In the Shadow of COVID, It’s Play Therapy to the Rescue

• Kevin’s Worried Parents
• A World Opens
• Bugs All Over You
• Mommy Dies
• Doctor Superhero
• Reflections
• Reference

Kevin’s Worried Parents

In March of 2021, families were emerging from almost a year of isolation due to the COVID pandemic. As a Licensed Professional Counselor Supervisor and Registered Play Therapist Supervisor in private practice specializing in children, I was flooded with requests for services.

During one particular intake interview, the parents of a four-year-old boy I’ll call Kevin asked me a fair question. “How will our son’s development and mental health be impacted by this year of isolation?” I immediately reflected their feelings with, “You are really worried about the long-term impact on your son.”

Their worry was understandable given the emerging research showing increases in children’s anxiety and depression since COVID began. Yet, multiple factors of genetics, parents’ behavior, peer interaction, and available resources contribute to children’s developmental and mental health trajectory after a crisis. To respond to their fair question, I needed more information from them.

I asked, “What is concerning you the most?” Both parents had college degrees and were well read so they had valid concerns in mind. “Our son has not seen, much less interacted with, another child for over a year. He is our only child. Even though we took him to the public playground, as soon as another child got within 20 feet of us, we would leave quickly.” I thought to myself, risk factor one — no peer interaction during a critical developmental period.

Preschool is when children learn to tune into peer facial cues, scaffold their own physical and cognitive learning by watching other children, negotiate sharing, and so on. I needed to provide some hope to the worried parents, so I tried to normalize the fact that most of his peers had a similar experience. I replied, “Some children’s social, physical, and cognitive development may be a bit delayed during COVID. Fortunately, children are resilient and can learn together, starting from where they left off.” They nodded with seeming understanding.

Then Kevin’s parents said, “Our son could tell we were stressed when we were working from home and paying bills with less money. We tried to play with him, but we had many conference calls. He didn’t understand and thought that we were ignoring him. He became clingy and we became irritated, occasionally speaking to him more harshly than we desired.”

I thought to myself, risk factor two — parent behavior that was interpreted by the son as anger, resulting in increased anxiety. Being a parent myself of an only child who also has ADHD, I empathized and normalized with a compassionate groan. “I get it. I experienced something similar with my child.

We can feel so disheartened, trying our best to juggle it all, and losing our temper more than we want. We are human, not superheroes. We need self-compassion. That’s why I go by the 80-80 rule of parenting. About 80 percent of the time, I try to do about 80% of what I know to be helpful. But during COVID, I lowered my standard to 70-70 because that is passing.” They laughed!

The parents added with a heavier tone, “We are also concerned about his anxiety because we both suffered with anxiety during our childhoods.” I thought to myself, risk factor three — genetics. Research shows a strong genetic influence on the development of childhood anxiety disorders. Again, the parents needed some hope. I reflected, “You both know the pain and struggle as a child with anxiety. You love your son so much that you want to intervene as early as possible. You are wise to do so. I can help with that. Research shows that play therapy can decrease children’s anxiety. Together, we can work to build those limbic system neural networks toward calmness rather than fight or flight.”

Yes, the risk factors for this child were compounded during COVID. He had no peer interaction for a year, stressed and distracted parents, and a genetic predisposition toward anxiety. Yet, he also had the biggest protective factor we could hope for — caring and proactive parents. This plus mental health treatment, interventions of parent guidance, twelve sessions of Child-Centered Play Therapy (CCPT), and psychoeducation could shift this boy’s development and mental health toward a more positive path.

Prior to beginning my work with Kevin and his parents, and to gauge the level of his behavioral and emotional difficulties, I sent his parents a link for the web-based child version of Achenbach’s System of Empirically Based Assessment (ASEBA) Child Behavior Checklist for ages one and a half to five. The results revealed a pattern of emotional reactivity, anxious and depressive symptoms, and sleep problems. While Kevin’s scores on the DSM-related scales for Autism and ADHD were in the normal ranges, his other scores were consistent with DSM anxiety and depressive symptomatology. These results corroborated his parents’ concerns.

