Originally published in the The Theraplay® Institute Newsletter of Fall, 1997

In Touch with Theraplay

David L. Myrow, Ph.D

Clinical Psychologist
West Seneca, NY

"The Therapist uses every opportunity for making physical contact with his patient." --Ann Jernberg, Theraplay

A bright, cheerful 14-year-old I know came up to me the other day to tell me how upset she was about a situation that occurred where she volunteered at a highly respected day care program. A three-year-old had fallen and hurt himself. Crying, he ran to one of the counselors, his arms stretched upward. Just as the counselor was reaching down to pick up the little boy, the director (an otherwise warm and gentle soul) reminded the counselor that children could not be picked up and held because they might be dropped.

The 14-year-old was quite angry and concerned about this. She found herself in a debate familiar to many teachers, ministers, therapists, and even scout leaders--many of whom understand the helpfulness of a reassuring hug, but who feel constrained because of potential misunderstandings or agency regulations. One might argue that the 14-year-old's anger is a healthy reaction to a harmful situation; children who grow up without experiencing loving care fail to develop loving feelings toward others. So, if we want to consider how best to care for the three-year-old, we might want to ask, "What probably happened to the 14-year-old that allowed her to have accurate empathy for the little child?" There is strong evidence that one of the things that happened was that, as a young child, she was touched in loving ways by at least one reasonably healthy caregiver.

The impact of physical touch on people (as well as higher animals) is profound. With the experience of touch from a loving caretaker, the child develops a sense of self; the capacity to relate to other people; essential skills in modulating affect; a sense of being able to master the environment; and a belief in his own worth. Without physical contact, a baby becomes a lost soul. The attachment that a baby develops with the primary caretaker sets the stage for all of the acts to follow. Research demonstrates that touch has a powerful impact on physical and mental health throughout the lifespan. In the form of massage, it "...helps asthmatics breathe easier, boosts immune function in HIV-positive patients, improves autistic children's ability to concentrate, and lowers anxiety in depressed adolescents..." (Colt, 1997, p. 58).

It is hard to talk about the value of touch in development outside the context of attachment. Bowlby's work on attachment is seminal. As Cicchetti, Toth, and Lynch (1995) summarize it, "...early experiences with the caregiver are central in the formation of working models of the self, others, and self-other relationships. These models allow children to form expectations about the availability and probable actions of others with complementary models of how worthy and competent the self is"(p. 9). Bowlby incorporated into his theory the work of Robertson, who identified the stages experienced by an infant separated from her mother (protest, despair, and detachment). Karen (1994) points out the significance of these stages in our clinical work: "Protest is an embodiment of separation anxiety, despair is an indication of mourning, detachment is a form of defense" (p.105).

Bowlby saw the attachment process as having a strong instinctual component. He thought of attachment as a "...fundamental form of behavior with its own internal motivation distinct from feeding and sex, and of no less importance for survival..." (1988, p. 27). In Bowlby's view, "Separations from the mother were disastrous because they thwarted an instinctual need. It's not just a nice thing to have someone billing and cooing over you, snuggling you, and adoringly attending to your every need. It is a built-in necessity, and the baby's efforts to obtain it, like the parent's eagerness to give it, are biologically programmed" (Karen, 1994, p.94).

The significance of physical contact in attachment is well established. For many of us, one of the images that we most remember from Psychology 100 was that of Harlow's work with rhesus monkeys. Stretching his little body about as far as it would reach, the baby rhesus monkey suckles from the bottle on the wire "mother," while clinging desperately to the cloth surrogate mother. The monkeys who were reared in isolation, of course, became extraordinarily incompetent in their relationships with peers. Less well known is research that followed. In this work, three-month-old monkeys, still in the clinging stage, were introduced to the troubled adult monkeys; the young monkeys were able to foster considerable improvement in the adults' capacity for relatedness (Suomi and Harlow, 1972). As Montagu points out, the negative effects of maternal deprivation "...are probably the result of perceptual deprivation, principally tactile, visual, and probably vestibular" (1986, p. 237).

