Care Through Play, Anywhere: Designing Solutions For Digital Play Therapy By Jingyuan Li MDES 2022 Supervisor: Jonathan Aitken A Thesis Project submitted in partial fulfillment of the requirement for the degree of Master of Design - Interaction Emily Carr University of Art + Design 2022 Care Through Play, Anywhere Table of contents Table of contents 1 Acknowledgement 3 Glossary of terms 3 Keywords 4 Abstract 4 Introduction 5 Thesis Statement 5 Research Questions 5 Project Rationale 6 Context and Framing 7 Play Therapy Methods and Usages 7 Sand Tray Therapy 8 Puppet Play Therapy 8 The Digital Transformation 8 Telehealth for Mental Health 8 Technology-based Interventions In Mental Health Treatments 9 Metaverse And The Future Of Digital Connection 9 Precedents Digital Tools For Play Therapy - Case Studies Scope of Intervention And Limitations Primary Research 10 10 12 13 Main Methodology 13 Design Thinking 13 Futures Thinking 13 Research Activities 14 Interviews 14 Affinity Mapping 15 Alternative Primary Research Sources 16 1 Care Through Play, Anywhere Design Principles Design Outcome Ideation 17 18 18 Brainstorm 18 Incremental Planning 20 Sketching and Prototyping 21 The emphasis on customization 21 Personas and user profile 22 Prototype #1: Virtual Playroom (VPR) 23 Prototype #2: Therapy Avatar AR (TAAR) 27 Reflections 30 Future Design Path 30 Clinical application considerations 30 Appendix 31 REB documents 31 Design explorations 32 References 33 2 Care Through Play, Anywhere Acknowledgement During the past two years at Emily Carr University of Art + Design, I received an immense amount of help and encouragement from the people around me and across the world. Especially at the time of the global pandemic COVID-19, with drastic changes in collaborations and communications, I find these generous support additionally precious. Without them, the thesis would be far from being completed. Among these supports, I’d like to thank my family, especially my parents’ role in my education. Every decision that I made has been graciously supported by them. Special thanks to you, Jonathan Aitken, my academic supervisor who has supported, challenged, and guided me, not only academically but also professionally with his incredible knowledge and experience in many fields. Thank you, fellow students, faculty and staff members in our MDes program, as we have learned so much from each other in these well structured courses, workshops, and other activities despite the difficulty brought by this strange pandemic. I want to express best regards to the professionals including counselors, and play therapists, who dedicate their time helping the wellbeing of many and generously offered time and knowledge to my thesis despite their busy schedule. Last but not least, thank you Grace, an amazing human, for both emotional and technical support as we were on parallel journeys in our education and career at different sides of the country. Glossary of terms Play Therapy A sum of psychotherapeutic approaches developed to help children and teenagers overcome emotional and behavioural difficulties. It utilizes children’s natural instinct to play and encourages them to use play as an expressive and problem-solving process, as opposed to using only verbal communication. The most frequently used equipment for play therapy are sand trays, dollhouses, crayons, and mini figures, with which children can tell stories by creating scenarios (Eugster, 2013). There are mainly two modes of play: nondirective or directive. The former encourages children to play freely and solve a psychological puzzle on their own under supervision, while the latter is 3 Care Through Play, Anywhere guided by a therapist in response to the children’s past experience (Tennessen & Strand, 1998, p. 112). Tele-play Virtual or remote forms of play therapy. Also known as tele-play therapy. Note that this is to be distinguished from “Teleplay” which is a term used in television programs. Counselor A person trained to give guidance on personal or psychological problems (“Counselor,” n.d.). In Canada, certified counselors are required to have a master’s degree in counseling or related fields (Overview of CCPA’s Certification Requirements & FAQ, n.d.). Client In a psychotherapy setting, a client is a respectful and inclusive name for the person receiving mental health support and treatment. In the context of this thesis research, most of the clients are children and adolescents. Cognitive Behavioral Therapy (CBT) Psychotherapy that combines cognitive therapy with behavior therapy by identifying faulty or maladaptive patterns of thinking, emotional response, or behavior and substituting them with desirable patterns of thinking, emotional response, or behavior. Cognitive behavioral therapy is used in the treatment of various mental and emotional disorders including depression, anxiety, anorexia, and substance abuse (“Cognitive Behavioral Therapy,” n.d.). Serious Games Interventions which are games or utilize elements of gaming as an integral and primary method for achieving their purpose. Many were developed for the purpose of personal health awareness and mental health rehabilitation (Fleming, et al., 2014). Keywords play therapy, teletherapy, mental health, digital transformation, therapist, health care for children Abstract Since the beginning of the COVID-19 pandemic, many services and businesses have been transitioned online to avoid travel and exposure. A number of these timely adaptations started as a compromise, but are now expected to continue even after the pandemic is over. Telehealth and teletherapy were among the most prominent examples—as doctors, therapists, and counselors 4 Care Through Play, Anywhere moved to deliver their services remotely. In the last week of March 2020, telehealth encounters in the United States increased by 154% compared to 2019 (Koonin et al., 2020, p. 1598). As counseling sessions were made available from home, many saw the benefits of teletherapy, including increased accessibility, timeliness, convenience, continuity of care, and patients’ comfort of being in their own space. However, unlike conversation therapies, play therapies for children rely on the act of physical play and equipment such as toys and a sand tray. As a result, play therapists have been challenged in adapting to the current model of video-based teletherapy. Based on information gathered from the primary research with counselors and play therapists, most