What Makes Theraplay® Effective:
Insights from Developmental Sciences

Originally published in the The Theraplay® Institute Newsletter of Fall/Winter, 2003

Jukka Mäkelä, M.D.

Helsinki University Central Hospital, Finland, child psychiatrist, psychoanalytic child psychotherapist, Certified Theraplay Therapist and Trainer

A Theraplay-therapist is holding a panicky, disorganized child in her lap, checking out what a wonderful girl she is. The girl cries until, all of a sudden, the therapist beeps her nose. The child is startled and smiles. The next time, with another sound coming from the therapist’s nose, the child giggles. Then, for three sessions she whines, cries, and turns away from all the therapist’s advances. One day, to the child’s amazement, a soap bubble pops before her finger even touches it. The therapist’s voice shows similar amazement: what happened? The child, who has forgotten to whine, pops the next bubble, and the therapist rejoices. The next session, the child is suddenly still, absorbed by the eyes of the therapist, who attunes to every gesture and vocalization of the child, matching them to the nurture she is giving to the child’s feet; playing peek-a-boo with them, rhyming the child’s “mama” into a familiar song. Never before in her 3 years has the child been in prolonged eye contact. Now her eyes spell-bind the therapist, and her mother and me, looking from behind the mirror. Her whole countenance has changed from a frizzled rag doll look to an intense, oriented, girl of three. Two sessions later as she is cuddled in her mother’s arms she reaches up to find the curly blond locks of her mother’s hair and starts to play with them, looking intently into her mother’s eyes. Her mother says her daughter was born to her at that moment. Needless to say, the intense separation difficulties and panicky behaviour that brought her into treatment had disappeared; there was soon no further need for treatment.

How could this happen in just a few sessions?

Any therapy that effects a change must, in some way, create new organization in the way the mind works. The matrix of the mind is in the intricate, interconnecting network of the brain (Siegel 1999), even though it will probably never be possible to truly explain the mind from the perspective of the brain. Nevertheless, the most central function of the brain is to organize sensory input into relevant action, which clearly is seen as the working of the mind: “I have a mind to do this...” An important principle for understanding this is that both the sensory system of each individual and the patterns of reaction develop in an experience-dependent way even though everyone is born with a personal threshold and activation-pattern for sensory information, usually referred to as temperament. How one deals with the input depends on the internal state into which it is assimilated. Thus, what we see and how we see (or hear, or feel) depends on our internal state. At the same time, the input creates new or strengthens old neural connections and thus creates for its part, the internal state that assimilates the next input. The regulation of internal states is the crucial developmental task of the growing child (Schore 2001).

The internal state is experienced as emotion. Emotions can thus be seen as the internal element of reality as experienced. They affect the way any situation is experienced. We all have our own, perceived reality, affected by the way our internal state has developed. Therapy must be able to organize the typical internal states of the client into more positive and more resilient forms to effect positive change.

Emotions, or affects, as they are called in psychological literature, can be divided into two major forms. Vitality affects (Stern 1985) are the ways and contours of activation: the sense of what is happening; the waxing and waning, the crescendos and de-crescendos of feeling. Categorical affects, those normally called emotions, are specific patterns of activation: joy, shame, anger etc. They both tell the person, how to orient into a new situation; they are the hard core of our immediate way of assessing situations. They are experienced as immediate knowing of what a situation is about. When the situation concerns being with another person, the internal state organization that arises with the contact causes one to act or react in ones typical ways. This is called implicit relational knowing (Stern et al 1998).

Implicit relational knowing can be conceptualized as being procedural models of acting and reacting in a relationship. The act reflects the way one experiences the other and oneself. At the same time, the act is experienced, and thus causes either strengthening of the previous implicit knowing or changes it, in a positive or negative way. Positive change in the way one experiences comes mainly from corrective experiences: the development of the matrix of the mind is experience-dependent. Positive change would mean the very thing Theraplay posits as its aims: experiences of oneself as more lovable and capable, of an adult as more safe and trustworthy, and of the world as more organized (less chaotic) and joyful. What are the forces of internal re-organization?

Of course there is the major element of genetic maturation of internal state regulation: an eight-year old is more capable of handling excitement than an eight-month old. However, left mainly to its own organizing capacities, the brain is left with a prevalence of highly charged emotions. That is because they represent situations that are potentially dangerous and have to be given precedence (Crittenden 1997). That is why fight-or-flight- and freezing-reactions are so typical of children with atypical or disorganized attachments.

There are three major ways in which the child can receive help in learning more flexible internal state regulation: on the physical, emotional and mentalizing levels. The most primitive is the physical co-regulation of both negative and positive vitality-states. This is what good-enough parents do almost continually during the first months of life: holding, touching, stroking, vocalizing softly (or enthusiastically, as the situation calls for) in “parentese”. All these activities directly strengthen the calming limbic circuits in the child's brain. They are also direct ways to co-regulation at any age, as this sensory input directly accesses the calming circuits.