The parents’ main goal was to decrease Kevin’s anxiety so that he could calmly engage with others without clinging to his parents. Their prior attempts to reassure him through reason were ineffective. Using Daniel Siegal’s Hand Model of the Brain, I explained strategies to calm the lower regions of the brain through deep breathing, rocking, and soft voice rather than trying to reason with his prefrontal cortex, which was “offline” during his anxious times.

To reinforce these concepts, I asked Kevin’s parents to watch a parenting video by Tina Payne Bryson called 10 Brain-Based Strategies: Help Children Handle Their Emotions, and to read Siegal and Payne Bryson’s No Drama Discipline. These two resources helped them improve their ability to calm their own anxieties so their son would co-regulate with their calmness. To deal specifically with anxiety, I also recommended Calming Your Anxious Child: Words to Say and Things to Do by Kathleen Trainor to guide them in the step-by-step process of systematically desensitizing his fears.

A World Opens

In the waiting room prior to his first play therapy session, I greeted Kevin, commented on his red tennis shoes and matching shirt, and said, “It is time to go to the playroom. Your mom will be waiting right here.”

I smiled with friendly confidence, moving toward the door, and gestured for him to follow me. “We have lots of toys there.” His curiosity was stronger than his anxiety, so, he followed me. Kevin’s eyes opened wide seeing my play therapy room filled with carefully selected toys for nurturing (dolls, doctor’s kit), creativity (puppets, paints and easel, dress-up clothes), real-life mastery (kitchen, tool bench), and aggressive release (swords, bop bag, army men). As we entered, I said, “In here you can play with all the toys in most of the ways you like.”

Kevin was hesitant and stood near me, asking questions. “What do I do first?” Given his anxiety, this was not surprising. “In here you can decide.” He moved his eyes but not his body. I view this as a “freeze” state, a survival response for people perceiving threat and feeling overwhelmed. The threat was not necessarily coming from the playroom but from being separated from his parents or close family members for the first time in over a year. I reflected his feeling with reassurance, “You are a little scared being in a new place,” and role modeled taking a deep breath. I waited patiently so he could sense my calmness and confidence, thereby communicating this was a safe place.

Kevin moved toward some small cars on the shelf and pushed them along the floor. This action with familiar toys gave him a sense of security and mastery. I reflected his feelings by saying, “You enjoy seeing how far you can push those cars.” My statement reassured him that he really was welcome to play and built his confidence. He said, “Yes, I have a blue and red one at home that I like to race.” I gave him credit for his skills, “You are an experienced car racer!” He smiled and pushed the cars toward the four-foot red bop bag, named “Bobo.” Kevin lightly pushed on it to see how quickly it moved. “What’s this for?”, he asked. I returned responsibility to him with “You are curious what you can do with that. In here, you can play with it in most of the ways you like.”

Little by little, he courageously experimented with different actions from punching it, sitting on it, hitting it with a sword, and shooting at it with a dart gun. With each step, his sense of power grew. Toward the end of the session, he expressed creativity by painting a picture of the bobo. I ended the session with 10 minutes of psychoeducation on managing stress. I demonstrated and guided him through deep breathing, progressive muscle relaxation, and a self-soothing butterfly hug. After walking Kevin back to the waiting room, I prompted him to demonstrate his new skills for his parents and asked them to practice at home each day.

Bugs All Over You

In the fourth session, Kevin began with rolling cars again followed by punching Bobo, providing him with a familiar rhythm and routine. Once he established his sense of mastery and power, he collected toy spiders, snakes, and bugs and put them on my legs, hands, and shoulders. “You have bugs all over you. You can’t move.” I stated, “You are showing me it is scary to have bugs on me and not be able to move around.”

He exclaimed, “Yes, you are going to be stuck there forever.” I responded, “It seems like it will never end!” Eventually, Kevin decided to rescue me by knocking off the bugs with a sword. His symbolic play reflected his experience during the pandemic of feeling scared and trapped. Yet now he was in charge, rather than being the one trapped. He was gaining an emotional understanding to master his traumatic experience of COVID isolation.

At the end of the session, I engaged him in a children’s book that illustrated listening to his body to notice when he may need to take deep breaths and seek soothing sensations such as rubbing his hands and legs. This combination of child-led restorative play reenactment plus the intentionality of anxiety management skills strengthened his ability to emotionally self-regulate.