challenges are related to the reduced therapeutic quality due to the lack of support from technology, despite the amount of interest to include more digital tools in their practice. To explore ways to solve these challenges, the researcher analyzed the data from interview sessions with the therapists and generated a list of design principles. Following these established principles, an iterative approach was initiated and included brainstorming, system mapping, wireframing, and a series of digital prototypes. Multiple possibilities of digital play therapy were explored with active participation and feedback from the professionals. Introduction Thesis Statement Designing new digital tools can enable play therapists to deliver online services to clients with improved quality and user experience. Research Questions The primary objective of this thesis project is to develop tools that can help play therapists deliver their services digitally. By providing a range of possibilities in digital play therapy instead of fixating on one solution, this project aims to provide design solutions that not only address today’s challenges in digital play therapy, but also speculate on new methods that will improve the quality and experience of play therapy as the technological infrastructure incrementally advances over the next decade. To reach this objective, the following research questions were posed to lead the secondary and primary research: The following questions formed the basis of the research. What can we learn from current models of delivering play therapy? 5 Care Through Play, Anywhere How might we improve the quality of digital play therapy? Lastly, how might we imagine the ways that digital methods can be developed in the future and what design methods will be needed? Project Rationale Play therapy is an effective and well-studied method of psychotherapy for children, and has traditionally been delivered through in-person sessions. Since the COVID-19 global pandemic, many therapists have started incorporating digital technologies into their practice and those who saw the benefits of convenience and accessibility continued this even after social distancing was no longer required. However, therapists often lacked the digital tools to match the experiential quality of in-person therapy sessions. Additionally, the meaning and the context of play has been changing following rapid advancements in technology and communication, and play therapists have become more open to adopt new tools to transform their practices to an online or hybrid model. Context and Framing Field of practice Illustrated by the field of practice diagram above, the thesis focus sits in the cross section between the approaches of traditional play therapy methods, technology-based interventions in psychotherapy, and telehealth. Each of the fields will be further detailed below. 6 Care Through Play, Anywhere Play Therapy Methods and Usages Generally, in-person play therapy methods involve childrens’ interactions with toys, puppets, and miniature models in a safe environment such as a playroom, or play therapist’s office. Through creative, problem-solving and therapeutic activities guided by the play therapists, clients can learn to overcome their mental challenges and solve behavioural problems. A guiding principle of the essential therapeutic powers of play are summarized by Charles Schaefer: play facilitates communication, fosters emotional wellness, increases personal strengths, and enhances social relationships (Schaefer, 1993). A couple of the most popular methods that are used in this thesis are listed as follows. Sand Tray Therapy Also known as the “Sandplay Therapy”, this is one of the most frequently used methods among play therapists. Originally a method named “World Technique” developed by British child psychiatrist Margaret Lowenfeld, it lets clients (mainly children) live through traumatic experiences and other mental challenges to construct solutions to those scenarios through playing with a specifically designed sand tray. When offered a safe space (a play room), the client can arrange a range of miniature figures in a sand tray into an imaginary or projective expression. (Homeyer & Sweeney, 2016) Puppet Play Therapy This method uses puppets therapeutically for the improvement of the psychological well-being of children. Not unlike Bert and Ernie from Sesame Streets, with “colourful bodies, melodious voices, realistic movement, compelling relationships with others, and relevant issues for children'', these puppets engage children in play and conversations at their developmental level (Hartwig, 2021). Puppet play also facilitates projective storytelling through theatrical use of the puppets (Dupree&Prevatt, 2003). Because of the nature of play therapy—the need for equipment, interaction, and space—the therapeutic power might appear to be questionable to some when these conditions are not met. This leads to the question: How do play therapy models adapt to a digital environment where an increasing number of therapists are working remotely with their clients? Digital technologies are widely seen in other disciplines of psychotherapy nowadays, and studying them helps in understanding how these interventions improve patients’ mental health. 7 Care Through Play, Anywhere The Digital Transformation Telehealth for Mental Health According to the definition by Substance Abuse and Mental Health Services Administration in the United States, Telehealth is “the use of telecommunication technologies and electronic information to provide care and facilitate client-provider interactions...It is composed of two forms: 1. Two-way, synchronous, interactive client- provider communication through audio and video equipment (also referred to as telemedicine) 2. Asynchronous client-provider interactions using various forms of technology…” (SAMHSA, 2021). The concept of teletherapy is not new but its actual implementation only began to become relevant in the 2010s (SAMHSA, 2021). Before the pandemic, remote therapy sessions using the internet or telephone were only scarcely adopted by the general public, despite the fact that they have been made widely available in many developed countries. This may be due to the usual slow rate of adoption for most new technologies, but there’s also the issue around personal connection, face-to-face interactions, and feelings of safety in the therapist’s office (Kluger, 2020). However, due to the COVID-19 