Remote SSP Delivery Guidelines
The COVID pandemic has affected many aspects of all our lives, including creating a need for therapy to be conducted remotely. While previous guidelines for those over the age of 13 have strongly favored in-person delivery of the SSP, time and experience has demonstrated that remote SSP delivery can be successful for many clients. Several advantages have emerged, including the opportunity for clients to participate in the safety and comfort of their home. While it cannot always replace in-person connection, providers are maintaining the ability to co-regulate and monitor their client’s response to the SSP with good success.
How we developed the Guidelines:
Best practices around the delivery of the SSP have evolved from the input of therapists in many disciplines who have adapted it for use with their specific client populations and adjusted their approach over time. These have been shared in the updated SSP Certification Training that was released on January 1, 2020. Please take the time to review this new information.
The Remote SSP Delivery Guidelines described below apply to the situation where your client is a teen or adult and a parent is not administering. They should be followed together with the recommendations of the SSP Delivery Manual: Polyvagal Informed Practices for Delivering the SSP (available in the Resources page on MyUnyte).
To develop the following guidelines, we reached out to many respected therapists for their input and ideas. Many of them emphasized similar themes and each had new aspects to contribute. We collated all of their advice to form this set of guidelines which both Dr. Porges and our Clinical Director, Dr. Minson, have also reviewed and contributed to.
We feel fortunate to have the Unyte-iLs community that we do – to have therapists offering to help us and one another as we find creative ways to assist those in and outside of our community. Remember also to care for yourself while you work with your clients. This might mean following the advice you give to them!
Thank you to each one of you and, of course, reach out to us with any questions or concerns.
Not every client is a candidate for remote facilitation. Some will need the personal presence, direction and guidance of a skilled therapist for safety and best results. For every client it’s important to assess the suitability of remote facilitation of the SSP.
Characteristics of a client who would not be appropriate for remote delivery:
- Engages in self-injury behaviors
- Experiences suicidal thoughts/ideation
- Has recently started or changed type/dosage of a psychiatric medication
- Recently suffered a head injury or experiences significant medical instability
- Experienced a recent major destabilizing personal life event (divorce, death, job loss, etc.)
- Lives in an unstable/difficult household
- Has been or is significantly impacted by COVID-19
- Is currently experiencing seizures
- Has a history of significant trauma
People experiencing any of the above will be best served by working one-on-one in person with a skilled therapist, when that is again possible. Instead, provide them regulation and support as possible and, if appropriate, refer them to a mental health professional.
Using a scale to test suitability:
In addition to any screening materials you are typically using, we recommend the addition of the General Anxiety Disorder (GAD-7) to assess client suitability for remote SSP delivery. The GAD-7 is user friendly and available for free. It can be completed in five minutes.
It is best to complete this assessment with your client via video conference. That way, you can gauge your client’s reaction from their facial expressions and tone of voice. This adds further information beyond just the score. Click here for tips and further information on delivering an assessment via video conference.
If a client scores 10 or higher on this assessment, remote administration of the SSP may not be appropriate. It may also indicate that a referral to a mental health professional is best. Please keep the results of the assessment in your client’s file for a case consultation should this be needed.
When deciding the safest and best course of action please consider the following factors: what is best for the individual client given the available options; what is within your knowledge, skills and availability; and what other support is available to your client.
The name ‘Safe and Sound’ is both descriptive and instructive. Safety is paramount and is the foundation of successful facilitation of the SSP. This is more important now due to social distancing, isolation, and global fear. Even the most resilient are struggling now.
Reassure your client that you will be with them every step of the way and they can trust that you will support them in every way possible. It is important to emphasize that this relationship of trust between you and the client involves a mutual agreement that they will share their responses to and experiences with the SSP and that you will be available to support them. If this changes the financial arrangements for you, clarify this upfront.
A trusting relationship with your client is the best start to a successful SSP experience. If you do not have the opportunity to form an in-person relationship with your client beforehand, be sure to spend time getting to know them. This is best achieved via a video conference platform.
