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

Creating a Coherent Attachment History: Combining Theraplay and Cognitive-Verbal Interventions

Kevin O'Connor, PhD, RPT-S

California School of Professional Psychology
at Alliant International University 5130 E. Clinton Way, Fresno, CA 93727

In recent years the study of attachment behavior has proliferated, yielding some findings that have significantly altered the way we think about the process and long-term effects of children’s early attachment experiences.Some of the initial conceptualizations of the attachment process roughly equated it with imprinting behavior in birds.The caretaker’s voice, facial features, scent and touch were seen as essential building blocks in creating the child’s initial bond.The psychobiological nature of children’s attachment to their caretakers is now seen as a very complex process nicely summarized by Polan and Hofer (1999).In turn, the degree to which infants come to see the interactions with their caretakers as both reliable and pleasurable leads to their ability to view the caretaker as a secure base.For the very young child it is the caretaker him or herself who serves as a concrete secure base allowing for the child’s successful individuation and exploration of the world and other interpersonal relationships (Mahler, 1967, 1972).The power of these ideas is clearly reflected in the effectiveness of Theraplay in treating children whose early relationships with their caretakers were less than ideal.Through the use of Structuring, Challenging, Engaging and Nurturing the Theraplay therapist provides children with experiences that build their sense of trust and pleasure in interpersonal interactions and that repairs or even creates the internalized secure base.This base then allows children to be successful in their interactions with their environment and the people in it.

More recently attachment research has focused less on the child’s actual bonding/attachment experience and more on the ways in which the child comes to understand and make sense of those experiences. For, one of the most stunning evolutionary capacities humans have developed is their ability to cognitively override and reorganize experiences. Good experiences can be reframed as disastrous and disastrous experiences reframed as good. The capacity to do the latter seems to be a key element in predicting a person’s ability to withstand stress and trauma, or resiliency. Similarly, this reframing is the basis of solution-focused and constructivist therapy techniques that emphasize helping people change the meanings they attribute to their experiences (e.g. Anderson & Goolishian, 1992; Eron & Lund, 1996). Thus, for older children and adults it is not their actual caretaker and their experience with that person that guides their interpersonal interactions but the internalized model of the caretaker and their reframed and recalled view of their attachment to him or her. For older children it is this internalized model that serves as the foundation for their peer relationships. For adults, their model is also the foundation of their peer relationships but it is also the frame for the relationships they create with their own children.In all cases the coherence of the person’s recalled attachment history as well as his or her ability to integrate the emotions associated with that history are excellent predictors of the quality of their current attachments (Fonagy, Steele, Steele, Moran & Higgitt, 1991; Hesse, 1999).

The remainder of this article will focus primarily on how traditional interpretation strategies can be used to facilitate children’s understanding (integration) of their emotions in Theraplay sessions and their use of what they learn in session in their daily lives.[2] Although interpretation is used primarily within sessions it is important to note that interpretation is only one part of the overall treatment process. Maximum treatment effectiveness depends on a multi- or ecosystemic approach. Within such an approach the therapist works with the child, the family and other systems impinging on the child’s development and well-being. These other systems might include the peer social system, the school, medical, legal, social service, community and cultural system as well as any other system in which the child is embedded. Usually therapists approach assisting child clients from two directions. One is to help the child learn to function well within these various systems, as they currently exist. This is the primary function of individual Theraplay. (Though it is certainly clear the parent-child dyadic system is changed as well.) The other is to change the systems so that it is easier for the child to function well. The knowledge gained by the child and therapist through the interpretive process usually impacts both. That is, better understanding helps children make necessary changes and may be used by the therapist to guide systemic changes.>

Through this process a Theraplay therapist can take events or emotions conveyed in the sessions and make meaning out of them so that the conflicts or problems they engendered can be addressed and resolved (Slade, 1994). However, therapists do not impose their a priori thoughts on the child. Rather, much as happens in traditional Theraplay, the interpretive process becomes a delicate dance between the therapist and child. Therapists continuously offer their knowledge to the child, gauge the child’s receptivity and response, adjust their thinking as needed and then re-offer these alternatives to the child. When all goes well therapists’ years of life and clinical experience are combined with the child’s drive to grow and rapid progress is made.

If interpretation is to help the child make meaning and gain knowledge to be used in problem solving it must be delivered in a way the child can use. This requires the therapist to do two things. One is to translate the sometimes complex thoughts and emotions behind the child’s verbal and non-verbal responses to the Theraplay activities into language the child can actually understand. Language that is developmentally appropriate. The other is to deliver interpretations in a stepwise and systematic way so the child is not overwhelmed. To facilitate this the author has developed the following model derived from the work of Lowenstein (1951, 1957); Devereaux, (1951); Bibring, (1945); and Lewis, (1974).

