Originally published in the The Theraplay® Institute Newsletter of June and 2005

CURRENT THERAPLAY® BEST PRACTICE: FOCUSING ON ATTUNEMENT AND REGULATION IN PLAY

Phyllis Booth, MA, LMFT, LCPC, PRT/S

It has been more than thirty-six years since we first went into Head Start classrooms to “play” with the children. Our plan at that time was to play with the children in the way that “good enough” parents play with their healthy babies. To quote from Ann Jernberg in the first edition of the Theraplay book, “Daily, the mother …with her baby nuzzles his neck, blows on his tummy, sings in his ear, …[plays] “peek-a-boo,” and nibbles his toes. She picks him up, twirls him, spins him, rocks him, bounces him, … She holds him close and nurses him. She powders him, lotions him…. She whispers, coos, giggles, hums, chatters….She holds him, … restrains him, protects him, defines his life space… And finally, by gently teasing, chasing, and eluding him (and returning), she remains one step ahead of him, thus encouraging him both to learn the art of mastery and to enjoy the challenge.” (Jernberg, 1979, p. 4-5) This was the model we adapted for the three and four year olds we encountered in the Head Start classrooms. By playing in this way we hoped to change the child’s view of herself and the world. We wanted the child to see herself reflected in the loving eyes of her parents and other caregivers as special, lovable and fun to be with so that she could begin to grow emotionally healthy and strong. We found that our playful approach made amazing changes in a very short time: unhappy, withdrawn children became outgoing and full of fun; angry, impulsive children calmed down and were a pleasure to be with. While our basic model has not changed over the years, we have found new ways to think about what we are doing based on the growing body of evidence about the nature of attachment and the importance of the mother-infant relationship. As a result we now place stronger emphasis on such issues as affect attunement and affect regulation—aspects of the healthy mother-infant interaction that, research tells us, are crucial to the development of secure attachment. I will briefly outline the influences on our thinking and then describe how things have changed from the beginning. In the fall of 1968, a year after our Head Start work began in Chicago, I went to London to study at the Tavistock Centre. My experience during that year was a great stimulus for me to think about our play with children and put it into the context of attachment theory. Although I had seen the film, “A Two Year Old Goes to Hospital,” (Robertson, 1952) nearly 12 years before, it wasn’t until my year at the Tavistock Centre, that I began fully to understand the importance of attachment. This was the year the first volume of John Bowlby’s three-volume work on attachment was published. I had the privilege of hearing Dr. Bowlby lecture about attachment, of seeing the Robertsons’ series of heart-wrenching films about the effect of separation on young children, and of hearing Winnicott lecture and respond to case presentations. Winnicott’s focus on the importance of the mother infant relationship, the idea of the holding environment and of the “good enough mother” all were important to me (Winnicott, 1965). I came back full of these exciting new ideas and began to put our play with the Head Start children into the framework that Bowlby, the Robertsons, and Winnicott provided. Not that they were talking about how to use these ideas in therapy at that time, but that the effectiveness of our play could be explained in terms of the importance of the mother-infant relationship and the nature of attachment.

