Theraplay Treatment Protocol

Theraplay® is a structured play therapy for children and their parents. Its goal is to enhance attachment, self-esteem, trust in others and joyful engagement. The method is fun, physical, personal and interactive and replicates the natural, healthy interaction between parents and young children. Children have been referred for a wide variety of problems including withdrawn or depressed behavior, overactive-aggressive behavior, temper tantrums, phobias, and difficulty socializing and making friends. Children also are referred for various behavior and interpersonal problems resulting from learning disabilities, developmental delays, and pervasive developmental disorders. Because of its focus on attachment and relationship development, Theraplay has been used successfully for many years with foster and adoptive families.

With this method, family interaction patterns have changed and schools and pediatricians have reported a reduction of symptoms and improved behavior in the child. Essentially the same treatment techniques extending over a longer period of time are used with children who have developmental delays, pervasive developmental disorders, and autism. It has been our experience that even in the rare cases where parents/caregivers cannot be involved, Theraplay is still of benefit to the child.

Theraplay® is modeled on the interaction of parents and children in a healthy relationship. In planning for treatment, it is useful to think of the activities that characterize the healthy relationship as falling into four dimensions:

STRUCTURE:	The therapist selects and leads the activities (but always remains attuned to the child's reaction). The fact that the adult is in charge is reassuring, helping the child to develop self-control, and assuring the child of order if the environment is unruly or chaotic. Thus structure addresses both inner and outer disorder. It is especially useful for children who are overactive, undirected, overstimulated, or who want to be in control.
ENGAGEMENT:	Engaging activities offer pleasant stimulation, variety, and a fresh view of life, allowing a child to understand that surprises can be fun and new experiences enjoyable. The child is focused on in an intensive, personal way in order to make a connection with the child. Engagement is necessary for all children, but is especially appropriate for children who are withdrwan, avoidant of contact, or too rigidly structured. Very withdrawn or autistic children may experience engagement as uncomfortable. In response, the therapist slows the pace and monitors stimulation, but still attempts to entice the child into a relationship.
NURTURE:	Soothing, calming, quieting, caretaking activities make the world feel safe, predictable, warm and secure. They also reassure the child that the adult can provide comfort and stability. Nurturing meets the child's unfulfilled younger needs; helps the child to be able to relax and allow herself to be taken care of; builds the inner representation that the child is lovable and valued. It is especially useful for children who are overactive, aggressive, or pseudo-mature.
CHALLENGE:	Challenging activities help the child take a mild, age-appropriate risk, and promote feelings of competence and confidence. They are fun, are not done alone, and are cooperative rather than competitive. Challenging activities are especially useful for withdrawn, timid, or rigid children.

In a typical case, families participate in a series of 20-25 weekly sessions with four follow-up sessions at quarterly intervals over the next year. The first session is an information-gathering interview with the parents. The second and third appointments are observation sessions using the Marschak Interaction Method (MIM), in which the child and one parent perform a series of interactive tasks together. The interactions are videotaped and later analyzed by Institute staff in preparation for a fourth session with the parents. In that session the staff and parents discuss their observations of the interaction and together agree on a plan for treatment.

Sessions five through twenty five involve direct Theraplay with the family, duplicating (regardless of age) the kind of playful behavior and fun games which parents and young children naturally engage in together. The interaction includes structuring, engaging, nurturing and challenging activities in combinations geared to the specific needs and problems of the individual child and his/her family. After every 3 family sessions a session is scheduled for the therapist(s) and the parents to meet without the child to discuss progress and goals.

Parents observe all Theraplay sessions and eventually enter the room and join in Theraplay directly. We often have two therapists, one who interacts with the child and one who works with the parents. When two therapists are present, the parent therapist observes with the parents and discusses the rationale for the activities, e.g., encouraging the development of trust and self-esteem, building a sense of self as lovable, developing confidence, permitting pleasurable experiences, encouraging intimacy, developing a positive body image, strengthening perceptual motor-coordination. This discussion includes ways in which the parents can implement these ideas at home. If one therapist is present, these discussions take place with the parents at the end of each session, by phone, or at a separately scheduled time.

The final session ends with a good-bye party. Four follow-up sessions are scheduled at quarterly intervals, with parents and child, over the next twelve months. A typical Theraplay program of twenty five sessions (4 assessment, 21 treatment & discussion) is summarized below:

Session	Program
1	Initial interview with mother and/or father.
2	One parent and child participate in Marschak Interaction Method (MIM), a structured technique for intensive observations of the ways parent and child typically interact with one another. Theraplay staff members observe and videotape this interaction.
3	Same as 2, except that other parent participates.
4	Feedback session with mother and father.
5,6,	The therapist interacts with child while parents watch. Explanations are given to parents ahead of time as to what will take place. Questions are answered after the session and parents are encouraged to try Theraplay techniques at home. Parents enter the session towards the middle or end of each session.
8	Meeting with parents only to go over videos of sessions/review progress/discuss issues with child at home.
9-11	Same as 5-7, with parents gradually becoming the focus of interaction with child with therapist’s guidance
12	Meeting with parents only to go over videos of sessions/review progress/discuss issues with child at home.
13-15	Same as 9-11, with parents gradually taking more of the lead role in interacting with child with therapist’s guidance.
16	Meeting with parents only to go over videos of sessions/review progress regarding therapy goals/discuss issues with child at home.
17-19	Same as 13-15, with parents gradually taking more of the lead role in interacting with child with therapist’s guidance.
20	Meeting with parents to evaluate therapy goals/decide on end date/refer for additional treatment.
21-23	Theraplay session wherein parents are actively involved in planning and leading the sessions.
24	Final “goodbye Theraplay party” or additional sessions as needed.
25	Final meeting with parents to review goals achieved and areas for future work if necessary.