We are all in this together, like it or not. There will be few corners of the world unaffected by this pandemic of the new coronavirus and its associated infection, COVID-19. Mental health professionals and play therapists can play an important role, but they also are affected themselves. This blogpost originated as a few posts on social media groups, but to make it more accessible to those interested, I am combining them here. Some of the material is pertinent to the United States, but much of it is relevant to anyone in a therapeutic capacity. The first section includes considerations about ourselves and our clients as we enter this new phase of living and working. The last two sections highlight ethical, legal, and practical matters of importance. This, in no way, is intended to be a complete document on the myriad issues involved.
Along with this blog, I am sharing an article, Roles Play Therapists Play: Post-Disaster Engagement and Empowerment of Survivors, cowritten several years ago by Claudio Mochi (Italy) and me here. It focuses on the use of play therapy in a disaster context, and pandemics do qualify as disasters. While this article has aspects that might not pertain to our current pandemic, much of the thinking represented in it does. The basic premises, principles, and processes apply.
We have to understand how the fears and helplessness and traumatic aspects of the situation are impacting our clients. Across several social media groups I’m in, I see signs of therapists feeling some pressure to get started with telehealth interventions or other out-of-the-box approaches. I’m sure some pressures might be financial, but I think the vast majority are likely concerned about their clients. It seems as though it should be easy to simply shift from usual ways of conducting therapy to telehealth forms, with the main challenge being how to do telehealth well. There are numerous trainings being offered for free, and if one is considering shifting their therapy work online, it is important to take one or more of them to build competence. It seems that our own education about new modalities is a useful first step while we permit our clients/families to get their feet beneath them with all the changes that have hit them.
The Mochi and VanFleet article linked above might provide a little feel of what it might be like for the families/parents we are trying to influence. For child work, I always work with parents on a regular basis (during individual play therapy) or fully (with family play therapy and the Guerneys’ Filial Therapy). That, of course, colors my perspective. I’m worried that if we therapists are feeling pressure to get telehealth started immediately, that urgency can translate to parents, who are already incredibly stressed. We need to avoid pressuring them, “convincing” them, tricking them, or pushing them in any way to participate in telehealth with us. I have seen too many examples of this during the past week, and while it is likely borne of the therapists’ own stress, it shows a disregard for where clients/parents are right now, and in some cases can be unethical. Because I’ve been trained in and done disaster work (and trained others), I’d like to offer several thoughts for consideration.
1) Is it possible to slow down? We are just a short time (in the U.S.) into the more stringent measures of physical distancing and school and business shut-downs. Maybe the transition to telehealth doesn’t all need to happen instantly. Give yourself and your clients/parents a bit more time. Let them know you’re available and some information about it, and then give them some space to decide. Don’t panic if they don’t immediately sign up. Understand that families need a few weeks to readjust their schedules, organization, overseeing schoolwork, reassess their finances, and many other things. They need their energies to do that, and if you think about Maslow’s hierarchy, these adjustments are some of the most fundamental, shown on the bottom two levels.
2) Have you worked through your own anxieties about this? The pandemic is very serious. It has just required a massive shift in lifestyle for nearly all of us. It is normal for us to have our own worries about ourselves, our families, our friends, and our work. I am not sure that very many of us have actually sorted everything out and feel grounded in the “new normal.” There really hasn’t been enough time. You might not be traumatized (although you could be), but lots has changed in all our lives. It might be important, perhaps as you take the telehealth trainings and think through how you want to work this way, that you also take some time for yourself to get as centered as possible. Use whatever coping methods work for you, but turning off the tv news some of the time is a very good idea. Talk through or think through or do a sandtray or talk with a trusted friend or take a walk in the woods to allow your own feelings and fears to be expressed. We can’t do our work effectively or intentionally if we are functioning at a higher stress level. Invite the clients/parents to talk with you about how they are doing and try to get rid of the mindset that you “have to get them to sign up.” There will be plenty of time for that. It is a common phenomenon in disaster situations for our own “need to help” to be activated. While a desire to help is admirable, we must be careful that we do not apply it in such a way as we remove agency from our clients. When we work through our own reactions and remain aware of them, we are in a better position to empower our client families to do the same.
