that align with their specific therapy goals. Many of the materials discussed can be plant in the home or purchased at a local thrift or discount store. Families should be instructed to go on the therapy toolbox supplied with materials and toys that volition merely be used during therapy sessions and stored safely between sessions unless otherwise instructed. Continued parent consultations between sessions can be conducted to evaluate and reevaluate the family play therapy toolbox. It may be necessary to restock certain supplies, remove others, or add together new items as therapy progresses. Additionally, therapists must assess for appropriateness of the family'southward multicultural values and beliefs to make up one's mind if specific toys or games would go against their values.

Technology

One central difference betwixt private TMH and systemic TMH is multiple clients' presence in a single video conference call. Moreover, for family unit therapy, it is recommended that family members treat telemental health sessions similar to face-to-face up sessions as much every bit possible (Wrape & McGuinn, 2019). Therefore, information technology is ideal for the family unit members to be together in 1 location, rather than on separate video screens as can be done in other systemic therapies (e.g., couple therapy). This is and then the therapist can monitor the play interaction of family unit members in a single location that mimics their existent-life interactions. However, this presents unique challenges for the therapist to straight, view, and hear what is occurring on the family's side of the video briefing. Consequently, there are several unique adaptations and requirements for equipment, placement, lighting, and sound when conducting DFPT in a single location.

Camera Equipment and Placement

Setting up an surroundings where all family members can be seen on photographic camera is essential to systemic TMH (Nelson & Patton, 2016). When utilizing the family's home rather than a video therapy site, clear communication from the therapist on the best place to ready up the virtual session should be communicated, tested, and continually reassessed. It may even be necessary to motility and change the camera placement during the session equally family unit members motility and play with each other. The therapist needs to encounter the family's play and interactions, sometimes at dissimilar angles or levels (Dimitropoulos et al., 2017). One manner to minimize the need to move the photographic camera too ofttimes is to use a table with play items or a designated area rug that could help focus the family on playing in a specific area and direction. The therapist tin then work with the parents to find a photographic camera placement to best capture this area so that the therapist can easily see the interaction. Doing so can prevent having to spend too much therapy fourth dimension finding adequate camera placement.

Whereas TMH can often be done on a tablet or phone, having a laptop or desktop allows for better equipment suited to systemic TMH. For instance, external cameras are frequently much better compared to internal cameras and microphones as they permit for greater movement, wider viewing angles, and often have much better microphones. That way, the family tin keep the therapist stationary while placing the photographic camera in a higher or amend location. Laptops and desktops likewise have larger screens or the power to connect to a larger screen than tablets and phones. A larger screen would make information technology easier for all family members to view the therapist despite where they are located in the room. However, suppose information technology is determined that the family unit simply has a small screen such equally a tablet or phone during the needs assessment. In that case, the therapist should adapt play therapy interventions and use innovative means to all-time capture the family unit play sessions. For example, placing a phone on tiptop of a tripod or a tall object to view the play infinite better is an innovative way to work with the family unit'southward technological resources.

Lighting and Sound

Proper lighting is essential to exist able to view the family fairly in the whole play area. When setting up the play space for the session, it is essential to examination out the surface area to examine where overexposure (likewise much backlight) or underexposure (as well much darkness) may hinder the therapist's ability to observe the family. We recommend this be included in the needs cess and initial consultation so that the play area can be set up with adequate lighting for the session. It may be necessary for the parents to move lights, embrace lights, or adjust window blinds to create a lighting environs where the therapist can adequately view the whole play surface area.

Merely as it is essential to see all family members, it is vital to hear all family unit members. When working with large families or active children, having external microphones tin can be extremely helpful. While many external cameras also have Hd microphones that will be more than than adequate, purchasing external microphones may be helpful or necessary. Microphones with long cords can be purchased for $20USD, which allows for microphone movement during the session and greater flexibility for the therapist to hear the family members wherever they may be in the room.