More recent research continues to support this line of thinking, and has begun to identify some of the specific processes by which physical touch affects psychological and biological development.

Field (1995a) presents work by authors from several perspectives, detailing some of the effects of touch on the developing animal and human organism. Schanberg shows how maternal separation in rat pups during the time in which they suckle triggers hormonal changes in the pups; these pups then demonstrate behavioral changes similiar to failure to thrive behavior in humans. The effects on the pups were reversed when the mother was returned. On closer inspection, it was revealed that the specific behavior that was required to return to health was heavy stroking, as when the mothers licked their pups. In another study, Suomi reports a long-term, naturalistic observation of 1400 rhesus monkeys in Puerto Rico. A direct relationship was found "...between the amount of contact and grooming an infant received during its first 6 or 7 months of life..." and the capacity of its immune system to respond to "...a tetanus shot and produce an appropriate antibody response later on" (p. 100). Field also reports on some of her own research, in which premature babies, after being released from intensive care, were given three 15-minute periods of massage daily. Although caloric intake was identical to the control group, the massaged preemies gained 47% more weight, were awake and active more of the time, performed better on the Brazelton Scale on habituation, orientation, motor activity, and regulation of state behavior, and averaged six days less in the hospital than the controls.

So what does this all have to do with Theraplay and the role of touch? The beginning of a therapeutic relationship with a child resembles the beginning of a parent-child relationship. "Starting from the beginning... the mother's face and the baby's smile soon become central features of a playful social interaction; this social interaction seems to be basic to the attachment process" (Wright, 1991, p. 11). "The adult is attuned to the infant's needs and responds accordingly, initiating playful, stimulating contact when appropriate and soothing, comforting contact when needed" (Koller & Booth, 1997, p. 205). The Theraplay therapist strives to create the same warm, engaging experience, regardless of the patient's chronological age. There are solid grounds in attachment theory for these efforts. The infant-mother relationship is motivated by the need for reduction of stress and anxiety (on the part of both mother and child): "...the attachment behavioral system includes those infant behaviors that are activated by stress and that could have as a goal the reduction of arousal and the reinstatement of a sense of security, usually best achieved in infancy by close physical contact with a familiar caregiver" (Lyons-Ruth, 1996, pp. 65-66). For children whose needs for a more "secure base" are central therapeutic foci, the Theraplay therapist hits the ground running.

The Theraplay Therapist uses this understanding in a variety of ways and for a variety of purposes, depending on a child's needs. For older children with insecure attachments, Theraplay provides an opportunity to re-experience the child/caregiver relationship with a more rewarding outcome. When a child presents with a disturbed attachment (whether it be because of a mismatch in child-parent temperament, inconsistency in caregiving, physical illness, abusive caretaking, physical limitations, etc.), the therapist provides or helps the parents provide (and experience) a corrective emotional experience, actually helping the attachment to develop. When a child already has a more secure attachment, physical contact is one channel for quickly establishing a therapeutic relationship, from which to help the child and caregivers resolve more contemporary conflicts, e.g., accepting consistent limits from parents. Fun and physical Theraplay activities work quickly to build trust and invite openness to change.

In Jernberg's scheme of the four dimensions of Theraplay (Structuring, Challenging, Intruding/Stimulating, and Nurturing), touch is a pervasive element. Holding the hand of an anxious child provides structure and reassurance. When the Theraplay therapist puts her arms on a child's shoulders for a staring contest (Challenge & Intrusion), it focuses the child (Structure) and has some of the qualities of a warm hug (Nurture). When a child jumps from a table into a therapist's open arms, the challenge leads the child to the warmth and intimacy of being hugged and swung through the air.

When considering the role of touch in child therapy, it is critical to be aware of how a child perceives the intent and meaning of the contact. Both James (1994) and Jernberg (1979) argue for caution in using physical contact with traumatized patients. James points out that "...intimacy and closeness in relationships can restimulate feelings of helplessness and fear related to the child's past trauma..."( p. 73). On the other hand, an important path to recovery may well include, as part of a corrective emotional experience, enjoying appropriate, well-bounded, and respectful physical intimacy. James argues that, "Children with histories of hurtful or inappropriate body contact are especially in need of a positive, intimate physical touch. The settings and structure for touching these children need to have clarity and be such that the child is not confused" (p. 76). In Jernberg's thinking, this would primarily come under the dimension of Nurture, although providing safe Structure would be an important aspect of this work.