Reflections
Since first developing this model of interpretation (O’Connor, 1991) I have split this category of interpretation into two subcategories, content and motive. Content reflections are those statements therapists make to identify the thoughts or feelings behind what their child clients do or say. When the child looks or acts angry or yells the therapist simply says, “You seem very angry.” When the child tells a story the therapist makes the underlying fantasy explicit. Content reflections are not restatements. They add new material. The therapist does not say, “You seem nervous.” when the child has just said, “That made me nervous.” Rather, the therapist would say, “You seem very nervous.” should the child try to pull away from an interaction without saying anything. Motive reflections are explicit statements of the child’s reason(s) for saying or doing a particular thing. “I think you just threw you’re M&Ms on the floor to let me know you don’t want me to feed you. You can feed yourself!” Because motive reflections involve a greater level of attribution on the part of the therapist they are considered somewhat more intense than content reflections and, as such, should be used more carefully.

Reflections serve several purposes. First, they demonstrate for the child the therapist’s interest in the ‘thoughts and feelings behind the action.’ As such, they help educate the child as to how the Theraplay process will unfold. Second, they help expand the child’s affective vocabulary. By using reflections therapists provide children with the words they need to express their innermost thoughts and feelings more accurately and effectively. Third, by replacing some of the child’s behavior with words the therapist helps reduce the child’s tendency to act out both in session and in the real world. >Fourth, they give therapists the opportunity to validate their perceptions of the child’s emotional state. When a therapist reflects incorrectly children tend, not only to negate what the therapist has said but, to spontaneously correct it. This provides the therapist with information the child might not have otherwise volunteered. Lastly, they begin to facilitate the child’s integration of their affect and experience; a key element of their coherent attachment history.

Present Pattern
At this level the therapist is simply identifying overt or covert repetitions in the child’s verbal and non-verbal reactions to the Theraplay activities. The therapist should operationalize the repetition as clearly as possible and give examples of how these have been manifested. The patterns may be very concrete: “This is the third time you started to cry when we were playing peek-a-boo.” “The last few sessions you have started out by telling me how stupid our sessions are.” Alternatively, the patterns may be thematic “Just today, you wanted to quit hide and seek, moved away when we were using the lotion and threw the M&Ms on the floor when we were feeding each other.” The primary purpose of such statements is to help children see their behavior as meaningful and psychologically significant as well as being consistent over time rather than as just a series of random events. Once these consistencies are labeled then solutions generated to resolve one of the problems in a cluster can be more easily generalized to the other, similar behaviors. This lays the groundwork for subsequent interpretations. Initially, the therapist would label repetitions of behavior within sessions; later patterns across sessions would be identified.

Simple Dynamic
At this level therapists draw connections between 1) the child’s thoughts, affects and motives as previously reflected and, 2) previously identified patterns of behavior. For example, the therapist might suggest that the child who withdrew from each of the activities as previously described did so because being nurtured or taken care of felt scary or dangerous. “I think you get really scared when I am being sort of ‘mushy-nice’ to you and so you try to pull away. That way you go back to being the boss. You can show me you don’t need me to take care of you.” Once the child has become accustomed to your making simple dynamic interpretations for in-session behavior, you proceed to making simple dynamic interpretations of behavior observed across sessions. At this point you are moving toward more traditional types of interpretation by helping the child understand the dynamics of her behavior in the recent past. Through simple dynamic interpretation, the child is encouraged to see the continuity of affects and meanings across behaviors. Children are sensitized to the internal feelings, processes, and motivations that guide their behavior. Because simple dynamic interpretations are built off of the two previous levels of interpretation, each of which the child has come to accept independently, acceptance of the interaction of the two is less likely to be resisted (O’Connor, 2000, p. 292).

Generalized Dynamic
These interpretations connect children’s in-session behavior to their out-of-session behavior. The therapist points out the similarities between the child’s pattern of thinking, feeling and behaving across contexts. For example, the therapist might point out how the child’s tendency to withdraw from ‘mushy-nice’ interactions stems from a fear that dependency will leave him or her vulnerable to neglect or abuse. “It seems like you worry people will only be nice for a little while and then they will stop and hurt your feelings. If you stop first you can’t be disappointed and that makes you feel a lot safer.

Genetic
In the original model (O’Connor, 1991) I included only interpretations of the origins of the child’s current problems in this category. These are the most traditional form of interpretation as they are structured and delivered so as to provide children with insight into the root of their problems. Since developing the original model I have added interpretation of the child’s significant organizing beliefs to this category. These are core beliefs the child holds that are rooted in early, usually repetitive experience. As examples, consider the abused child who now believes the world is a dangerous place and all adults are potential abusers or the neglected child who believes he or she is unlovable and worthless. These beliefs derive from the child’s genetic experience and are often the primary reason the child cannot or will not change his or her behavior. To change would engender intolerable cognitive dissonance. To the child with a fear of being nurtured the therapist might suggest that the fear of failure is connected to the belief that he or she is truly, fundamentally unlovable. That fundamental belief might, in turn, be linked to the child having been constantly disappointed by his or her mother during their early interactions when she was abusing substances. The therapist then goes on to help the child accurately evaluate the reality of his or her lovable-ness versus the overwhelming negative effect of the mother’s behavior.