Technology Testing & Instructional Materials

During the initial consultation with the parents, and equally necessary throughout treatment, information technology is crucial to communicate clearly and direct with the family how to use, set upwards, and troubleshoot engineering. Creating instructional materials (e.grand., videos and handouts) that walk clients through setting upwards their own infinite tin can assist initial consultations motion quickly and easily. Such instructional materials can also help clients empathise the all-time camera placements, lighting, and which kinds of equipment are recommended. Consequently, we suggest that these materials be easily attainable to clients and provided earlier the initial parent consultation.

Therapists must exist flexible and assertive about lighting, audio, and camera equipment for family therapy TMH sessions (Wrape & McGuinn, 2019). Therefore, we recommend that the therapist and parents test and troubleshoot the play space setup and assess video, lighting, and sound equipment before the first family session during the initial parent consultation. This tech run-through can as well allow the therapist and the parents to assess if additional equipment is needed for purchase.

After conducting the needs cess of play, art, and technology resources, therapists must consider whether it would be necessary to purchase or loan equipment for families who do not have the necessary fiscal means to obtain the appropriate equipment for TMH sessions. This can include play and art therapy kits, cameras, laptops, and microphones. When this is not possible or feasible, the therapist's flexibility and inventiveness become extremely important. For example, if the family unit has but i working tablet with poor mic quality, the therapist may adapt to where the tablet is placed where the family can be viewed with the mic muted, and a cell telephone is used for audio. Again, therapists and families must be flexible and piece of work together to determine the all-time technical and strategic arroyo.

Therapist Role: Play Autobus

One of the critical adaptations necessary for DFPT in telemental health is that the therapist must have a directive part as a play coach. Considering therapists are non physically present in the room to directly and participate in the play, therapists must direct parents to perform all of the play. While the therapist tin can play virtually, they cannot have the same shared play touch through the screen as they have in face up-to-face sessions. Thus the DFPT must be axiomatic in communication on directing the play, explicitly using a virtual platform. In a virtual session, therapists will need to direct the parents' movements using verbal communication. For example, "Mom, I desire you to cull an animal out of the animate being toys to show me what it feels like when you are feeling mad." The mother would choose an brute and play out the feelings, with farther direction from the therapist as necessary. The therapist would then state to the kid, "At present Johnny, now you pick an animal from the animal toys and show me what it feels like when Mom is feeling mad." The child would so select an animal toy and then play out his feelings towards the mother. Therapists in virtual sessions must exist detailed in their verbal directives to parents communicating with their children through play.

Setting Limits

Using the language of play allows children to bring their emotions to the surface; no emotional expression is taboo, including feelings of aggression (Landreth, 2002). Additionally, children may non have an awareness of how their emotions are manifesting in session. Limit setting helps create sensation of responsibility, self-command, boundaries, and emotional condom by anchoring the session to reality (Landreth, 2002). Therefore, working with children during family unit therapy is vital to the therapeutic human relationship for the therapist to prepare limits. These limits can range from how toys and others are treated, length of the session, voice book, and participation during the session to create a prophylactic place to express feelings. For instance, in a confront-to-face session, should a child get out the therapy room, the therapist may choose to redirect the child to the session's rules, and the parents would reinforce this limit bringing the child back to the session. However, during a virtual session, a child could feel freer to leave due to a session existence held in the child'southward domicile, a identify without the aforementioned kind of location and physical boundaries as a therapist's office. The essentials of limit setting can be used by therapists and modeled to parents for future apply. The limit setting formula is: "Step ane: admit the child's feelings, wishes, and wants; Footstep 2: communicate the limit; Step 3: target acceptable alternatives" (Landreth, 2002, p. 533). Therapists must communicate and continually reevaluate with parents how to troubleshoot limit setting during family therapy sessions.