While touch is intrinsic to effective Theraplay, as in all treatment, the work must serve the client's purposes. When considering the role of physical contact in treatment, the therapist needs to be clear on the goals. While the therapist may enjoy physical closeness with a child, it needs to be clear that the contact is for the child's benefit, based on the treatment plan. While most often physical contact will be associated with fun and intimacy, there may be times when it raises anxiety in a child. Avoidant children, who fear social contact but may want or need it, are sometimes quite anxious when the therapist first offers his hand to go to the playroom. The autistic child may experience anxiety to the point of fear, but the therapist who approaches him with firm persistence and kindness (and optimism) is likely to help the patient overcome the discomfort. It is the therapist's duty to be extraordinarily sensitive to the child's experience of the contact and to titrate the "dosage" so that it is sufficient to foster change but not so intense as to disrupt the relationship.

In the context of a Theraplay session, the therapist utilizes physical closeness for a variety of reasons. Initially, physical contact lets the child know that the relationship is intended to be fun, safe, and close. The therapist attends to physical hurts by putting lotion on small scratches and bruises. He makes the child aware of his physical presence and invites the child to know himself. The therapist may help a child conquer anxiety by realizing that she can be close, or develop self-confidence when she realizes that she can win at arm wrestling. The child may find out that at least one adult (for starters) can be trusted when she is able to fall backward into his outstretched arms. It is exciting to find out how far one can jump - and be caught safely in the arms of a kind adult who will give a hug and swing you around! And it is a very warm feeling indeed when a caring adult can pick you up and comfort you when you need it! And by the time the child gets to be fourteen years old, it will be obvious to her how to treat a needy three-year-old.

References:

Bowlby, J. (1988). A Secure Base. New York: Basic Books.

Cicchetti, D., Toth, S.L., and Lynch, M. (1995). Bowlby's dream comes full circle: the application of attachment theory to risk and psychopathology. In Ollendisk, T.H. and Prinz, R.J. (Eds.), Advances in Clinical Child Psychology, 17. New York: Plenum.

Colt, G.H., Schatz, H., and Hollister, A. (August, 1997). The magic of touch. Life: 53-62.

Field, T. (1995a). Touch in Early Development. New Jersey: Lawrence Erlbaum Associates.

Field, T. (1995b). Infant massage therapy. In T. Field (Ed.), Touch in Early Development. New Jersey: Lawrence Erlbaum Associates: 105-114.

James, B. (1994). Handbook for Treatment of Attachment-Trauma Problems in Children. New York: Lexington Books.

Jernberg, A. (1979). Theraplay. San Francisco: Jossey-Bass.

Karen, R. (1994). Becoming Attached. New York: Warner Books.

Koller, T.J.& Booth, P. (1997). Fostering attachment through family Theraplay. In K.J. O'Connor & L.M. Braverman (Eds.) Play Therapy Theory and Practice: A comparative presentation. New York: Wiley: 204-233.

Lyons-Ruth, K. (1996). Attachment relationships among children with aggressive behavior problems: the role of disorganized early attachment patterns. Journal of Consulting and Clinical Psychology, 64, 1:64-73.

Montagu, A. (1986). Touching (3rd ed.). New York: Harper and Row.

Schanberg, S. (1995). The genetic basis for touch effects. In Field, T.M. (Ed.), Touch in Early Development. New Jersey: Lawrence Erlbaum Associates: 67-79.

Suomi, S.J. & Harlow, H.F. (1972). Social rehabilitation of isolate-reared monkeys. Developmental Psychology, 6: 487-496.

Wright, K. (1991). Vision and Separation: Between Mother and Baby. New Jersey: Jason Aronson.