pandemic in 2020, telehealth usage for mental health received a 556 percent increase between the first month of the quarantine (SAMHSA, 2021). The unprecedented use of telehealth therapies was accepted by an increased number of clients and experts for its advantages: the comfort of being at home / familiar space, the ability to deliver services across geographical boundaries (especially to communities that used to have limited accesses), decreased costs, saved time and effort in transportation, and often timely reservations (Kluger, 2020), (SAMHSA, 2021). Technology-based Interventions In Mental Health Treatments Technology-based mental health interventions have been explored extensively since the 1980s. Digital tools and platforms such as Virtual Reality Exposure Therapy (VRET) and Serious Games are often created using patient-centred design methods around one specific set of problems. By using VRET, the patient can get immersed in a realistic but safe environment and navigate through simulated challenges that offer a cure for their fears and trauma (Shiromani et al., 2009). Under the guidance of health professionals, these solutions explored methods that were simply unavailable without the advancement in digital technology. Metaverse And The Future Of Digital Connection Metaverse has become a buzz word in media and conversations around 2020, and especially mentioned frequently after the renaming of Facebook to Meta in October, 2021. In short, the name 8 Care Through Play, Anywhere Metaverse claims to represent the next step of Internet-based social connection existing within virtual spaces. In Epic Games’ founder and CEO Time Sweeney’s words, metaverse is “a realtime, 3D social medium where people can create and engage in shared experience as equal participants in an economy with societal impact...The metaverse has to be a next-generation platform that’s a successor to a lot of communication media that came before it and has to take off at an unprecedented scale.” (Sweeney, 2019) So, why is the metaverse mentioned in relation to the context of the thesis project? To begin with, I agree with the view that the metaverse is going to play an important role that encompasses and directs many aspects of our life, just like the Internet nowadays. Although the outcomes of this project would not depend on the metaverse platform, they can benefit from it. With advanced graphics and interactions that simulate the physical world, the ways that play therapists connect and interact with their clients can be fundamentally changed when they meet through the soon-to-be available systems of the metaverse. Meanwhile, as the metaverse becomes a technology that exists in the everyday life of a larger population like mobile phones today, the learning curve of using digital play therapy tools for play therapists and their clients could be greatly reduced. Precedents In common types of teletherapy sessions such as conversation therapy, video conferencing tools like SecureVideo, Doxy, and Zoom are widely used. The counselor and the client usually have a treatment session through a conversation while being connected through video, and their interactions generally do not differ too much from face-to-face sessions. However, in the case of play therapy, the need for play activities and equipment adds to the complexity of achieving a therapeutic effect in its virtual equivalence. Consequently, the therapists now face the limitation in how the play activities could be engaged. And the immediate challenge for the play therapists was to find appropriate ways to resume activities together, virtually. Attempts to make play therapy available in digital formats predated the COVID-19 pandemic, but most solutions came out after it. Examples are listed as follows. Digital Tools For Play Therapy - Case Studies Virtual Sandtray App (VSA) by Dr. Jessica Stone Dr. Jessica Stone has been developing this tool for digital play therapy since 2011, when she felt the need to make clunky sand trays more portable and accessible for both play therapists and clients. The app was published in the Apple’s App store and initially runs on iPads, and now it is being expanded to a VR version. Using this tool, the therapist and client can connect online and interact in 9 Care Through Play, Anywhere a 3D environment that features a digital sand tray and miniature figurines. The tool has massive potentials beyond its convenience in unlocking more engaging interactions than the real life sand tray method. For example, there are advanced controls that can adjust the size of the figurines and make them animated, which is impossible in real life. Virtual Play Therapy Room by Dr. Rachel Altvater In mid 2020, Altvater shared tutorial videos on Youtube detailing the DIY ways to assemble a virtual play therapy room using online presentation tools such as Google Slides. Altvater uses the Google Slides as meeting spaces when she meets with her clients via video. Each slide contains or links to an interactive activity, such as online games or collage boards, and the therapist can observe the client and their shared screen. The advantage of Alvater's tool is that it is free and simple for many therapists to adopt. It can also be customized and add elements based on its users' needs. Online Sand Tray by Dr. Karen Fried A 2D web tool that represents the top-down view of a virtual sand tray was made in 2020. Its users can make a virtual scene by placing illustrations that represent miniature figurines in real life scenarios onto a backdrop that resembles the sand tray. In online play therapy sessions, the therapist and their clients would use it with video conference software and screen-share functions to observe and guide the play. It is hosted in an easily accessible web page and is easy to use without any requirement for sign up, which has encouraged many to adopt it in their practice. However, because of its 2-dimensionality, clients who are not familiar with the physical sand tray might have a hard time learning its mechanics. The other drawback about this tool is that the provided illustrations can feel limiting when making choices, as the therapist cannot add their own figurines into the tool. These three cases tackled different aspects of the play therapy through different degrees of fidelity. Altvater’s Virtual Play Room, is a low-tech but enveloping way that engages many scenarios of digital play therapy, positioning itself as a portal to existing tools. The other two focus on the digital sand tray therapy, which is the most widely-used method in play therapy. The opportunities discovered here show that there’s not yet a complete collection of solutions for play therapists delivering their services digitally. In another word, the sense of play therapists’ office, or the playroom, that is stocked with equipment for various methods does not exist in the virtual world. As a result, play therapists need to find resources on their own and have to invent ways of conducting digital play therapies. Inspired by the concept of the metaverse introduced in the “Context and Framing” section, the thesis project aims to provide an immersive and expandable platform that not only offers the space and environment for digital play, but also connect the therapists with other tools. 