Pre-session routines and environmental queues are two means to assistance manage the boosted challenge of therapy boundaries. One of the critical differences betwixt in-person therapy and TMH is the minimal transition time required for TMH. For example, there is no drive to the therapist's office or waiting for your date in a waiting room. With some planning and training, therapists and parents tin can assist give children a developmentally appropriate transition into the session. Because therapy is taking place in the child's home environment, nosotros recommend that therapists work with families to institute routines and rituals before the session starts. For example, children should take had a drink, snack, and use the restroom. Depending on the child'southward historic period and maturity, parents can include children in preparing the therapy space for the session, including preparing lighting, getting the play therapy toolbox, spreading out a rug or coating, or getting the laptop or tablet in place.

This preparation helps give the kid fourth dimension and space to emotionally and mentally set for the therapy session and establish ecology queues similar to those in a therapy function. Changing the space past making a family play therapy area creates an environmental queue that is now a unique and special time with dissimilar boundaries and rules than typically occurs in the home. We recommend that the therapist and parents reinforce these ecology queues straight (e.g., "We are now in special playtime. This time has different rules than you ordinarily have in your house. These rules include…"). The therapist and parents can as well employ additional ecology queues, such equally a visual timer demonstrating the time spent or remaining in the special family unit play session (Dimitropoulos et al., 2017). This can assist children learn the boundaries of remaining in that room for family play sessions during that special time. Play therapists go to keen lengths to make their role play infinite unique and rubber, and we recommend doing the same for the home play space. Doing then requires the therapist to be directive and passenger vehicle the parents through this procedure. The therapist cannot be physically present to constitute rituals and environmental queues for the family.

Transitioning out of Session

Although transitioning out of the session using a virtual format may be quicker, the family needs to build transitional rituals. There is no walk-out of the office or car ride domicile. Edifice in some decompression or processing fourth dimension tin can be just equally crucial for children as it can exist for adults, particularly for emotionally intense sessions (Wrape & McGuinn, 2019). Following family unit therapy with a ritual of putting abroad the therapy materials with music or doing a lighthearted activeness, game, yoga, or meditation exercise tin let families to shift out of the session into a dissimilar headspace earlier returning to the "normal" life at habitation.

Preparing for Subsequent Sessions

When conducting virtual sessions, treatment planning requires arrangement and weekly communication with parents. In the DFPT model using a virtual platform, the therapist is the play coach, and the parents perform the play with the child(ren). This approach requires advice and directives with parents before each session. Parents must be provided ample time to prepare for the session. Therefore, therapists must decide what 24-hour interval to communicate the treatment plan for the calendar week for each family. This consistency allows parents to be prepared mentally and logistically to ensure they have all the necessary items before the session. For instance, if worksheets need to be printed and cut, the parents need time to perform these tasks in advance. If specific items are needed that are not in the premade play therapy kit, parents demand ample time to secure them for the family play session and put them in the play therapy kit.

This advanced preparation requires additional time for the therapist, and each therapist must detect ways to block out time for handling planning and communicate to parents. This procedure ensures both therapists and families accept equal opportunities for family play therapy sessions to be organized and consistent. For example, the DFPT therapist would inform families that they will receive an email of the upcoming family play session and items required every Friday. Friday afternoon, the DFPT therapist would email the Hernandez family addressing their handling plan, "This calendar week we will be working on family advice. For our family play session, you will demand two zip log bags filled with fifteen identical Legos in each bag. Label one bag A and ane handbag B." The Hernandez family would receive an electronic mail addressing their specific treatment plan stating, "This week, we are using finger puppets to work on family relationships. Please print out the attached puppet characters and cut them out for our session. Experience free to colour them if y'all choose." While this may require extra time during the week, it is essential to create consistency for families to feel comfortable and prepared when they attend their virtual session. Additionally, it allows therapists not to spend session fourth dimension with family members locating items that might not accept been in their toolbox.

Online School & TMH

Online schooling is condign a pick some families have made for their child's didactics. Many children take experienced online schooling, especially throughout the COVID-19 pandemic. We recommend therapists assess the family'south experiences with online learning and how the children take responded. Careful assessment tin can aid therapists avoid or mitigate negative experiences or experience challenges from countertransference of negative online learning experiences. TMH can apace experience the same as online learning for children, impeding the therapy procedure due to countertransference. We recommend that therapists capitalize on what works well for the family and find ways to make therapy different from online school in the ways that affair well-nigh.