Mommy Dies

By the sixth play session, Kevin had gained enough comfort in the playroom that he was ready to play out a hidden fear — mommy dying. He approached the playhouse and put the “daddy doll” upstairs in the office to do his work. The “boy doll” was downstairs by himself watching TV. The mommy doll ran out of the house to go to a work meeting on a nearby table. Kevin drably said, “Mommy went out of the house, got COVID and died.” I reflected, “Super scary and so sad she died.” Kevin quipped, “Yup. Now who’s going to make dinner? Daddy is busy working.The boy will have to go out and hunt for food.”

I responded, “The boy feels all alone AND he knows how to get some of what he needs.” Eventually, Kevin brought in the army to help him hunt for food. I facilitated understanding: “There were strong people out there who could help the boy when he needed it. They kept him safe.”

Underlying Kevin’s fear of his mother dying was the basic existential question of “Will I survive?” Through play, Kevin created his answer — letting strong people help him. During the last 10 minutes of the session, I facilitated psychoeducation by playing a detective game with Kevin. “Let’s list lots of things many kids are worried about these days.” Kevin said, “Losing their favorite toy and their dog running away.” I added, “Family members getting sick, going to the hospital, and dying.”

Then I challenged his all-or-nothing thinking. “There are 100 kids. One kid loses their toy. Does that mean every kid loses their toy?” “No.” “There are 100 dogs. One dog runs away, does that mean everyone’s dog will run away?” “No.” “There are thousands of people. One person may get sick from COVID and die. Does that mean everyone will?” “No. If someone gets sick, they go to the doctor and the doctors do their best to help them.” “Let’s think about all the kids who are playing with their toys, dogs, and family members. What would they be doing?” “Playing fetch.” “Yes! I love to play fetch with my dog.” Since Kevin was calm, he could engage in basic reasoning that most people will be OK and the importance of focusing on the positives in the here and now.

Doctor Superhero

In the tenth session, Kevin walked in with confidence. He rolled the cars, punched the Bobo, and took the baby to the doctor. “Your baby is sick. I am the doctor.” He used the stethoscope, took the temperature and blood pressure, and gave the baby a shot. I reflected, “You knew how to doctor the sick baby and get the baby better.” He got the cash register and declared, “That will be $10,000.” I paid up — a small price for his victory.

Then Kevin put on the Superman costume and flew around the room “saving everyone.” I enlarged the meaning: “You are an important, powerful person who can help so many — even yourself.” With his chin tilted up, he said, “Yup, I’m not scared anymore!” Indeed, his parents had confirmed that he was no longer sleeping with them, and he was willing to stay with a babysitter for them to have a date night.

Reflections

From a Child-Centered Play Therapy perspective, Kevin was experiencing incongruence between his ideal self as a confident, engaging boy, his current self as an anxious boy, and his experiences of isolation and fear during the COVID pandemic. He was not accurately symbolizing the behavior of his parents and other adults in that he interpreted their cautions as a lack of confidence in him. Over months of physical and emotional isolation, his self-concept was of a timid, weak child who was unable to move forward in his world.

Kevin’s time in the playroom with me along with his parents’ support provided him with a developmentally appropriate intervention in a safe playroom with an empathic play therapist, representing a microcosm through which he could master his world. He was able to come to an emotional understanding that his past anxious experiences were about an illness doctors were trying to heal and not about him. His self-concept strengthened to see himself as a strong, powerful boy who knew how to get help, help others, and help himself. Parent consultation, Child-Centered Play Therapy, and psychoeducation were the healing components of treatments that showed such love to this family. Kevin emerged from his isolation and anxiety. He flies like Superman toward a more positive developmental trajectory.

Parents and children experienced suffering during COVID. Many experienced existential anxiety from recognizing mortality, confronting pain and suffering, and struggling to survive. Mental health professionals were trained to support people in crises such as COVID. Yalom and Josselson remind us, “No relationship can eliminate existential isolation, but aloneness can be shared in such a way that love compensates for its pain.”

Reference

1. Yalom, I. D., & Josselson, R. (2011). Existential Psychotherapy. In R. Corsini & D. Wedding (Eds.), Current psychotherapies (9th ed., pp. 310–341). Brooks/Cole, Cengage Learning.  

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