10 Care Through Play, Anywhere Scope of Intervention And Limitations The goal of this project is focused towards creating digital solutions that may enhance the service delivery experience of digital play therapy for play therapists. The project recognizes the advantages of traditional, in-person play therapy for it is a modality that offers physical play interactions that are distinctive to digital interventions. The design outcome is not aiming to replace the original modalities, but rather to provide options for effective therapeutic experiences that can be achieved through digital or hybrid play therapy. With more options available between in-person to digital, the play therapist can comfortably make decisions based on their client’s needs without considering technical limitations. Apart from the design outcome, the analysis of the research data, and the summarized design principles, as part of publication of this research, can help inform other digital content creators and psychologists working in the related areas. Moreover, the research acknowledges the issues of accessibility to technology in residents in underserved communities. The Internet and capable hardware devices are the prerequisite for the modality of digital play therapy proposed in the design outcome, and the lack of which poses a great challenge for those in need of digital care. Fortunately, initiatives are underway in Canada and worldwide to provide Internet access to remote areas (Broadband Fund: Closing the Digital Divide in Canada | CRTC, 2020)。 Primary Research This thesis project was approved by the Emily Carr University of Art + Design Research Ethics Board (ECU-REB). See Appendix XX. Main Methodology Design Thinking Design Thinking is a process that uses a series of iterative phases through research and design to understand the challenge and generate solutions (IDEO U, 2020). In the thesis project, the general steps of the Design Thinking process including: Empathize, Define, Ideate, Protype, and Test will be followed to thoroughly understand the problem space and produce iterative solutions. Futures Thinking Futures thinking emphasizes possible futures and encourages design for the changing system. Proposed by Zoë Prosser, futures thinking is not only a method but also a mind-set that addresses 11 Care Through Play, Anywhere what is possible and what is preferred, in order to change and shape the future to arrive. “By exploring futures thinking, designers can create services that are more resilient to potential change, and may even take an active role in shaping the change that affects them”. (Prosser, 2021) To design effective solutions for play therapists, understanding their immediate challenges within current digital therapy technology is considered the primary goal of the “empathize” and “define” stage. Once the project moves on to the last three stages, however, as the landscape of connection and communication is changing rapidly, to design the platform only based on the current technology is going to limit the potential impact of this project. Looking at the challenge from the perspective of futures thinking, it is constructive for the thesis to hear about play therapists’ hope for future tools, as if they are practicing digital play therapy in a decade. Research Activities Interviews After receiving ethics approval, seven play therapists were approached and agreed to participate in the research. The interviews were held online via a video conferencing software. The major goal was to understand the following aspects of each play therapist’s experience: ● Theories and methods prior to and after the transition to digital play therapy ● Opportunities and challenges found in digital play therapy ● Ideas on improvements that can improve the quality of digital play therapy. Recruiting Process: An introduction webpage was made for the recruiting process. Mainly play therapists that have shared their contact information online were reached through email. One of the contacts introduced me to several other participants. The criteria in identifying the appropriate participant was fairly simple: Practicing play therapists who have delivered both in-person play therapies and online scenarios. Consents were signed by each participant prior to the online meeting. 12 Care Through Play, Anywhere Introductory website made that provides thesis information for participants The Questions The interview was semi-structured, meaning that the questions weren’t strictly following a script, but also not too loose in the time allocated on each aspect. To best understand the play therapists, the three major aspects were expanded to the following areas (non-sequential): ● Main play therapy theories and methods used in regular play therapy sessions ● Current digital play therapy activities being used ● Usage of technologies beyond video conferencing ● Desired improvements or features in digital play therapy ● Changes in their practice following the pandemic ● Play therapists, clients, and clients’ parents reactions to digital play therapy ● Security and confidentiality issues or concerns following the usage of online tools Affinity Mapping Also called an affinity diagram, this is a method that groups research data into more general topics to summarize useful insights (Sanders & Stappers, 2013). Repeated or related themes of data from the interview participants can be interpreted as common experience, a factor for deciding priorities 13 Care Through Play, Anywhere to focus on when finding solutions. As a result of the semi-structured interview, there were more topics touched upon than the plan. A detailed view of