Using TMH Platform to Raise Modify

The virtual format of TMH affords unique tools and structural differences from contiguous therapy that tin can potentially contribute positively to the modify procedure. When therapists direct play in confront-to-face sessions, the play takes place in a controlled part environment exterior of the family's dwelling house environment. The parents and the child(ren) are provided exact directives by the therapist to create change at home by recreating the therapeutic environment interactions at home. When families leave the controlled, therapeutic environment created by the therapist and return to their natural, dwelling house environment, their usual communication and interaction patterns can create barriers to modify. Families who the therapist instructs to consummate a homework consignment may feel uncomfortable or anxious almost doing homework outside of the office and in their ain home. The familiar, safety, and controlled part is where families are used to working together. The transitional phase from office to dwelling house is eliminated in a virtual setting considering the therapeutic environment interactions are actually occurring within the dwelling house.

During systemic TMH, play interactions occur in a controlled environment inside the family's dwelling environment. Thus, the directed play can easily exist repeated in the domicile because it has already occurred in the home. For example, a therapist interested in directing a family to talk openly about emotions and validate feelings may play the "Feeling Hide and Seek" carte du jour game during a session. In this card game, each family unit member would take turns hiding a bill of fare with a feeling written on information technology in the room for the other players to find. When the feeling card was establish, the DFPT would ask them to recall a fourth dimension when they each experienced that emotion. At the conclusion of the game, the DFPT would give the feeling cards to the family unit and direct the family to play this game once more at home. Since the family unit has not played the game outside of the function, barriers could arise. The feeling cards might get lost or not even make information technology out of the car. During a virtual session, the family unit has already played it in the domicile. The cards are at that place, gear up to apply. The virtual session makes the transition from session to homework much easier for family members because it is more familiar.

Using the Virtual Presence

Therapists tin also use their virtual presence in ways to enhance therapy gains and augment treatment. With appropriate applied science and consent, therapists tin can tape session segments, as they already accept cameras and audio equipment well positioned on the family. These recordings can aid the therapist review sessions and playback to the family for boosted interventions. Therapists can also utilise the reduced power of the virtual presence to enhance handling. Therapists can intentionally make their virtual presence smaller to requite parents greater power and responsibility for their family's change process. Past requiring parents to practise more than and be the concrete presence with the child, therapists can take advantage of their reduced ability to brand the parents the agent of change in the family more quickly and effectively. For instance, because the therapist is non physically present, he/she may be less inclined to "step in" during a moment of silence, doubt, or disagreement the family may be having. This can be helpful when the family tends to rely on their therapist to "help" or "rescue" them during a hard time in the session. This reduces the presence and influence of the therapist and empowers the family unit to make adjustments to be their own agent of change.

Applied science Facilitated Play

Another way to adapt DFPT to TMH is to integrate technology-assisted play resources, such as virtual whiteboards, sand trays, and games, into the therapy session. Many video conferencing platforms have whiteboard features that therapists and families tin can efficiently utilize during virtual sessions. Additionally, there are virtual sand tray programs, online lath games, card games, trivia and quiz games, and virtual playroom programs. When utilizing technology-facilitated play, therapists must follow play therapy standards regarding the use of figurer programs every bit beneficial for treatment (Luxton et al., 2016). Additionally, all HIPAA and HITECH guidelines must be followed as well.

However, there is one notable drawback of using such technology-assisted play resources. Many engineering science-facilitated play programs are designed for interaction with 1 person on each screen and may non be ideal for family therapy. This tin lead to family members crowding effectually a screen or taking turns on the device, thereby minimizing therapists' power to view members' faces and body linguistic communication. Additionally, this can lead to the family members interacting with the screen rather than directly with each other through play. Therefore, therapists should carefully consider the fit, purpose, benefit, and HIPAA compliance of any technology-assisted play resources earlier integrating it into play therapy sessions.