3) If you have never had disaster mental health training, or training that focuses on traumatic events, it would be a very good idea to get some. This is different from training on complex trauma. The American Red Cross, for one, offers this training, and I believe some of it is online. I’m sure there are others. As we reconnect with clients, things are going to be in a different place — for us, for them. This situation bears the marks of other disasters. Read the article I shared above, but then seek out solid disaster mental health training. This is to ensure that you are practicing within the boundaries of your training and also because clients might be experiencing reactions to this type of trauma.
4) Educate yourself about the disaster, in this case about the coronavirus. Clients might well ask you questions or express their anxieties in terms of things they have heard or read. This is no small task because there are many false claims and myths that arise, including conspiracy theories not based in fact. Find two or more sources that are highly reliable, and even then, fact check the main points. Some claims sound very credible while being misleading or false. Furthermore, stay within the bounds of your training. When clients ask you medical questions, point them back to their medical professionals. Having a solid background is important so you can ensure you are pointing them in the right direction.
5) When you do reengage with clients, start out with another assessment. What is happening at home? How well is the family functioning? How have the kids been behaving? Do they have questions the parents don’t know how to answer? Are any children talking a lot more or a lot less? How stressed are the parents (their functioning plays a big role in how the kids function). Really listen, empathically, with your mind clear, to what the parents or clients are saying to you. Reflect their feelings and show you understand them. Don’t try to convince them immediately of the importance of doing telehealth. See what they tell you they need (this exactly fits in with the article above). Experiencing a traumatic event, even if a person is not traumatized by it, shifts what is important to people, children and adults. At least a brief reassessment (perhaps just 1 session) should be completed with clients and the parents of clients.
6) Think family, not just the individual child. I think we should do this all the time, but I know there are plenty of training programs and grad schools who do not teach how this all fits together. Remember, too, that the family and the kids need time to adjust to this new way of living. Even though we have been asked to follow guidelines for at least a few weeks, I’m sure it’s going to be longer. What clients and their families need will likely swing dramatically as this pandemic progresses. For example, right now everyone is dealing with uncertainty and anxiety, but there is likely to be significant grief in coming days. Family provides the context for many child and adolescent clients, or even for the parents. Disaster mental health research clearly shows that if we can strengthen the family, we help all members within it. This also applies to foster families, residential programs, and other contexts surrounding families. What supports do they have? What stresses are they facing? How can resilience be built into the system?
7) Finally, remember your core therapeutic values and principles. This work is far less about activities and techniques and far more about relationship. I see numerous posts on social media asking for activities to use for one problem or another. Activities are fine, but they are never a substitute for the therapeutic relationship. What specific methods we select should be linked to clients’ needs and the treatment plan we create with the clients and/or their parents. All good therapy works through the relationship. Your core values and principles will serve you well in the long run. If this creates some confusion for you, getting some professional case or personal consultation can be critical.
Select Ethical and Legal Issues
One of the biggest topics I’ve seen debated on social media this past week is the notification by the Department of Health and Human Services of “Enforcement Discretion for telehealth remote communications during the COVID-19 nationwide public health emergency.” Some who have not read this document really carefully have interpreted it to mean that they do not need to use HIPAA-compliant telehealth platforms. This is an inaccurate interpretation for a few reasons. This does not provide release for practitioners to engage in a “looser” manner of practicing.
First, our professions are regulated by more than HIPAA. We also must meet the requirements of our licensing boards, standards for ethical practice, and other laws that govern our work. These other items do not fall under the jurisdiction of HHS, and licensing boards have their own mandates of the standards they must uphold. Our first obligation is to our clients, and confidentiality is an exceptionally important aspect of our work. It is our obligation always to use the most confidential platforms when communicating with clients.