the map can be seen in the image below. Affinity map and design principles Alternative Primary Research Sources In addition to interviews, many resources publicly available online became excellent primary research sources. Blogs, podcasts and online courses documented the thought processes of bringing certain play activities into the online play therapy sessions and were explained in detail. From here, criteria considered by the therapists when adopting or appropriating methods were inferred and understood to assist the design creation. Online videos granted access to demonstrated online play therapy sessions, a rare opportunity to understand how they operate today. Online play therapy modalities, the dynamic and live interactions between the therapist and client were documented truthfully as they happened 14 Care Through Play, Anywhere something exclusively unavailable before. The way of utilizing limited resources when connecting by video conference software and how the therapist observes the client’s action contributed to the understanding of the entire process, validating and adding to the responses from the interviews. Observed challenges: ● Scrambled methods and ad-hoc solutions that were made recently to respond to the need for online play therapy. These can work temporarily but are not comparable to the traditional modalities. ● There are too many limitations due to the reliance on the video conference - only sitting in front of the device and the interactions are confined by what’s physically close to the client. Design Principles Through the affinity mapping and the journey mapping activity, it was possible to generate a conclusive set of insights from the primary research into seven design principles. Note that these principles focus on the human interactions and user experience side of the solutions, and do not cover the requirements of clinical standards (such as HIPAA-compliance) as these were assumed to be the prerequisite in any interventions and modality in play therapy. The principles acted as general parameters that should be addressed by the design outcomes. ● Digital tools for play therapy should give space to clients’ expressive and exploratory nature, and do not impose too many restrictions on the interactions. ● Digital tools for play therapy should emphasize storytelling and emotion projection as they are important aspects of play experience. ● Therapists and clients need to see each other’s face and movements during the entire therapy session on top of the other interactions in the digital tool for play therapy. ● Digital play therapy tools can become an important component of hybrid practices in the future, but it should not claim to replace the methods of face-to-face play therapies. ● Clients need to feel safe and cared for when using digital tools for play therapy at all times. ● The tool should accommodate all technology levels of the therapists and offer easy shortcuts for them to manage the play elements. ● Comprehensive tutorials of new tools should be provided to help therapists get orientated. 15 Care Through Play, Anywhere Other Insights ● Some play therapists include video games as a part of their therapy activities. Design Outcome Ideation Brainstorm In a brainstorming session, I generated as many ideas as possible, and then edited down to a few choices according to the design principles. Taking inspiration from serious games used for educational or therapeutic purposes, the possible solutions often involve the usage of 3D simulation, especially virtual reality. The characteristics of the 3D environment make it an effective tool for realizing imaginations, which is an essential component of many play therapy modalities. Considering the potential for ubiquitous usage of 3D interfaces across the Web3.0 Internet and the increasing popularity of VR devices in the next decade, creating tools that live in the near future became another important aspect of the design outcome. Brainstorming session documentation 16 Care Through Play, Anywhere Storyboard for digital play therapy 17 Care Through Play, Anywhere Select brainstorm outcome, a structural map According to the design principles, the core function for the design solution is that it can offer an immersive mutual space for clients and the play therapist. The two parties need to feel the presence of each other in the said space, on the basis that they can still see each other through video feed. Another function to help play therapists manage their online practices, for example, the storing and transferring of client-generated content in digital therapy sessions. Assumptions are that an online platform for play therapy with a 3D environment might be relevant to address play therapists’ challenges today but also in the future. Incremental Planning A platform that uses a 3D environment as its major means of interaction seems like a great leap forward from what many play therapists are using today. Considering that technical abilities vary among the play therapists, some might face hurdles with such a platform and may not be comfortable using it with their clients until they get orientated. Besides, the ideal equipment for 3D 18 Care Through Play, Anywhere immersive space, VR headsets, although readily available, are not a popular purchase among the larger population as of 2022. How to make the digital platform easier to access and navigate for play therapists became another great challenge. One way to achieve that is to make available three levels of digital involvement, and the therapist can choose to receive ones that they are comfortable with. The first level is to have all interactions in 2D interfaces with browser-based access to 3D spaces. The second level opens up the possibility to use VR in the 3D spaces with VR-focused interactions such as interacting items with hands. The third level leads to the overall maximum mixed reality (MR) experience where the 2D interfaces in previous levels are often replaced with immersive 3D ones. The other difference among these levels besides the interactions and touchpoints is the level of fidelity in play therapy. First two levels are intended to gradually bridge play therapists to familiarize with digital play therapy, thus the designed experience will have a strong resemblance to the real-life scenarios, such as the appearance of play therapy room, or sandtray models. The last level of digital involvement will break the boundary of what is possible in real