Cautions and Contraindications

As with any treatment modality, it is essential to consider contraindications to TMH treatment with families (see Table 1). First, therapists should assess whether the home is a safety environs to deport TMH. This is particularly of import as prophylactic is critical to successful and upstanding play therapy do. If there is any history of abuse or neglect in the dwelling, children tin can feel dangerous or retraumatized by holding therapy in a place where abuse or neglect has occurred. Therefore, part of initial consultations needs to include a history of abuse and traumatic events of the space itself and, if necessary, move therapy to a different location. A thorough review of assessing for abuse in a TMH session is beyond the scope of this manuscript. For more than information, we recommend the following resource:

• Applied science safety (National Network to Finish Domestic Violence, 2021).

• Violence, corruption, and neglect in telehealth (New South Wales Regime, 2021).

2nd, therapists must follow whatsoever contraindications for TMH, equally contraindications for TMH generally would likewise apply to virtual play therapy. This requires therapists to assess the fit of TMH regularly, be trained in TMH practices, and have all the required hardware and software for TMH practice. A total review of TMH contraindications is across the scope of this paper, and we suggest readers review the following resources:

• Best practices in the online practice of couple therapy (Caldwell et al., 2017).

• Teletherapy guidelines (Clan of Marital and Family Therapy Regulatory Boards, 2016).

• A practitioner's guide to telemental health: how to conduct legal, ethical, and evidence-based teletherapy (Luxton et al., 2016).

3rd, therapists must follow whatsoever contraindications for directive play therapy and in-home play therapy generally. For example, children who struggle with remaining in the designated virtual playroom, refuse to participate, or follow the therapist's directive may not be appropriate for play therapy. Likewise, parents who are either unwilling or unable to follow therapists' directives to engage in play would contraindicate play therapy handling. Not all children and families are a good fit for directive play therapy, and a non-directive, child-centered approach may be a better fit. Consequently, therapists must plan for transitions to another handling arroyo or provider should they determine a family is inappropriate for DFPT (for more, encounter Landreth, 2012; Ariel, 1992; Bailey, 2005).

Call for Future Research

The suggestions, recommendations, and guidelines proposed in this newspaper are based on the authors' anecdotal experiences, breezy discussions with other TMH therapists, and the existing literature on TMH practice. Consequently, these recommendations need to be researched and tested. At that place is very fiddling inquiry on DFPT using a virtual platform. COVID-xix inverse how therapists practice and how DFPT is being used. The pandemic forced therapists to begin practicing with but knowledge of their model and telemental health training. This lack of resources and research forced therapists across the earth to practise the best chore they could with what they knew. As engineering advances and more therapists are comfy using DFPT, it must exist researched. Qualitative studies exploring the lived experiences of therapists, parents, and children participating in DFPT using a virtual platform are imperative for laying the groundwork for future research.

Additionally, the need for controlled studies, case studies, and focus groups of both therapists and families would assistance accelerate the field on implementing DFPT using a virtual platform. One of this paper's primary purposes is to advise methods, structure, and theory for conducting systemic TMH play therapy that researchers tin can exam and evaluate. Hereafter studies would allow proper training and implementation in the treatment of families using the DFPT model.

Summary

DFPT is a unique model that allows for a businesslike approach to working with families with young children. In this paper, nosotros have proposed various methods and recommendations for how therapists can conform directive play therapy to the practice of TMH. Table 1 includes a summary of the benefits, challenges, and contraindications. We recommend that therapists brainstorm with a parent consultation to acquit a needs assessment, examination engineering equipment, establish a special play therapy place, and create a play therapy toolbox. We also recommend that therapists take a more straight arroyo, every bit the parents must be the actors of change while the therapist has a virtual presence. This virtual presence requires boosted session preparation time, advanced communication with parents before sessions, and augmenting how therapy limits and rules are gear up. Play therapy in a virtual format can work well if therapists brand advisable adjustments and rely on their creativity, high regard for ethics, and innovation in the spirit of our field'due south founders.

