Theraplay

Theraplay​ is an approach to child and family therapy that aims to address behavioral, emotional, or developmental issues and improve the parent-child relationship through play and healthy interaction.

Typically, this approach is used in treatment with children up to age 12. However, Theraplay techniques may be combined with other modalities and can be adapted for use with teenagers and adults seeking therapy for these same concerns. 

• Development of Theraplay
• Theraplay Theory and Techniques
• How Does Theraplay Work?
• Issues Treated with Theraplay
• Training for Theraplay
• Concerns and Limitations

Development of Theraplay

This approach to treatment was developed by Ann Jernberg in the late 1960s, during her time as Director of Psychological Services at the Chicago Head Start Program. Jernberg's position involved identifying children who needed professional care and referring them to outpatient clinics, but as she began to realize how many children needed help, she began working to create a treatment program that could be implemented at the Head Start facilities. 

In order to care for the large number of children identified by her team as in need of service, Jernberg employed paraprofessionals who worked under the direct supervision of licensed therapists. She chose people she felt were lively and playful and would be able to readily engage the children. Initially, there was some resistance to her methods, but she provided video evidence of the effectiveness of the approach to refute criticism. Today, Theraplay is a widely respected therapeutic model, and The Theraplay Institute—established by Jernberg in 1971—certifies, supervises, and trains therapists from around the world in Theraplay. 

Theraplay Theory and Techniques

The Theraplay model incorporates concepts from several developmental theories, including attachment theory, self psychology, and object relations theory, and draws from the work of therapists Austin Des Lauriers, Viola Brody, and Ernestine Thomas. In Theraplay sessions, children are actively engaged in a friendly setting and encouraged to focus on the present rather than the past, while therapists and parents work to maintain a strongly positive attitude about the child's present and future prospects.

The core tenets of Theraplay include the following:

• Human behavior is influenced primarily by a drive to increase kinship and connection; thus, interpersonal interactions are likely to have a significant impact on an individual's personality. Parents and caregivers tend to play a key role in the early development of a child’s personality and sense of self.
• An infant who is consistently exposed to positive relationships is likely to develop inner representations characterized by a high regard for self (“I am lovable. I am special”), a high regard for others (“This person is caring. This person is trustworthy”), and a positive, hopeful view of the world (“I am safe. I can explore. I can contribute.”).
• An infant who is consistently exposed to negative relationships is likely to develop inner representations characterized by a low regard for self (“I am unlovable. I cannot do anything properly”), a low regard for others (“This person is unloving. This person is unreliable”), and a negative, hopeless view of the world (“I will get hurt. I am not safe”).
• The major contributing factor toward a child's positive development is the maintenance of a positive relationship between parent and child. 
• The activity of playful, responsive caregivers is vital to a child’s ability to develop a secure attachment, the capacity to regulate emotions, empathy, and a strong sense of self-worth.
• As an individual’s perception of trust and self are rooted in the early years of development, it is crucial to revisit the point at which the child’s healthy emotional development was interrupted and administer the positive experiences necessary to restart healthy, positive interaction.

Included in each session are four fundamental dimensions that, according to Theraplay theory, form the basis of a healthy parent-child relationship. These dimensions take the form of specific behaviors, activities, and words.

• Structure: The parent or guardian takes the lead in the session and defines all rules and boundaries in order to promote feelings of safety and a sense of organization and foster the development of self-regulation in the child. This dimension is often effective for children who display high impulsivity and a lack of focus and for parents who have difficulty setting rules or taking the lead.
• Engagement: The parent/guardian focuses on the child in a personal manner so the child knows they are seen and heard in the moment. This dimension promotes joyful, responsive companionship and helps parent and child form a deeper emotional connection. Engagement is often effective for children who are socially withdrawn and parents who tend to be inattentive to or disengaged.
• Nurture: Parent and child take part in soothing, calming activities that are believed to foster feelings of warmth, safety, and comfort. Soothing touch is a fundamental part of this dimension, and nurture can help a child develop inner knowledge of being special, lovable, and valued. This is most often appropriate for children who are anxious, overactive, or aggressive and parents who are harsh, dismissive, or who have difficulty displaying feelings of affection.
• Challenge: The child is helped to complete a fun but challenging task or take a mild, age-appropriate risk in order to promote feelings of self-confidence and competence. Activities are performed in an environment that is positive, fun, optimistic, and non-competitive. Children who are shy or rigid and parents who are competitive or who have inappropriate developmental expectations may obtain benefit from this dimension.

How Does Theraplay Work?

Theraplay sessions, which run 30-60 minutes in length, usually involve two therapists. One therapist tends to initiate the session with the child while the other therapist explains the purpose of the activity to the parents. Parents are able to directly observe each session. After the child is comfortable with the activity and the parents have learned how to properly administer the activity, one parent generally then enters the room and takes part in the session. If only one therapist is available, explanations about the purpose of each activity generally take place after the session or over the telephone.