life and focus on creating therapeutic experiences that are unreplicable otherwise, benefiting from the usage of mixed reality technology. It is important to note that this thesis is intended to create prototypes of the second and third level of digital involvement, that builds on the speculation around the prevalence of mixed reality. Sketching and Prototyping Both ideas from the brainstorming session were brought into sketches and prototypes. The plan is to find ways that can make them work in conjunction with each other in one ecosystem. After all, the digital play therapy platform for therapists is going to be connected with approved and compatible softwares. Together, these prototypes form a toolkit for therapists and their clients. The emphasis on customization With the initial structure of the digital platform and incremental planned above, the design naturally fell down to the part where an actual visualization of the space was needed. The challenge was to decide how the room should look and feel. Despite the essential items that could be carried over from in-person therapy rooms such as a sandtray and collections of toys, other parameters such as the size of the environment, colors, furniture placement, etc are now only subject to device specifications and bandwidth, but not constrained by physical conditions. This change opens the door to more freedom to focus on the design of such parameters. However, a dilemma was also 19 Care Through Play, Anywhere posed here: without research on children’s preferences, it is unclear on what visual style to go after and any decisions upfront would seem arbitrary. After closely reviewing the analyzed interview data once again, I came to the realization that an emphasis on customization was overlooked. From the interview, the several therapists addressed that clients’ preferences in what to play should weigh on the therapy plan. In the case of the digital space, their preferences could also help direct the design of the entire space. What would be a better way to design the experience than letting both parties customize the therapy experience on their own? Although the need to make a 3D space as a prototype is still needed to illustrate the thesis design, by incorporating the customization function upfront, the following 3D design will be one but not definitive version of the possible looks. The ability to decide the look and feel of the therapy space added an important feature and benefit to the digital therapy experience and was illustrated in the scenario below. Personas and user profile Two pairs of personas and profiles were developed to represent the users of the design outcome. The therapist personas were directly created from the primary research data, that includes their professional approach, relationship with technology, as well as challenges and goals in using digital play therapy. As for the client group, due to the understanding mostly coming from secondary research, their information was summarized as user profiles instead of personas. The profiles illustrate their basic biographical information such as age, gender, interest, and location. These personas will help illustrate the scenarios of usage for the following prototypes. 20 Care Through Play, Anywhere Personas and user profiles Prototype #1: Virtual Playroom (VPR), the go-to platform for therapists The prototype consists of a simple meeting management portal for the therapist and a 3D-simulated play therapy room that resembles its equivalence in real life, although many changes which will be explained below. The management portal can be accessed through either a browser on a laptop, or a VR headset. Besides its primary usage for connecting to the 3D space of Virtual Play Room, the therapist can also use it to start a video meeting with their client before jumping into the 3D world. They can also check clients’ live avatar updates, manage client files such as drawings or play scene documentations generated during the sessions, and schedule digital therapy sessions. The marketplace and toolbox function directly controls the purchase and installation of 3D assets and other digital play therapy tools or games in the VPR. The VPR itself is a customizable virtual space that shares a similar role to real life play therapy rooms, accessible from desktops, mobile devices, and mixed reality equipment. In the same way that the physical play therapy room (shown below) is stocked with toys, props, and other equipment for a great range of possible activities, the VPR has an incredible collection of digital objects that can be interacted with. The interior and placements of furniture can be freely customized by the therapist to suit various therapeutic needs. Therapists can also place links to other (VR-based) play therapy tools or games that are viewed to be beneficial for the client, and launch them directly from the 3D 21 Care Through Play, Anywhere space. To sum up, although by default the VPR resembles the appearance of a play therapy room in real life, it is flexible enough to be expanded beyond the definition of a “room”. The play therapist and client appear as virtual avatars in the VPR, with voice chat feature and video overlays of each other’s camera feed. The virtual avatar is customizable through various settings explained in the Prototype #2 below, and could reflect the real-life movements. Each party sees the world via a first-person view and can interact with objects, toys in accordance with the program built into each asset. The client can play mini games, make drawings, adjust the room settings, or try on different clothes for their avatar, while the therapist observes and analyzes the emotional experience reflected by these activities. VPR configuration process VPR Therapist vs. Client view (Human portraits in use are open source, pexels.com) 22 Care Through Play, Anywhere VPR Model scaling An illustrated 3D space interaction options 23 Care Through Play, Anywhere Expert feedback Participating play therapists were approached and presented with the design mockups, and they offered constructive feedback. Many appreciate the general stylistic decisions and are excited for the ability for customization. One mentioned the need to see the avatar's actions to reflect real life movements. More importantly, a common concern is around younger clients’ (under 8 years old) ability to operate in the 3D space. The interactions for them will need to be different from the proposed