Originally published in the The Theraplay® Institute Newsletter of Spring, 2004

Theraplay In An Inpatient Unit for Psychotic Disorders

Lillian Ing, MA, Clinical Psychologist

Cape Town, South Africa

I was the Unit Manager and member of a multi-disciplinary team in the Therapeutic Unit for Psychotic Disorders, one of a number of special units in a large modern psychiatric hospital in Mitchell’s Plain. The Unit is a self-contained single dwelling with living and therapeutic facilities for 22 men and women.

Individuals are referred to the Unit from a range of private and public sector hospitals and medical practitioners, from closed admission wards, or are self-referred.

• Functional psychosis as primary disorder
• Sub-acute, recovering or resolved psychosis
• May have had previous psychotic episodes or
  psychiatric admissions
• Average to borderline intelligence
• Adolescent to about 60 years
• Motivated to receive treatment or acknowledgement
  of psychosis

The Unit had been running a successful 6-8 week program (research indicated relapse rates of 25% over a four year period) in which therapeutic interventions were aimed at reality orientation, gaining insight, and development of appropriate life skills. The main focus, however, was to provide a good experience so that the individual’s self-esteem was nurtured and enhanced.

In-patient therapeutic activities consisted of: community meetings, physical exercise, group therapy, individual and family counselling and therapy, arts and crafts, art therapy, educational talks, sport/relaxation/games, life skills, role play, goal setting, concentration activity, personal hygiene, entertainment, and relaxation therapy.

At that time, our practice had been to assign all individuals who were admitted to the unit to an Orientation group, run by a therapist and co-therapist twice weekly for an hour. In the group, psychotic material could be discussed and framed within the perspective of psychiatric illness, aetiology explored, and individuals supported in their understanding of the reasons for their current “breakdown”, including stressors and/or non-compliance with their medication. Once an individual had some level of insight into their illness, they were moved to a “working” group to work through issues.

Theraplay was introduced initially as an experiment after I had attended a Theraplay training session. I was intrigued by what I perceived to be similarities between Theraplay goals and the goals we had established in the Unit, as well as the case studies and stories I heard about Theraplay use with autistic and psychotic children, adolescents and the elderly.

While the Orientation Group clearly had some merit (viz. research), I was excited about the possibility of a therapeutic intervention which emphasized direct individual interaction and included activities which provided enjoyable sensory experiences, required the individual to engage with others in a non- threatening way, provided a high level of structure, were nurturing, and of sufficient impact to be stimulating and self-enhancing. This seemed of particular value since we were being asked to take increasing numbers of individuals who were still psychotic and who appeared to be taking longer than two weeks to settle. There were also individuals who we believed were not benefiting from the working groups, with their emphasis on a “talking” therapy.

The team set about designing sessions to promote increased self- awareness, positive feelings, and firm impressions of self worth and increased self-confidence-- goals which are of particular importance in the treatment of psychosis.

• Sessions provide a “here and now” good experience, the kind that builds trust so that the individual learns that they can build positive relationships which do not harm
• Sessions involve emotionally attuning, interactive, physical play
• Nurturing touch is encouraged
• Sessions are designed for individuals who have regressed and include activities that may seem appropriate for children

Group Theraplay, in our context, was a therapist-directed, structured activity that incorporated playful, cooperative and nurturing activities to enhance the emotional re-connection of individuals who had experienced a psychotic breakdown. They were designed to promote self-esteem, a sense of connectedness to society, as represented by the community, care for oneself and others (that one was even worth being cared for!) and trust. While we were not attempting to enhance attachment to significant individuals, we certainly were involved in enhancing attachment to Self and reality.

• The group (6-12 individuals) is seated on the floor in a circle
• The therapist, co-therapist and assistants are seated in the circle and participate in the activity
• Activities involve a combination of structure, nurture, engagement and challenge
• Instructions are simple and understandable and individuals take their cue from others in the group
• Number of activities is tailored to the group’s tolerance for stimulation- this often means fewer activities that are repeated
• Rules include: no hurting others, have fun, try
  it, and sit out if you become uncomfortable (Interesting that very few
  ever chose this option)
• Acceptance by the staff is fundamental and “problem behaviour” is redirected and shaped, not punished
• The staff is in charge
• The staff is gentle and encouraging in attempts to engage individuals in the activities
• Sexually stimulating activities are avoided as this is an inpatient mixed gender group
• Limited requirement for individual to engage in sustained verbal communication

• Welcome and introductions-to allay anxiety, orientate to here and now and give each person special attention, e.g. individuals introduces themselves and say their favorite color; individuals do eye hellos
• Music and movement-- to encourage active, yet structured participation, e.g. If you’re happy and you know it; Head, shoulders, knees and toes
• Food share-- treats to nurture, e.g. feeding each other
• Physical touch promotes awareness of self and others
• Challenging activities, e.g. balancing on pillows, lining up and walking on a straight line like a tightrope. pass the clap; hand stack
• Relax-- massaging hands or shoulders; lotion

While we did not standardize our assessment of the progress that an individual made in Theraplay, the areas that we observed and used as a yardstick for progress were the following:

• Establishing and maintaining eye contact
• Initiating and receiving appropriate nurturing
• Taking others into consideration
• Asserting self and setting boundaries
• Initiating action
• Joining in and co-operating
• Experiencing positive feelings
• Participating in social interactions
• A more integrated self

Our experience was that:

• Theraplay created an atmosphere that was warm and nurturing, engaging and challenging. In this environment, the individual with a tenuous attachment to reality could experience nurturing and connection with others. “It’s never too late to have a happy childhood!” said an intern psychologist when asked to describe his experience after participating in a Theraplay session.
• Theraplay met the basic needs of individuals so there was no need to retreat into their own world
• The activities engaged withdrawn or passive individuals
• Positive communication and connection with others was fostered without relying on talking or verbal skills
• The sessions let fun into what had been a traumatic experience for most individuals
• The interplay of activities provided a model for healthy interaction
• Theraplay promoted positive social interaction
• It supported the reconfiguration of psychological order
• It encouraged a “can cope” approach

The Theraplay activities appeared to provide the right level of stimulation for psychotic individuals, and they seemed to settle more quickly. Individuals who were passive and withdrawn became more active in the community and when transferred to “working” groups, appeared to be more “integrated” and able to benefit from these and other therapeutic activities. The groups also provided a positive experience for those whom we assessed as needing sustained, ongoing nurturing, structure and support and who were not transferred to the working groups. Individuals named these groups “play groups” and said they felt at ease there.

Finally, an unexpected bonus was that staff benefited from participating in the activities which appeared to provide support and nurturing for those who carried the load of working in an emotionally demanding environment.

What had begun as an experiment was soon adopted as a valuable adjunct to our therapeutic program.