Regulation and Attunement

As the years have passed there has been an increasing body of new research into the kind of parenting that leads to secure attachment. The concepts of affect attunement (Stern, 1985), contingent response (Ainsworth, 1969), and more recently, regulation of internal states (Schore, 2001) and reflective function or mind-reading (Fonagy, 1991) heightened my sense that it is not just play, but attuned play that is important. The mother’s capacity to reflect accurately the baby’s emotional state and intentions—to read his mind—is now seen as essential to her ability to respond contingently. And to repeat, it is this matching of response to the baby’s needs that leads to secure attachment. Thus we are reminded that all our playful activities must be done with a sharp eye and heart attuned to the child’s needs and emotional state. Back in 1967, I did not think much about the fact that a mother’s attuned responses would have a powerful effect on the child’s later capacity to self-regulate. I saw many children who could not regulate themselves. They were fidgety, impulsive, hyperactive, constantly running about and often aggressive. When I asked the mothers of these children what they were like as babies I was amazed at the consistency of the response: they had been restless, hard to soothe babies. They had arched their backs, cried when held, and in order to avoid a fuss the mothers had placed them in their cribs and propped their bottles. I could see that the mothers had found it so difficult to soothe their babies that they had been unable to provide the attuned calming and soothing experiences that their babies needed. Here was a striking example of the baby’s temperament making it hard for the mothers to respond in a way that would lead to self-regulation at the age of four. Among our dysregulated Head Start children there were probably many others who as babies might have been less challenging to care for but who missed out on the co-regulation that secure mothers provide because of the mothers’ own emotional problems and attachment difficulties. They had not been able to attune to their babies and provide the external regulation essential to later self-regulation. New research techniques have made it possible to look closely at the effect of the mother’s attuned responses on the development of self-regulation. I see fully the implications of this early interruption of the normal process of attunement. Clearly the essence of attachment is based on the mother’s providing the essential regulatory experience that helps the baby achieve and maintain the optimal level of excitement and calming. As we do our Theraplay activities we are more and more attending to these aspects of the interaction. Theraplay provides multiple opportunities for physical and emotional co-regulation and special moments of connection (Makela, 2003. pp 5-7). Theraplay contributes to the development of the affect regulating system by accessing the appropriate brain structures, rehearsing regulatory processes, emphasizing dyadic interaction and providing strong positive stimulation (Buckwalter & Schneider, 2002). We now better understand the underlying reasons for Theraplay’s effectiveness. Thus as we play with the children and encourage parents to join in that play, we constantly have in mind the importance of regulation and attunement, of mind reading and of being able to dance together with the children.

CURRENT BEST PRACTICE

So how has this accumulating new evidence changed the way we do Theraplay? What would we consider our current best practice in the use of this playful and amazingly successful approach to working with children? I will present the change in terms of the dimensions of normal parent child relationship: Engagement, Structure, Nurture, and Challenge. Redefining Intrusion: Engagement: When thinking of our beginnings I always have in my mind the work of our first and best teacher, Ernestine Thomas, as she worked with the Head Start children. Her genius lay in finding ways to engage and connect with the children. In the early days and in the first edition of the Theraplay book, we called this aspect of the interaction, “intrusion,” following Austin DesLauriers’ terminology. Because of its negative and arbitrary connotations, the idea of intrusion has always been resisted by those unfamiliar with our work. People associate intrusion with riding roughshod over the child’s feelings, with ignoring the child’s uniqueness and emotional state in favor of some preconceived adult notion of what the child needs. In response to this negative view of intrusion and recognizing that the real goal of any intrusion is to engage the child in interaction, I used the word “engagement” instead of intrusion when writing the second edition of the Theraplay book (Jernberg & Booth, 1999). The change of word, however, is more an effort to convey a true picture of what we do with children, than a major change in approach. If you recall Ernestine’s work with Pat in the film, “Here I Am,” (Jernberg, et.al., 1969) she was wonderfully attuned to Pat’s needs. She also had an amazing capacity to entice Pat into interaction, to get her to laugh, relax, and enjoy herself, to share fun with a trusted new friend. When I first watched Ernestine at work, I missed the point of some of what she did. I thought I needed to acquire her skill as a clever clown and mimic. I even went so far as to attend a number of circuses in order to study the ways in which the clowns engage the audience and make them laugh. I realize now that it was not the clowning and entertaining, but the attuned awareness of where the child was emotionally and what the child needed that made Ernestine so effective. (At the time I missed how important to the effectiveness of clowns is their ability to observe and attune to the responses of the audience). This emphasis on attunement to the child’s feelings and emotional needs has shifted our focus from the playful activities themselves to a focus on reading the child’s responses. In our early trainings, we often emphasized repertoire. We tried to find as many new, engaging activities as possible. While it is very helpful to have at your fingertips an extensive repertoire of activities—so that you can counter the child’s “boredom,” disengagement or resistance, it is not the essence of Theraplay. Repertoire can never take the place of attunement to the child’s needs. It is this dance of attunement that we initiate with the child and invite the parent into that makes it possible for the child to change. Ernestine understood Pat’s need to be enticed into interaction, and to be nurtured. She had an amazing repertoire for doing this, but it was not Ernestine’s repertoire but her fine attunement with Pat and her strong conviction that Pat was special, could enjoy life and could grow that made the difference. Thus the essence of good Theraplay practice is not just to have a repertoire of activities to amuse and engage the child, but to provide the essential attunement that leads to a true sense of being connected with and understood. The child must feel seen and noticed, must feel that she is held in the caregiver’s heart and mind.