design, probably by offering less text, and even simpler control. Prototype #2: Therapy Avatar AR (TAAR), client-facing application for character customization While the main scope of the thesis is focused on designing for play therapists, it is hard to ignore the information from the interviews that showed the potential of digital tools when used in therapies by children. Children clients nowadays are considered to be digital natives who are well versed in using digital products. Their familiarity with the digital culture can often change the interpretation of the activity of play. What tools can best assist children with their digital therapy journey? According to the insights from the secondary research and interviews, it seems that emotional-embodiment-role (Schaefer et al., 2010) methods such as puppet play (see definition in glossary) and dramatic play have a great potential to be adapted into digital therapy. The idea is to have a mobile application for clients to create customizable avatars for themselves and use them as AR filters during video meetings with the play therapists. These avatars are digital representations of themselves that can change throughout time responding to the emotion at the moment. When a children's client can show up as a character created by themselves, assumptions are, the digital characters might exceed physical puppets for their therapeutic power since the former can offer opportunities for frequent updates and more accurate projection than the latter. When clients are offered the freedom to create visual representations of their own imagination with ease, it opens doors to valuable opportunities for therapists to discover insights. How does it work? The VPAR exists as a mobile application and can be accessed from most smartphones and tablets in the market. “Virtual puppets” are avatars that clients can create and then use to interact with therapists in digital play therapy sessions. Similar to character customization functions in video games, the clients can customize their digital appearances by adjusting elements such as body shape, skin color, head-to-toe clothing items, accessories and other decorations, etc,. There need to be an expanding collection of elements that clients can choose from and combine that matches their need for expression. They also have the option to import characters from other approved and compatible sources, such as their video game character. A client can create unlimited amounts of 24 Care Through Play, Anywhere avatars but can only choose to “wear” one at one time. During off-session time, a therapist can view live updates on client avatar change (if agreed and shared by the client) through the Virtual Playroom portal. When a digital play therapy session starts in Virtual Playroom, the client enters the room using a chosen avatar that mostly represents their thoughts at the moment. During the session, the play therapist might choose to have conversations with the client around the avatar and even give prompts to the client which can be responded to by drama acting or storytelling using the characteristics of the avatar. The client can change the avatar at any time during the session. Besides therapies conducted in VPR, simple video meetings between two parties can be held from the app directly, and the client may use the avatar as an augmented reality filter, meaning that the avatar will be mapped onto the face of the client in the video feed to facilitate the immersiveness of drama play therapy.With this application in addition to the first prototype, VPR, the therapist and the client will have a therapy experience that is customizable, individual, and expandable. Expert feedback Participating play therapists were approached and presented with the design mockups, and they offered constructive feedback. The app feels more helpful to solving the immediate challenges faced by therapists now. A few participants mentioned that their clients will be already excited and familiar with using the filters based on its similarity with applications such as Tiktok and Instagram. Lastly, a therapist expressed her wish for using this feature in today’s commonly used video meeting softwares such as Zoom. (3D Client avatar illustrations by Amrit Pal Singh, Toy Face collection, Regular extended license) (Human portraits in use are open source, pexels.com) TAAR prototype features (top to bottom): client dashboard, scheduled meetings, add/edit avatars, apply avatar AR filter during video therapy session 25 Care Through Play, Anywhere Reflections Future Design Path The features chosen for the Virtual Playroom carry the appearance and methods from real life play therapy settings; a consideration for therapists new to digital play therapy who have limited experience with working with the latest digital technology. The transition between physical and digital can feel like a great leap, and maintaining some familiarity, especially in an initial stage, may bring some comfort for therapists making transitions. The learning curve was mediated with familiarity built into the platform when frequently used methods are represented in a digital form. Once the basic controls of the 3D interface are learned, therapists can engage in therapy sessions and organize the room just like they would in real life. While these kinds of features exist for the onboarding process for therapists in transition, they can feel a bit constraining as therapists get more familiar with working in a 3D environment. Nonetheless, the play therapy methods such as sand tray therapy was originally designed with the physical interactions in mind. Even though mixed reality devices might reach a point where physical senses such as touch and olfactory are well simulated, the simulations are still confined in its limited possibilities. In the future, most play therapists will become digital natives who might frequently engage in digital play therapy compared to today. Wouldn’t they want to try out methods that are born digitally? The Therapy Avatar AR stands at the middle ground between a legacy format and what’s brand new, but what would completely digital therapy methods look like? There are many rooms and paths to pursue after this thesis project, such as more involvement with augmented reality technologies that blend the familiar home environment with digital assets, or innovative play therapy rooms that facilitate hybrid play activities. Clinical Application Considerations Since the research process only involved play therapists due to the limitation of time and resources, the toolkit was not intended to be clinically ready or proven. Rigorous clinic research that involves a team of professionals as well as client participants are needed in the development of a tool that is prepared for market-level implementations. For example, a mixture between co-design workshops and observed digital play therapy sessions involving the therapist, the client and the designer can open up doors to the intricate and tacit details such as the dynamic involved in the therapy process. In the user testing sessions, the opportunity for designers to observe how clients interact with digital play therapy tools at different ages would help them to develop different tools that are suitable across age groups and improve the individual experiences further. 