References

• Ariel, South. (1992). Strategic family unit play therapy. Wiley.

  Google Scholar

• Ariel, S. (1996). Restorying family therapy. Gimmicky Family Therapy, 18(1), 3–17. https://doi.org/10.1007/BF02196847

  Article  Google Scholar

• Association of Marriage and Family Therapy Regulatory Boards. (2016). Teletherapy guidelines. AMFTRB.org. Retrieved September 30, 2021, from https://amftrb.org/wp-content/uploads/2017/05/Proposed-Teletherapy-Guidelines-Typhoon-as-of-09.12.16.pdf

• Axline, V. M. (1950). Play therapy experiences every bit described by kid participants. Journal of Consulting Psychology, 14(1), 53. https://doi.org/ten.1037/h0056179

  Article  PubMed  Google Scholar

• Bailey, C. E. (2005). Children in therapy: Using the family as a resource. Norton.

  Google Scholar

• Botkin, D. R. (2000). Family play therapy: A artistic arroyo to including young children in family unit therapy. Journal of Systemic Therapies, nineteen(3), 31–42. https://doi.org/10.1521/jsyt.2000.19.3.31

  Article  Google Scholar

• Boydell, K. M., Hodgins, Chiliad., Pignatiello, A., Teshima, J., Edwards, H., & Willis, D. (2014). Using technology to deliver mental wellness services to children and youth: A scoping review. Journal of Canadian Academy of Child and Adolescent Psychiatry, 23(2), 87–99.

  Google Scholar

• Bromfield, R. (1994). The use of puppets in play therapy. Child and Adolescent Social Work Journal, 12(half-dozen), 435–444. https://doi.org/10.1007/BF01875812

  Article  Google Scholar

• Caldwell, B. E., Bischoff, R. J., Derrig-Palumbo, Grand. A., & Liebert, J. D. (2017). All-time practices in the online do of couple and family therapy. Retrieved September 30, 2021, from https://www.aamft.org/Documents/Products/AAMFT_Best_Practices_for_Online_MFT.pdf

• Campos, B. (2009). Telepsychology & telehealth: Counselling conducted in a technology environment. Counselling, Psychotherapy, and Health, 5(one), 26–59.

  Google Scholar

• Cravens, J. (2020). Adaptations of therapists' theory of therapy: Preparing for teletherapy services. Family Therapy Mag.

  Google Scholar

• Desmond, One thousand., Kindsvatter, A., Stahl, S., & Smith, H. (2015). Using creative techniques with children who have experienced trauma. Journal of Creativity in Mental Wellness, ten(4), 439–455. https://doi.org/10.1080/15401383.2015.1040938

  Commodity  Google Scholar

• Dimitropoulos, A., Zyga, O., & Russ, S. (2017). Evaluating the feasibility of a play-based telehealth intervention program for children with Prader-Willi syndrome. Periodical of Autism and Developmental Disorders, 47(9), 2814–2825. https://doi.org/10.1007/s10803-017-3196-z

  Article  PubMed  Google Scholar

• Drewes, A. A., Bratton, S. C., & Schaefer, C. East. (2011). Integrative play. Wiley.

  Book  Google Scholar

• Eaker, B. (1986). Unlocking the family unit hole-and-corner in family play therapy. Child Boyish Social Work Journal, 3, 235–253. https://doi.org/10.1007/BF00758255

  Article  Google Scholar

• Fleming, A. P., McMahon, R. J., & Rex, K. M. (2017). Structured parent-child observations predict development of conduct issues: The importance of parental negative attention in child-directed play. Prevention Scientific discipline, eighteen, 257–267. https://doi.org/10.1007/s11121-016-0672-1

  Article  PubMed  Google Scholar

• Fromberg, D. P., & Bergen, D. (1988). Play from nascency to twelve and across: Contexts, perspectives, and meanings (2d ed.). Garland Pub.