Changing the Emphasis on Structure

From the beginning, we focused a great deal on the idea of Structure. The adult needs to be in charge in order to make the child feel safe. We still believe this. No father can play effectively with his child if he cannot provide the structure that makes the experience safe and satisfying. In the early days we did a lot more holding and containing than we do today. It is not that we do not believe as much in the importance of providing structure for children, but that we have found better ways to help the child accept the structure we provide. I remember a crucial moment in my early training as a Theraplay therapist when Ernestine was supervising my efforts to practice with another colleague who was taking the role of the resistant child. My plan was to take the child’s shoes off in order to play “This Little Pig Went to Market.” In my inexperience and with my head full of the idea that the adult should be in charge, I quickly found myself locking horns with the “child.” I pulled at her shoe and she pulled back. In the midst of this impasse, Ernestine came to the rescue. With a deft and playful gesture she disarmed the conflict by saying to the child, “I’ll bet you can take your shoe off quicker than I can.” The job was done. We could get on with our play. Structure was maintained. We were all winners. But it was not always that smooth and we often worked with children who, for whatever reason, had become tyrants, behaving in outrageous ways, and generally running wild. We knew that these children were unhappy, at sea and frightened by having no one to make the world safe for them. We therefore focused on providing structure in Theraplay sessions and teaching parents to provide more structure at home. We were not always as clever as Ernestine at defusing conflicts and still maintaining control. This led in many cases to episodes where the child tested the limits and we had to contain an angry, upset child. We practiced good ways of containing the child, we focused on calming and soothing the child—talking reassuringly while the child was upset, “I know you don’t like me to hold you. I can see that you are very upset. I’ll stay with you until you feel better.” We had the parents soothe and comfort the child as they began to calm down with a damp towel and a sip of water. As soon as we felt the child relax, we released our hold and returned to our playful interaction. Although we are still prepared to contain a child who is out of control, likely to hurt himself or someone else, we have far fewer episodes in which a child needs to be contained than we used to do. I believe that this is because we now are much more attuned to the child’s moods, reactions and regulatory problems than formerly. Our initial focus on playful, engaging activities led us on occasion to over-stimulate the child. Being more attuned to the child’s need to be calmed and comforted before escalating out of control, makes it possible to avoid many episodes of dysregulation. We are also more attuned to situations where the child is genuinely frightened or needing the security of having his parent close at hand. The following is our current statement about the use of what we are now calling Structuring Touch:
While we focus our efforts on helping a child to interact in a calm and well regulated manner, it is not always possible to avoid having a child escalate to a point where it is necessary to contain her in order to protect her from harming herself or others. If a child is angry, dysregulated or out of control in a session, and has not responded to other efforts to calm her, the Theraplay therapist stays with and contains the child in some way; this may involve a cradling hold, an arm around the child, or close, soothing physical contact. Parents are often called in to help calm the child or may be asked to hold the child if they are able. As soon as the child settles, the containment stops. The model for this type of holding is that of a parent who holds an overtired, overstimulated, or frightened toddler in order to calm him. The reasons for the containment are:
• To keep the child and the therapist or parent safe,
• To communicate to the child that the therapist can help contain aggressive or self-injurious impulses,
• To let the child know that the therapist can accept and assist the child with strong emotions, and
• To control the situation until the child is able to regain self-control.