26 Care Through Play, Anywhere Appendix REB documents Research Ethics Approval Certificate 27 Care Through Play, Anywhere Research Ethics Course Certificate Design explorations Early visualizations for play therapy space 28 Care Through Play, Anywhere References Broadband Fund: Closing the Digital Divide in Canada | CRTC. (2020, June 1). BROADBAND FUND Maps of Areas to Enhance Broadband Access. Retrieved January 10, 2021, from https://crtc.gc.ca/eng/internet/internet.htm Ben-Zeev, D. (2014). Technology-based interventions for psychiatric illnesses: Improving care, one patient at a time. Epidemiology and Psychiatric Sciences, 23(4), 317–321. https://doi.org/10.1017/S2045796014000432 Brahnam, S., & Brooks, A. L. (2014). Two innovative healthcare technologies at the intersection of serious games, alternative realities, and play therapy. Studies in Health Technology and Informatics, 207(December), 153–162. https://doi.org/10.3233/978-1-61499-474-9-153 Dupree, J. L., & Prevatt, F. (2003). Projective storytelling techniques. In C. R. Reynolds & R. W. Kamphaus (Eds.), Handbook of psychological and educational assessment of children: Personality, behavior, and context (pp. 66–90). Guilford Press. Frías, Á., Solves, L., Navarro, S., Palma, C., Farriols, N., Aliaga, F., Hernández, M., Antón, M., & Riera, A. (2020). Technology-Based Psychosocial Interventions for People with Borderline Personality Disorder: A Scoping Review of the Literature. Psychopathology, 254–263. https://doi.org/10.1159/000511349 Frewen, P., Mistry, D., Zhu, J., Kielt, T., Wekerle, C., Lanius, R. A., & Jetly, R. (2020). Proof of Concept of an Eclectic, Integrative Therapeutic Approach to Mental Health and Well-Being Through Virtual Reality Technology. Frontiers in Psychology, 11(June), 1–25. https://doi.org/10.3389/fpsyg.2020.00858 HARTWIG, E. K. (2021). PUPPET PLAY THERAPY. In H. G. Kaduson & C. E. Schaefer (Eds.), Play Therapy With Children: Modalities for Change (pp. 107–124). American Psychological Association. http://www.jstor.org/stable/j.ctv1c3pdnk.11 Homeyer, L. E., & Sweeney, D. S. (2016). Sandtray Therapy: A Practical Manual (3rd ed.). Routledge. IDEO. (2015). The Field Guide to Human-Centered Design. Retrieved from https://cipe.yale-nus.edu.sg/wpcontent/uploads/sites/9/2015/12/IDEO_Field-Guide-to-Human-C entered-Design.pdf Lindner, P., Hamilton, W., Miloff, A., & Carlbring, P. (2019). How to treat depression with low-intensity virtual reality interventions: Perspectives on translating cognitive behavioral techniques into the virtual reality modality and how to make anti-depressive use of virtual reality–unique experiences. Frontiers in Psychiatry, 10(OCT), 1–6. https://doi.org/10.3389/fpsyt.2019.00792 Li, J., Theng, Y. L., & Foo, S. (2014). Game-based digital interventions for depression therapy: A systematic review and meta-analysis. Cyberpsychology, Behavior, and Social Networking, 17(8), 519–527. https://doi.org/10.1089/cyber.2013.0481 Prosser, Z. (2021). Futures Thinking: A Mind-set, not a Method - Touchpoint. Medium. https://medium.com/touchpoint/futures-thinking-a-mind-set-not-a-method-64c9b5f9da37 29 Care Through Play, Anywhere Rehm, I. C., Foenander, E., Wallace, K., Abbott, J. A. M., Kyrios, M., & Thomas, N. (2016). What Role Can Avatars Play in e-Mental Health Interventions? Exploring New Models of Client–Therapist Interaction. Frontiers in Psychiatry, 7. https://doi.org/10.3389/fpsyt.2016.00186 Richardson, C. G., Slemon, A., Gadermann, A., McAuliffe, C., Thomson, K., Daly, Z., Salway, T., Currie, L. M., David, A., & Jenkins, E. (2020). Use of asynchronous virtual mental health resources for COVID-19 pandemic–related stress among the general population in Canada: Cross-sectional survey study. Journal of Medical Internet Research, 22(12), 1–13. https://doi.org/10.2196/24868 Sanders, L., & Stappers, P. J. (2013). Convivial Toolbox: Generative Research for the Front End of Design. In Convivial Toolbox: Generative Research for the Front End of Design (Illustrated ed., p. 196). Laurence King Publishing. Schaefer, C., McCormick, J., Ohnogi, A., Ariel, S., Cattanach, A., Bundy-Myrow, S., Jennings, S., Levin, S., Hudd, S., Lahad, M., Kirk, K., Mielcke, J., Carroll, J., Russ, S., LeVay, D., Lowenstein, L., Hudak, D., & Oren, G. (2010). Embodiment-Projection-Role: A Developmental Model for the Play Therapy Method [E-book]. In International Handbook of Play Therapy: Advances in Assessment, Theory, Research and Practice (pp. 65–76). Jason Aronson, Inc. Shrinivasa, B., Bukhari, M., Ragesh, G., & Hamza, A. (2018). Therapeutic intervention for children through play: An overview. Archives of Mental Health, 19(2), 82–89. https://doi.org/10.4103/AMH.AMH_34_18 Stamm, B. H. (1998). Clinical applications of telehealth in mental health care. Professional Psychology: Research and Practice, 29(6), 536–542. https://doi.org/10.1037/0735-7028.29.6.536 Stone, J. (2020). Digital Play Therapy (1st ed.). Routledge. Substance Abuse and Mental Health Services Administration. (2021). Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders. http://store.samhsa.gov Sweeney, T. (2019). Foundational Principles & Technologies for the Metaverse. In Proceedings of SIGGRAPH’ 19 Talks. ACM, Los Angeles, CA, USA. doi: 10.1145/3306307.3339844. The Metaverse and How We’ll Build It Together -- Connect 2021. (2021, October 28). [Video]. YouTube. https://www.youtube.com/watch?v=Uvufun6xer8 Wilkinson, N., Ang, R. P., & Goh, D. H. (2008). Online video game therapy for mental health concerns: A review. International Journal of Social Psychiatry, 54(4), 370–382. https://doi.org/10.1177/0020764008091659 30