Second, “non-compliant” communication methods are to be used only when HIPAA-compliant methods are not available. In most of the discussions I’ve seen, therapists have access to a wide number of HIPAA-compliant methods, although there might be a cost associated with them. Selection of a free noncompliant method when a paid-for compliant method is available does not meet the litmus test. As stated by a national expert on mental health ethics and legalities, “It would be a mistake to assume that anything goes and that non-compliant methods of communication are always acceptable.”
Third, despite the HHS loosening of requirements, individual insurers and payment sources have not done so. Apparently, Medicare loosened its rules to some extent, but not entirely. Others still require full HIPAA compliance for payment. Without that, a therapist could risk his/her contract with those insurers that fall into this category.
With this said, it is important to consider your state licensing board’s and insurers’ requirements concerning telehealth for your work if you are considering using a HIPAA-noncompliant platform. At least one state requires practitioners to get a special license to practice telehealth. This is another reason to avoid rushing into the use of this modality unless you’ve done this research previously.
As you gear up for any telehealth practice, it might be a good idea to re-read all of your profession’s licensing laws and ethical standards to ensure you are following all of them!
Numerous ideas and activities and books are springing up everywhere on social media. There are lots of good ideas out there. It is important to evaluate each one thoughtfully in terms of your clients’ needs as individuals. One must also consider what we are asking of families if we expect them to provide props for child or family sessions. They may not have the items at home, and your request sends them out when they should be staying at home. Similarly, they may not have money available, or their newfound worries about income loss and the future might preclude their purchasing anything. These are reasonable considerations in situations such as this. It is also important to consider whether or not the methods you typically use in therapy are a good “match” for telehealth.
Helping parents know how to talk with their children about what is going on is a big role therapists can play. Behavior issues with children often come up quite a time after the disaster seems over, but the pandemic is likely here for a long time, or else sporadically over many months or even beyond a year, so child behavior issues might show up earlier than usual. There is no such thing as a normal type of response to this, and the key consideration is how well the child and/or family is functioning in this “new normal.” To give parents some basic guidance for talking with their children, here’s an article I wrote long ago and have just updated, How Parents Can Help Children Through Traumatic Events. Please feel free to share the link to it.
Probably my favorite book for children about traumas is Brave Bart. In it, a small black cat, Bart, experiences something bad, sad, and scary. The book tells his story about symptoms and loss of functioning, the meeting of Helping Hannah, a ginger cat who helps him learn about trauma, and his eventual realization that he is a survivor. The illustrations are wonderful and I have had children from 3 to 18 enjoy it.
Another resource that our International Institute for Animal Assisted Play Therapy® is offering at no cost is designed to help children understand and cope with different aspects of the pandemic experience. It uses “talking” animal images to share information and suggestions. It is lighthearted and child-friendly in nature, and it features different animals involved in Animal Assisted Play Therapy®. There will be a number of these added every couple days as long as families or therapists find it helpful. Please feel free to use or share this. It is called Animals Speak! Light Messages for Kids of Every Age During the Pandemic.
Please feel free to “like” my professional page, Risë VanFleet, Ph.D. on facebook for announcements of other resources, new blogposts, and ideas. You can access the websites here.
This information is brought to you by Risë VanFleet, PhD, RPT-S, CDBC, who has over 45 years of experience in the mental health and play therapy fields. She is well known for her work in furthering the Guerneys’ original form of Filial Therapy and co-developing the field of Animal Assisted Play Therapy® (AAPT) with Tracie Faa-Thompson of the UK. She has written dozens of books, manuals, chapters, and articles on play therapy, Filial Therapy, AAPT, and has received 14 national and international awards for her training programs and her writing. She administers a number of groups on facebook related to play therapy, Filial Therapy, AAPT, and human-animal relations. She is an acclaimed speaker and workshop leader who has trained tens of thousands of people throughout the world. She can be reached at firstname.lastname@example.org.
Article and photos © 2020, Risë VanFleet, PhD, in conjunction with the International Institute for Animal Assisted Play Therapy® and Play Therapy Press. All rights reserved.