Nurture and Touch

Since touch is a normal, healthy part of all parent-child interaction, we have always emphasized touch and nurturing activities in our work with children. In the first edition of the Theraplay book, Ann Jernberg listed among her recommendations for Theraplay Therapists, “Take every opportunity to make physical contact with the child.” And we have supported parents in doing this in order to help the child feel good about herself and well cared for. We have always been comfortable with this emphasis but it has been gratifying to see the growing body of research demonstrating the positive impact of healthy physical contact on people of all ages. Physical touch can relieve stress, decrease anxiety and depression and increase comfort (Field, 1993). Withholding touch because of a fear of inappropriate touch can be as damaging to the growing child as inappropriate touch (Harlow, 1958). It is important that children experience gentle, kind, loving, and safe touch. We use touch in many ways in our Theraplay work. The touch is playful and engaging as seen in many of the fun, surprising, playful activities; it is nurturing in the care giving activities; it is organizing and modulating in the structuring activities; and it is used to help or guide the child in the challenging activities. Holding, cuddling, rocking, and calming are essential and natural parts of healthy parent child interaction. They help the child develop the capacity to soothe and calm himself. Because our model explicitly meets the child at his emotional level, many of our activities are taken from the repertoire of parents with very young children. We feed, cuddle, rock, play baby games and take care of hurts. As soon as possible we bring the parents into sessions so that they can be the ones who actually provide this nurturing experience for the child. If a child has been physically or sexually abused, we reduce our physical contact and proceed slowly. We continue to provide the Theraplay experience, but focus more on the safety provided by good Structure, or the confidence building provided by Challenge, while using less physical forms of Engagement and Nurture until a relationship is developed. In Theraplay, the goal is to touch carefully and respectfully, to touch only to meet the needs of the child, and with a full recognition of the effect that touch has on the child.

Challenge

Right from the beginning we have always tried to counter the forces that push children to achieve. In Ann Jernberg’s day the fashion was to create Super Babies with early cello lessons and flash cards. Even among Head Start families where cello lessons and flash cards were not available, there was a general fear of just letting children be children. We often heard parents say, “Life is serious, why should I play with my child? He needs to learn that he can’t play all the time.” Although other child care trends have replaced Super Babies, the anxious push toward achievement and growing up is all pervasive. Families enroll their unborn children in well regarded preschool programs in order to make sure they will get into the college that they have their hearts set on. Parents dress their children like little adults. Children interact with their electronic toys instead of each other. Exposure to adult themes via movies and music is common. Children are encouraged to read at younger and younger ages. Even the Head Start program, which started out as a well-rounded program with lots of emphasis on play and social learning, is becoming more and more geared to reading readiness. How soon will I hear about homework for Head Start children? Our emphasis in Theraplay has probably changed the least in this area. We are committed to play that, while it may challenge the child to try a little harder, to climb a bit higher, is essentially interactive, cooperative, and fun. Like good fathers, we get down on the floor; we bounce children in the air. And not only do we encourage fathers to do this, we encourage mothers to do it as well.

The Role of Parents

Probably the biggest change from the earliest days in our use of Theraplay is the greater emphasis on the role of parents in the Theraplay sessions. During the Head Start years as we were developing Theraplay, we focused on treating the child. We worked with some of the parent-child pairs and also trained some Head Start parents to be Theraplay providers to other children. As we developed the practice of Theraplay, we shifted our focus to the parent-child relationship and expected that both parents would be involved in treatment. We asked parents to observe their child with his Theraplay therapist for the first 4 or 5 sessions from behind the one-way mirror so that the parents could observe and learn under the guidance of an interpreting therapist while the Theraplay therapist learned more about how to help the child. This model still is important to our work. Theraplay continues to differ from other models of parent-child psychotherapy in which the therapist does not directly interact with the child. At the beginning of Theraplay, the therapist is the more active member of the team and initiates the interaction, for the following reasons:
• To provide a model for a new way of interacting for this particular parent and child
• To get past the child’s initial resistance so that the parent’s first experience with the new kind of interaction is positive
• To help parents who are unsure of themselves or uncomfortable with this more direct style of engagement and structure to gain confidence.
However, as we work with very young children or those in new adoptive or foster relationships, we bring the parents in earlier. It is not uncommon for us to have the parents in the room right from the beginning. We want the child to feel the presence of a familiar caregiver even as we begin the playful interaction. It is still important that the Theraplay therapist take charge and guide the parents to interact in ways that their child can accept. As soon as possible we want the parents to become our co-therapists, providing the nurturing and forming the important secure relationship with the child. We encourage fathers to share the nurturing role as well.

References:

Ainsworth, M. "Object Relations, Dependency and Attachment: A Theoretical Review of the Infant-Mother Relationship.” Child Development, 1969, 40, 969-1025. Buckwalter, K, & Schneider, M. “Why Theraplay Works.” Connections, May 2002, 2-4.