  Google Scholar

• Grady, B., Myers, G. M., Nelson, E. L., Belz, Due north., Bennett, Fifty., Carnahan, L., Decker, 5. B., Holden, D., Perry, 1000., Rosenthal, Fifty., Rowe, N., Spaulding, R., Turvey, C. 50., White, R., & Voyles, D. (2011). Testify-based practice for telemental wellness. Telemedicine and E-Wellness, 17(2), 131–148. https://doi.org/10.1089/tmj.2010.0158

  Article  PubMed  Google Scholar

• Haley, J., & Richeport-Haley, G. (2003). The art of strategic therapy. Brunner-Routledge.

  Google Scholar

• Harter, Southward. (1977). A cognitive-developmental approach to children'due south expression of alien feelings and a technique to facilitate such expression in play therapy. Journal of Consulting and Clinical Psychology, 45(three), 417–432. https://doi.org/10.1037/0022-006X.45.three.417

  Article  PubMed  Google Scholar

• Kaminski, J. W., & Claussen, A. H. (2017). Evidence base update for psychosocial treatments for confusing behaviors in children. Journal of Clinical Kid & Adolescent Psychology, 46(4), 477–499. https://doi.org/10.1080/15374416.2017.1310044

  Article  Google Scholar

• Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. Fifty. (2008). A meta-analytic review of components associated with parent grooming program effectiveness. Periodical of Abnormal Kid Psychology, 36(4), 567–589. https://doi.org/10.1007/s10802-007-9201-9

  Article  PubMed  Google Scholar

• Landreth, G. (2002). Therapeutic limit setting in the play therapy relationship. Professional Psychology: Research and Practice, 33(half dozen), 529–535.

  Article  Google Scholar

• Landreth, One thousand. (2012). Play therapy: The art of relationship (third ed.). Routledge.

  Volume  Google Scholar

• Lin, Y. C. (2010). Improving parent-child relationships through block play. Education, 130(3), 461–471.

  Google Scholar

• Lin, Y. Westward., & Bratton, S. C. (2015). A meta-analytic review of child-centered play therapy approaches. Journal of Counseling and Evolution, 93(1), 45–58. https://doi.org/10.1002/j.1556-6676.2015.00180.x

  Article  Google Scholar

• Lingley-Pottie, P., & McGrath, P. J. (2008). Telehealth: A child and family unit-friendly approach to mental health-intendance reform. Journal of Telemedicine and Telecare, fourteen(5), 225–226. https://doi.org/10.1258/jtt.2008.008001

  Article  PubMed  Google Scholar

• Luxton, D. D., Nelson, E. L., & Maheu, M. M. (2016). A practitioner's guide to telemental health: How to acquit legal, ethical, and evidence-based telepractice. American Psychological Association. https://doi.org/10.1037/14938-000

  Article  Google Scholar

• Myers, One thousand., Vander Stoep, A., Zhou, C., McCarty, C. A., & Katon, W. (2015). Effectiveness of a telehealth service delivery model for treating attention-deficit/hyperactivity disorder: A community-based randomized controlled trial. Journal of the American University of Child & Adolescent Psychiatry, 54(iv), 263–274. https://doi.org/x.1016/j.jaac.2015.01.009

  Commodity  Google Scholar

• National Network to End Domestic Violence (2021). Engineering Safety. Retrieved September 30, 2021, from https://www.techsafety.org/

• Nelson, E. L., & Patton, Due south. (2016). Using videoconferencing to deliver individual therapy and pediatric psychology interventions with children and adolescents. Journal of Child and Adolescent Psychopharmacology, 26(3), 212–221. https://doi.org/10.1089/cap.2015.0021

  Article  PubMed  PubMed Central  Google Scholar

• New Southward Wales Authorities (2021). Violence, corruption, and neglect in telehealth. Retrieved September thirty, 2021, fromhttps://www.health.nsw.gov.au/Infectious/covid-xix/Pages/van-telehealth.aspx

• O'Connor, K. J. (2001). Ecosystemic play therapy. International Journal of Play Therapy, 10(2), 33–44. https://doi.org/10.1037/h0089478