After the development of core-self and core-other consciousness at about eight months (Stern 1985), the second way of helping the child create flexibility in reacting develops: emotional co-regulation. This happens through the attunement of vitality affect. The parent picks up the intensity or rhythm of the child's gesture and mirrors it back with a calming or positive modification through expression, voice and touch. In good-enough parent-child dyads, the attunement of the child's emotional communication happens nearly continuously while the child is awake and within communicative reach of the parent. This is attunement to low-intensity emotional states. It can be seen as a resonant flow of being together; a resonant hum of emotion. This is also what the basic stuff of Theraplay is. Theraplay is not effective because of a series of playful activities. The activities are the going-on-being of Theraplay while the resonating of every possible emotional expression of the child is the crucial element in communication. This continuous attunement to low-intensity states leads, every now and then, to moments of increased intensity. These are moments of possible sudden dynamic shifts in the internal states of both child and therapist. These special moments, now-moments (Stern et al 1998), are immensely important. When lost, they increase the sense of isolation of the child and the experience of being responsible over one's self.

The Process of Change Study Group, a group of child development researchers, psychoanalysts and child psychotherapists have presented (and documented supportive evidence for) a theory of change in psychotherapy, in which intense now-moments, or moments of meeting, are the crucial points of new forms of internal organization (Tronick et al 1998). I conceptualize them as moments of attunement of high-intensity states, in which intense resonance expands the experience of both child and therapist. Tronick refers to a dyadic state of consciousness, in which there is a true possibility of novel states being first experienced and then incorporated by both. When grasped, these moments create a sense of true difference with no going back. There is a re-organization of the implicit ways of knowing of relationships – and the knowledge is shared by both.

Theraplay offers an ideal form for creating these intense moments. The basic flow of ongoing attunement builds the necessary trust. The surprise element, so typical of Theraplay creates discrepancies between the child's implicit relational knowing and his or her present experience of being in relation to an adult. Theraplay also plans the experiences along lines of evolutionary priorities for the child: with the adult being in charge and continuously thinking about what experiences the child needs. Our societies do not model themselves along these lines. Using attachment-research terminology, there is a strong avoidant, (dismissing of interpersonal values) tendency in both the Finnish and Anglo-American cultures. The very human needs of being in contact, being heard in a personal way and finding comfort from another, are shunned as childish and people are seen with mainly utility-value. This is especially true of the global economy philosophy. Many children of our cultures live in a world impoverished of meaningful adult contacts and are too often left to experiencing the world of inanimate objects through TV, video-games, PC’s, and mobile phones.

The third way of co-regulating internal experience comes through thinking together of meanings. Meanings are supposedly the stuff of classical psychotherapy. But true meanings are created when one experiences the sharing of ones bodily reality and ones emotional reality in expanded, dyadic states of preverbal consciousness. I know of no therapy more geared towards this end than Theraplay.

Theraplay is tailored to give corrective experiences in physical co-regulation through its extensive use of touch, eye contact and “parentese”, the calming and stimulating way of speaking throughout ones activities. At the same time it creates a resonant hum of emotions through (ideally) noticing the minutest emotional cues of the child and responding to them. The response is often just an attuned statement of having noticed, but being noticed makes all the difference. Theraplay also creates an atmosphere of expecting intense moments of meeting. In these the child realizes being not only seen but also thought about, living and having an effect in another's mind. This builds what Peter Fonagy calls mentalisation. He sees this as being the primary focus of all truly curative psychotherapy (Fonagy 2003).

At the same time Theraplay has the power of all parent-child psychotherapies: it has multiple foci of change. This gives it the possibility of being exponentially more potent than therapies with a single focus (Stern 1996). Theraplay aims at causing simultaneous changes in the child's experience of him or herself, of adults and especially their parents and of the outside world. Simultaneously it offers the parents a new view and experience of their child. Seeing the well-being of ones own child enhances ones own feelings of being worthy and is thus a potent organizer of mental well-being for the parent also. And Theraplay gives a rare opportunity to tend to the emotional hurts of the parents through not only mutual mentalization and emotional attunement but through direct physical co-regulation to diminish anxiety and enhance feeling good.

Crittenden, P.M.  “Truth, Error, Omission, Distortion, and Deception: The Application of Attachment Theory to the Assessment and Treatment of Psychological Disorder,” Assessment and Intervention Across the Lifespan, (pp. 35-76). S.M.C. Dollinger & L.F. DiLalla (Eds), Hillsdale, NJ: Erlbaum, 1997.

Fonagy, Peter. Plenary lecture at the 13th ESCAP (European Society for Child and Adolescent Psychiatry) Congress, Paris, France, 2003.

Schore, A.N. “Effect of a Secure Attachment Relationship on Right Brain Development, Affect Regulation, and Infant Mental Health,” Infant Mental Health Journal 22 (1-2), pp.7-67, 2001.

Siegel, D.J. The Developing Mind: Toward a Neurobiology of Interpersonal Experience. New York: Guilford, 1999.

Stern, D.N. The Interpersonal World of the Infant.NewYork: BasicBooks, 1985.

Stern, D.N. Plenary lecture at the 6th world congress on Infant Mental Health, Tampere, Finland, 1996.

Stern D.N., Bruschweiler-Stern N., Harrison A.M, Lyons-Ruth K., Morgan A.C., Nahum J.P., Sander L., Tronick E.Z. “The Process of Therapeutic Change Involving Implicit Knowledge: Some Implications of Developmental Observations for Adult Psychotherapy,” Infant Mental Health Journal Volume 19, Issue 3, Pages: 300-308, 1998.

Tronick, E.Z., Bruschweiler-Stern N., Harrison A.M, Lyons-Ruth K., Morgan A.C., Nahum J.P., Sander L., Stern D.N.“Dyadically Expanded States of Consciousness and the Process of Therapeutic Change,” Infant Mental Health Journal Volume 19, Issue 3, pp. 290-299, 1998.

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