The parents are interviewed in the first session, and therapists use the information gathered to tailor subsequent sessions in order to best address specific issues affecting the family. The second and third sessions are used to observe the child and parent as they complete activities together. These sessions are videotaped and analyzed using the Marschak Interaction Method (MIM), a structured procedure used to evaluate the bond between two individuals and reveal relationship strengths and weaknesses. During the fourth session, therapists and parents come together to discuss their findings from the two previous sessions and develop a specific treatment plan. In the fifth session, therapists typically demonstrate the activities to be used in treatment, the purpose of the activities, possible reactions the child may have, and encourage thoughts or other reactions from the parents.

Sessions 6-25 involve standard Theraplay games, interactions, and activities—each of which is based on the model’s four fundamental dimensions for a positive parent-child relationship. After every three sessions with the family, a fourth session is scheduled without the child. This session allows the therapists and parents to review treatment goals and the progress that has been made. Homework assignments may be given between sessions. Theraplay has been proven to be a beneficial and effective approach for treating young people who are experiencing or have been affected by a range of issues and challenges.

Theraplay treatment typically lasts from 18-26 weeks, but depending on a family's needs, treatment period may continue for 9-18 months. In the last treatment session the parent-child relationship is typically reevaluated, and recommendations are made for future treatment. Four follow-up visits, which take place over the course of a year, are typically scheduled. 

Issues Treated with Theraplay

Theraplay has been proven to be a beneficial and effective approach for treating young people who are experiencing or have been affected by a range of issues and challenges. While services are typically offered to one family at a time in order to build trust, engagement, and attachment, Theraplay can be adapted to be effectively delivered to multiple families in a group setting. Theraplay sessions can be conducted in a variety of settings—outpatient clinics, schools, foster care, adoptive homes, hospitals, community agencies, or residential care facilities.

When children experience severe or chronic concerns, they may receive treatment at a slower pace or over a longer period of time.

Theraplay has been used to help children with diagnosable concerns—oppositional and defiant behavior (ODD), posttraumatic stress, and attachment issues, among ​others—as well as behavioral and emotional issues that are not typically diagnosed—shyness, fearfulness, and withdrawal, for example. This approach can also address communication issues, social issues, developmental delays, grief and loss, and foster care and adoption issues. 

Also addressed in Theraplay are parenting concerns and other caregiver issues, particularly those occurring when the parent experiences behavioral or relationship challenges with the child.  

Training for Theraplay

​The Theraplay Institute offers local and international training programs for mental health professionals, teachers, and other individuals who routinely work with children and families. Training is divided into several sections depending on the needs of the applicant: 

• Theraplay Level One consists of a four-day course that teaches fundamental techniques. This course may be taken simultaneously with Theraplay Group Therapy.
• Theraplay Level Two is a three-day modular course that discusses core concepts. Theraplay Level One is a prerequisite for this program.
• Theraplay Master Class, a two-day course, features advanced study and work. Theraplay Level One is a prerequisite for this program.
• Theraplay Group Therapy is a one-day course for people who wish to use Theraplay in group settings—classrooms, family groups, day care, or residential care facilities. Theraplay Level One is a prerequisite or corequisite for this course. Applicants who do not fulfill the prerequisites may apply for a two-day course.

A fifth stand-alone program, MIM Skills Development, is available for people who wish to pursue skills training in the delivery and interpretation of the Marschak Interaction Method. 

These training programs are specially designed for people with a master's degree or higher in a mental health field, but individuals without these credentials who demonstrate a thorough understanding and background in psychology or child development may also be accepted. In order to be certified as a Theraplay therapist, however, individuals must hold a master's degree or higher and be licensed to practice. Others may work as a Theraplay Associate under the supervision of a certified therapist.

Concerns and Limitations

Since its initial development, numerous clinical studies have highlighted the advantages of Theraplay, and The California Evidence-Based Clearninghouse has rated it a 3 on a scale of 1-5, indicating it has been well-supported by evidence. The Washington State Inventory of Evidence-Based, Research-Based, and Promising Practices has also rated it as a promising practice. 

Empirical evidence supports the therapeutic benefits of this treatment, but it is not considered appropriate in certain settings. Children or parents with severe cognitive deficits may experience only limited success from Theraplay. Theraplay is not recommended for abusive caregivers or caregivers who are experiencing substance dependency. 

Theraplay focuses on strengthening the child-caregiver relationship; therefore, issues existing between the child and individuals other than the caregiver, especially individuals who exist outside of the family setting, may not be thoroughly explored or addressed. Techniques learned in Theraplay may help children become better able to manage maladaptive issues, but the issues themselves are not directly treated. In some cases, additional treatment may be indicated. 

References: 

1. Theraplay. (2016). Retrieved from http://www.cebc4cw.org/program/theraplay/detailed
2. Theraplay treatment outcome research. (n.d.). Retrieved from 
3. Who should attend Theraplay level one training? (2013). Retrieved from http://www.theraplay.org/index.php/about-our-training/who-should-attend
4. Wettig, H. H. G., Coleman, A. & Geider, F.J. (2011). Evaluating the effectiveness of theraplay in treating shy, socially withdrawn children. International Journal of Play Therapy, 20(1), 26-37. DOI: 10.1037/a0022666.