Since the SSP is a physiological bottom-up tool, shift the focus away from the client’s narrative to tune into their nervous system. Help them to understand their autonomic nervous system and create a language from which to build a shared experience of trust during facilitation of the SSP. Learn your client’s demeanor: their voice (vocal prosody and modulation), their facial expressivity, posture, and body language. This will help you to recognize signals of state change as you check in on their SSP experience.
Spend time bringing the client’s awareness to what it is like to engage in the video format. It’s important to acknowledge that, while it feels personal, some aspects of being together in person are missing. For example, it’s difficult to make direct eye contact; when you look at your client’s image on the screen, your eyes do not track theirs and vice versa. Sometimes there may be a lag in the audio or the video may freeze momentarily. Verbal language becomes more important. Discuss the importance of making implicit feelings explicit. This will improve your ability to support them.
Feeling safe, stable, and secure is central to your client’s health and wellbeing during their experience with the SSP.
We recommend that the SSP be delivered for a maximum of 30 minutes per day. The shortest time that it would take to complete the whole program, then, would be ten days. Of course, it is possible to take it slower based on the client’s tolerance.
Dr. Porges’ mantra of “Less is More” guides this recommendation. Since the therapist is not physically alongside the client for SSP facilitation, the therapist is less able to understand the client’s window of tolerance and to titrate the listening in response.
A slower facilitation schedule allows for the nervous system to better process, digest, and integrate the experience.
While delivering the SSP alongside your client in person is the best option, video conferencing opens up new opportunities for facilitation when physical distancing is necessary.
The benefits of SSP facilitation via video conferencing are that you can visually monitor your client and help them to process their response in real time. As described in the Polyvagal Informed SSP Delivery Manual, you should pause the SSP when any signs of discomfort are recognized by you or your client.
Another good option is to pause the SSP at predetermined times – such as every 10 minutes – to discuss and explore any physical responses your client may be experiencing. This creates an opportunity for them to learn more about their state and to become better able to intuit the physical and emotional aspects of a state shift. It also safeguards against progressing with listening too quickly if the client is not able to feel the changes in their body (for example, as a result of trauma). This is even more important when delivering remotely.
Before beginning the SSP, have a video conference meeting to:
- Become familiar with the video conference technology and seeing and hearing each other on screens
- Set expectations about the SSP experience
- Discuss the logistics of SSP facilitation including navigating the digital delivery version of the SSP or operating the MP3 player
- Discuss how the client will communicate their feedback to you
- See the setting where they will do the SSP and ensure it is appropriate
- Guide different activities and items of comfort they may want to have
Together with your client, decide how they will listen to the SSP. This will depend on their particular circumstances. Assess how much of your client’s SSP listening will be monitored by you. Be aware that you can combine or change the methods as you proceed.
Here are some suggestions to consider as you determine the best route for you and your client:
- Begin by playing 1A for 5-10 minutes and then pause the music for a conversation to get a more accurate assessment of your client’s response to the SSP. This will provide insight into how the subsequent sessions should be delivered.
- One option is for all of the client’s SSP listening to be monitored by you via video conferencing. Schedule one-hour meetings during which 30 minutes of SSP listening will be done. Use the other 30 minutes – before, during, and after the listening – to talk with the client about their physical sensations and any emotions or memories elicited. Talk about the physiology of the nervous system, how to sense shifts, and to balance their state. Use the client’s response to titrate their listening schedule accordingly.
- Another option is for some segments of the client’s SSP listening to be done together with you via video conferencing and some on their own. It is recommended that you participate in more segments during the first three hours of listening as this is when physical and emotional responses to the listening are more likely to occur and your client may need your support.
- If you pursue the route of not participating in all the sessions, check in with your client every day they are listening to debrief and support them. Request they keep notes during and after each session to share with you. Specific feedback about their experience will help track their responses and titrate their future listening schedule accordingly.