Interpretations are usually offered in the sequence just listed, however, in formulating them the therapist usually works backwards. That is the therapist will first develop hypotheses about the etiology of the child’s problems and the child’s core beliefs. The therapist will validate these with examples of the child’s behavior in their day-to-day lives as reported in the intake. Next the therapist will develop ideas of how these behaviors and feelings may manifest in session. Having developed these hypotheses the therapist will watch for those things that either confirm or negate the original hypotheses and interpret accordingly. As previously stated, the hypotheses are continuously reevaluated and refined as the therapy progresses. The levels of interpretation are also listed in accordance with the frequency with which they will be used in session. Therapists will reflect on a nearly continuous basis while they may make only a few genetic interpretations over the course of the child’s entire therapy.

One other issue to be considered in the delivery of interpretations is the various ways in which the impact of the interpretation can be modulated so that the child is able to make use of the information without becoming overwhelmed. The impact can be modulated by adjusting the ‘distance’ between the child and the content by interpreting within the play, making an ‘as if’ interpretation or interpreting in the context of the therapeutic relationship before interpreting historical material directly to the child.

Interpreting within the play simply involves framing the interpretive material so that it applies to characters in the child’s play, stories, drawings or other fantasy material. It is the figure in the drawing who is sad, or the person riding in the careening toy car who is frightened, not the child. When such interpretations are on target children often exaggerate them. The figure in the drawing isn’t just sad they are overwhelmed like the figure in a Greek tragedy. The superhero isn’t just strong he is invincible. This type of interpretation offers the child a good measure of distance from which to examine the content before internalizing it.

‘As if’ interpretations are those where the therapist applies the interpretive material to other children who share similar characteristics with the client rather than to the client directly. It is other 7-year olds, or other boys who think lotioning is silly or who feel proud when they successfully complete a physical task. This strategy provides a great deal less distance and children often see through the pretext if the therapist overuses it. In spite of this it is a way of transitioning from the content of the play to the child’s real life issues.

Interpretations in the context of the relationship are those that involve the therapist identifying feelings the child is having towards the therapist, him or herself. When the therapist offers such interpretations there is very little distance between the child and the content but the power of the content is often tempered. That is, it may be much easier for children to admit being angry with the therapist than to admit being angry with their mothers. These interpretations are particularly effective in managing resistance and transference.

Finally, the therapist will be offering interpretations directly to the child in the context of his or her real life experience. These interpretations are as simple as, “You seem angry.” and as complex as, “You feel unlovable because your mother hurt you many, many times from the time you were very little.” Applying interpretive content directly to the child’s experience is critical if generalization of the gains made in therapy is to occur. (This model of interpretation formulation and delivery is presented in great detail and illustrated with case examples in O’Connor (2000) and O’Connor and Ammen (1997).

When used effectively and consistently the combination of the experiential nature of Theraplay and the cognitive work of interpretation support the majority of the essential psychotherapy processes identified by Shirk and Russell (1996). Based on an extensive review of the existing child psychotherapy literature and research they proposed a list of 11 processes that seemed to account for most of the change that occurs in effective child psychotherapy. While their work was not play therapy or Theraplay specific the findings certainly apply.

They identified 4 cognitive processes. 1) Schema transformation is the process of changing the child’s implicit assumptions or expectations (core beliefs). “Just because your mother abused you does not mean ALL adults will abuse you.” 2) Symbolic exchange is the process whereby a problem becomes clearer as you discuss it with someone. The process of telling it and the process of hearing the other person’s reaction gradually modifies your understanding of the experience. 3) Insight is simply the reorganization of the meaning of one’s experience. And, 4) skill development is the process by which one learns adaptive or compensatory skills.

Shirk and Russell (1996) also identified 4 affective processes. 1) Abreaction/release involves the discharge of feelings resulting in a sense of mastery. 2) Through the process of emotional experiencing children come to integrate their emotions into their overall sense of their experience. They come to understand why they feel a certain way in a specific situation. 3) Therapists use affective education to help the child identify, label and express their emotions. And, 4) as children learn new coping strategies and develop new defenses they become capable of better emotional regulation.

And, finally, Shirk and Russell (1996) identified 3 interpersonal processes. In play therapy the therapist provides 1) validation and support which foster the child’s emotional, cognitive, behavioral and social growth and development. Therapists also provide 2) supportive scaffolding when they help children face problems or engage in behaviors that currently exceed the child’s capacity. This occurs when a therapist helps a child face a bully or make a difficult request of a parent. And therapists provide children with a 3) a corrective relationship in that they respond to children differently than have persons in the children’s past and thus provide them with experiences that disrupt their core beliefs.

In summary, the effectiveness of the experiential aspects of Theraplay can be greatly enhanced for any child through the use of systematic interpretation. Such interpretations facilitate the essential therapeutic processes described by Shirk and Russell (1996). Interpretation facilitates the child’s use of language and greatly enhances the generalization of the gains children make in session to their day-to-day lives. At this point the model presented herein has solid theoretical support but little hard research backup. There is a great need for clinical research to verify the existence of the underlying therapeutic processes in Theraplay, the ability of interpretation to support those processes and the effectiveness of a combined experiential-cognitive-verbal approach in helping children develop an coherent, internal working model of their attachment history to serve as the secure base on which to build their future relationships.

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