  Article  Google Scholar

• Peckett, H., MacCallum, F., & Knibbs, J. (2016). Maternal experience of Lego therapy in families with children with autism spectrum conditions: What is the impact on family relationships? Autism, 20(vii), 879–887. https://doi.org/10.1177/1362361315621054

  Article  PubMed  Google Scholar

• Perle, J. G., Langsam, L. C., Randel, A., Lutchman, S., Levine, A. B., Odland, A. P., Nierenberg, B., & Marker, C. D. (2013). Attitudes toward psychological telehealth: Current and futurity clinical psychologists' opinions of Internet-based interventions. Journal of Clinical Psychology, 69(ane), 100–113. https://doi.org/10.1002/jclp.21912

  Commodity  PubMed  Google Scholar

• Perle, J. G., & Nierenberg, B. (2013). How psychological telehealth can alleviate society'due south mental wellness burden: A literature review. Periodical of Engineering science in Human Services, 31(1), 22–41. https://doi.org/10.1080/15228835.2012.760332

  Article  Google Scholar

• Piaget, J. (1962). The stages of the intellectual evolution of the kid. Bulletin of the Menninger Clinic, 26(3), 120.

  PubMed  Google Scholar

• Rasmussen, Fifty. A., & Cunningham, C. (1995). Focused play therapy and not-directive play therapy: Can they be integrated? Periodical of Kid Sexual Corruption, four(ane), ane.

  Article  Google Scholar

• Strehle, East. Yard., & Shabde, N. (2006). One hundred years of telemedicine: Does this new technology have a place in paediatrics? Athenaeum of Disease in Childhood, 91(12), 956–959. https://doi.org/x.1136/adc.2006.099622

  Article  PubMed  PubMed Fundamental  Google Scholar

• Tate, K. A., Lopez, C., Fob, R., Love, J. R., & McKinney, E. (2014). In-home counseling for young children living in poverty: An exploration of counseling competencies. The Family Journal, 22(4), 371–381. https://doi.org/10.1177/1066480714530268

  Article  Google Scholar

• VanFleet, R., Sywulak, A. Due east., & Sniscak, C. C. (2010). Child centered play therapy. Guilford.

  Google Scholar

• Wade, Southward. L., Wolfe, C. R., & Pestian, J. P. (2004). A web-based family unit trouble-solving intervention for families of children with traumatic encephalon injury. Beliefs Research Methods, Instruments, & Computers, 36, 261–269. https://doi.org/10.3758/BF03195572

  Article  Google Scholar

• Wrape, E., & McGinn, Yard. (2019). Clinical and ethical considerations for delivering couple and family unit therapy via telehealth. Journal of Marital and Family unit Therapy, 45(2), 296–308. https://doi.org/x.1111/jmft.12319

  Commodity  PubMed  Google Scholar

Download references

Funding

The authors did not receive support from whatever organisation for the submitted work.

Author data

Affiliations

1. Section of Human being Development, Family Studies, and Counseling, Texas Woman'southward University, Denton, TX, USA

   Tiffany Smith, Aaron M. Norton & Latrisha Marroquin

Corresponding author

Correspondence to Tiffany Smith.

Ethics declarations

Conflict of interest

The authors have no relevant fiscal or non-fiscal interests to disembalm. The authors have no conflicts of interest to declare that are relevant to the content of this commodity.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Almost this commodity

Cite this article

Smith, T., Norton, A.Thou. & Marroquin, L. Virtual Family unit Play Therapy: A Clinician's Guide to using Directed Family Play Therapy in Telemental Wellness. Contemp Fam Ther (2021). https://doi.org/10.1007/s10591-021-09612-vii

Download citation

• Accepted: 04 October 2021

• Published: fifteen October 2021

• DOI : https://doi.org/10.1007/s10591-021-09612-vii

Keywords

• Directed family unit play therapy
• Telemental wellness
• Virtual family play therapy
• Telemental wellness training

zeringuebefory.blogspot.com

Source: https://link.springer.com/article/10.1007/s10591-021-09612-7

Share this post