- Always remember that ‘less is more’. Collaborate with your client to adjust their listening schedule based on their responses. This is especially important when you are not there to notice subtle changes in their responses and state.
- If your client is uncomfortable being “watched” by you, you can continue monitoring them via video without them seeing you by simply turning your camera off. In this case, the video link will remain open, but your client will not see you. It would be better, though, if they can see you so they can look at you to gain your attention and reassurance if needed.
- Endings are important. Have a conversation to summarize the client’s experience, to follow up on how they are feeling, and to offer strategies for maintenance. If this is the end of your commitment to them, remind them that the SSP is not a standalone tool and suggest they continue with their regular therapy. If they are not in therapy, offer some suggestions and recommendations which reflect their SSP listening experience. Define how any further communication will occur.
To reiterate, please use the Polyvagal Informed Practices for Delivering the SSP to guide your delivery and support of your client.
Help your client create layers of support. Request that they list the people in their life who will be near or with them as they listen. Preferably, they will have one key person who can be with them consistently. Everyone’s nervous system is different and the SSP can provoke a wide range of responses. Some people don’t have a significant response to the SSP; to them, it’s just music. For others, it may provoke strong feelings. The Safe and Sound Protocol is designed to re-activate the Social Engagement System. Remember that for those with a profound trauma history, the SSP may trigger the nervous system’s resistance against any attempt to be ‘retuned.’
If – despite your care and titration of the listening – your client experiences discomfort, it is important for them to have a trusted person available for support. Discuss this before beginning the SSP to ensure that your client has someone to reach out to. This is an essential part of the SSP since you as the therapist cannot be physically present.
There are three possibilities for how your client can access the SSP Playlists:
1. Use the digital delivery version of the SSP:
With digital delivery of the SSP, the physical MP3 player is replaced with an app (Unyte-iLs app) that can be downloaded on any phone or tablet (Android is available now and an Apple version is coming soon). This gives you more control and the ability to track your client’s listening progress.
Your client will listen with over-the-ear headphones (see list of recommendations) to the playlist you assign them. Soon, you will be able to “unlock” segments of the playlist at a time, but for now, designate the length of each listening session. The app will “remember” the last completed point and cue the next listening session from that point. You will be able to track your client’s listening behavior and modify their schedule as appropriate.
We recognize there is some concern around the safety of shipping items to clients at this time, given reports that the coronavirus can live on some surfaces for extended periods of time.
We want to assure you that we are taking every necessary precaution to ensure the safety of our practitioners and their clients by cleaning all systems thoroughly before shipping. This cleaning is being undertaken in strict compliance with the Center for Disease Control’s (CDC) Infectious Disease Guideline for Disinfection and Sterilization in Healthcare Facilities, using only Environmental Protection Agency (EPA)-approved disinfectants and applying them based on CDC-recommended processes. This ensures that everything leaving our facility is clean and safe for client use.
The guidance provided above for individual practitioners who wish to ship their own systems is also in line with these guidelines and recommendations.
Ultimately, it is in every clinician’s judgment as to whether the potential risks associated with providing therapy outweigh the potential benefits, and we trust each of you will be making your own best judgments at this time.
We are here to help! Please reach out with any questions you have. We can be reached by phone at (303) 741-4544 from 9am- 6pm ET or by email at [email protected].
We continue to offer complimentary case consultations with our Clinical Director Dr. Ron Minson. We ask that you fill out the case consultation form as completely as possible as all information can be relevant. Please be as specific as possible with your questions.
If you don’t already use a HIPAA compliant video conferencing platform, we recommend Google Hangouts or Skype. Both are free, easy to use and temporarily HIPAA compliant as per the most recent guidance from the US Department of Health and Human Services (click here to learn more).
If you have a Google or gmail account, it may be easiest for you to use Google Hangouts; we use it every day at iLs and have found it to be both reliable and easy to use. However, if you are more familiar with Microsoft products, you may prefer Skype.
To get started, we’ve included some basic resources for you to follow: