Theraplay

About This Program

Target Population: Children ages 0-18 who exhibit behavioral problems and their caregiver (biological, adoptive, or foster)

For children/adolescents ages: 0 – 18

For parents/caregivers of children ages: 0 – 18

Program Overview

Theraplay is a structured play therapy for children and their parents. Its goal is to enhance attachment, self-esteem, trust in others, and joyful engagement. The sessions are designed to be fun, physical, personal, and interactive and replicate the natural, healthy interactions between parents and young children. Children have been referred for a wide variety of problems including withdrawn or depressed behavior, overactive-aggressive behavior, temper tantrums, phobias, and difficulty socializing and making friends. Children also are referred for various behavior and interpersonal problems resulting from learning disabilities, developmental delays, and pervasive developmental disorders. Because of its focus on attachment and relationship development, Theraplay has been used for many years with foster and adoptive families.

Program Goals

The goals of Theraplay are:

  • Increase child's sense of felt safety/security
  • Increase child's capacity to regulate affect
  • Increase child's sense of positive body image
  • Ensure that caregiver is able to set clear expectations and limits
  • Ensure that caregiver’s leadership is balanced with warmth and support
  • Increase caregiver's capacity to view the child empathically
  • Increase caregiver's capacity for reflective function
  • Increase parent and child's experience of shared joy
  • Increase parent's ability to help child with stressful events

Essential Components

The essential components of Theraplay include:

  • Session structure:
    • First session: Information-gathering interview with the parents.
    • Second and third sessions: Observation sessions using the Marschak Interaction Method (MIM), in which the child and one parent perform a series of interactive tasks together
      • The MIM is a structured technique for observing the relationship between two individuals.
      • It consists of a series of simple tasks designed to elicit a range of behaviors in the four Theraplay dimensions:
        • Structure (key concepts: safety, organization, regulation)
        • Engagement (key concepts: connection, attunement, acceptance, expands positive affect)
        • Nurture (key concepts: regulation, secure base, worthiness)
        • Challenge (key concepts: competence, confidence, supports exploration)
      • The interactions are videotaped and later analyzed by the therapist(s) in preparation for a fourth session with the parents.
    • Fourth session: Planning session where the therapist(s) and parents discuss their observations of the interaction and together agree on a plan for treatment
    • Fifth through 20th session: Direct Theraplay with the family
  • Treatment components:
    • Interactive and relationship-based which utilizes innate capacities for social interaction (rhythm, affective resonance and synchrony, and mirror neuron functions)
    • Provides a direct, here and now experience and utilizes now moments, non-congruence, and multiple foci of change
    • Guided by the adult and utilizes concepts of holding environment, authoritative parenting, and resilience building
    • Responsive, attuned, empathic, and reflective and utilizes contingency, primary intersubjectivity, attunement to vitality and categorical affects, empathy, mindfulness, and reflective function
    • Geared to the pre-verbal, social, right brain level of development and utilizes concepts of experience-dependent brain development, primacy of right brain development in early life, and co-regulation of physical and emotional internal states
    • Multisensory and utilizes touch and appropriate stimulation of body senses for social development, attachment, regulation of physiological development, stress reduction, and positive body image
    • Playful, but does not employ a lot of toys or props and utilizes affective synchrony and amplification of interest and joy to connect with the child
    • Involves parents in the treatment and strives to give parents a more positive, empathic view of their child, to have them become competent co-therapists, to teach them about appropriate developmental expectations, and to consult about behavior management
  • Typically provided as family therapy but has a group version available with a recommended group size of 4-10
  • There is also a group format for teacher-led school groups called Sunshine Circles that has not been reviewed by the CEBC.

Program Delivery

Child/Adolescent Services

Theraplay directly provides services to children/adolescents and addresses the following:

  • Withdrawn, depressed, fearful, shy, acting out, angry, non-compliant, Oppositional Defiant Disorder, relationship and attachment problems, Reactive Attachment Disorder, posttraumatic stress disorder (PTSD), complex relational trauma, Developmental Trauma Disorder, regulatory problems, attention-deficit hyperactivity disorder (ADHD), autism spectrum disorders, and developmental delays
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: In residential care settings, house parents or other caregivers may participate in therapy with the child.

Parent/Caregiver Services

Theraplay directly provides services to parents/caregivers and addresses the following:

  • Has a behavioral/relationship problem with their child, was not well-parented, and needs to experience how being taken care of feels

Recommended Intensity:

Families typically receive 45-60 minute weekly sessions (shorter for younger children). In some severe cases, sessions may occur more than once a week.

Recommended Duration:

Short – typical protocol runs for 26 sessions, which roughly equates to six months of weekly sessions. However, this can be adapted to families with greater needs to be used for longer periods of time.

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Foster / Kinship Care
  • Hospital
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • Group or Residential Care
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)

Homework

Theraplay includes a homework component:

Parents use the play activities at home with their child, starting with activities that have been enjoyed during therapy.

Languages

Theraplay has materials available in languages other than English:

Danish, Finnish, French, German, Italian, Japanese, Korean, Spanish, Swedish

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Although Theraplay may be conducted in any setting, ideally, an agency would have a treatment room of approximately 150 square feet (12 x 12) or so, with a small couch or love seat. A cabinet with doors for supplies or a tote bag is needed to contain materials and to keep distractions to a minimum. If the floor is hard or chilly, two 3 feet by 8 feet gym mats may be nice to have. Optimally, there would be very few other games/toys/furniture in order to reduce distraction. Optimally there would be an adjacent observation room with a one-way mirror to see the session; however, this is exceedingly rare in practice. A camera for recording the sessions and a computer or other mode to play back the videos is necessary. Video recording requires client's consent. It is possible, but not optimal, to practice the model without video recording.

Education and Training

Prerequisite/Minimum Provider Qualifications

The practitioner must have a Master's or doctoral level degree in a mental health field that prepares them to provide clinical services to families and children, and must be fully licensed to provide these services independently. Licensure is not required to participate in the introductory training, but is required for full certification. Individuals may earn associates status and work under competent clinical supervision, if they have not fulfilled the education or licensure level required to be a certified mental health practitioner. Supervisors and trainers must be licensed practitioners for at least two years prior to entering the supervisor/trainer practicum.

It is recommended that all participants in the introductory level training have a masters or doctoral degree as above, but masters level students will be admitted as well.

Education and Training Resources

There is a manual that describes how to deliver this program, and there is training available for this program.

Booth, P. B., & Jernberg, A. M. (2010). Theraplay: Helping parents and children build better relationships through attachment-based play. San Francisco: Jossey-Bass.

Training Contact:
Training is obtained:

The training is offered at least three times annually in Evanston, Illinois. Closed, on-site trainings can be provided to agencies upon request. Numerous open registration trainings are offered throughout the country and internationally each year. These are advertised on The Theraplay Institute’s website well in advance of training dates.

Number of days/hours:

The Level One Theraplay & MIM training is 25 contact hours over four days. The Level Two Theraplay and MIM training is 19.5 contact hours over three days. The supervision practicum is a tiered system. The Foundational Level of certification is an additional 8 hours of supervision. The Intermediate Level of certification is 16 hours of supervision (8 hours in addition to what was presented for Foundational Level). In order to become a fully Certified Theraplay Practitioner, one must engage in 24 hours of supervision (8 hours in addition to what was submitted for Intermediate Level).

Implementation Information

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Theraplay.

Formal Support for Implementation

There is formal support available for implementation of Theraplay as listed below:

The Theraplay Institute maintains a Theraplay Certification program. Professionals who have taken the Level One Theraplay and MIM training can enroll in the supervision practicum, which has three levels of competence. The most intensive level, with 24 hours of training, ends with full certification. The supervision portion of the training requires participants to submit videos their sessions. Supervision is conducted online, individually and in groups, with the Theraplay Institute via a secure website.

Fidelity Measures

There are fidelity measures for Theraplay as listed below:

The Theraplay certification practicum enables practitioners to verify the fidelity of their implementation by recording their sessions and submitting them to Certified Theraplay Supervisors. Practicum students then complete self-reflection forms in each supervision session and receive feedback from certified Theraplay supervisors. There is a standard Theraplay session evaluation form that supervisors and students must complete at 3 levels of advancement in the practicum. During the mid-term and final, another reflection form is completed by the student, reviewed by their supervisor, and reviewed a second time by another supervisor.

Implementation Guides or Manuals

There are implementation guides or manuals for Theraplay as listed below:

The book Theraplay: Helping Parents and Children Build Better Relationships Through Attachment-Based Play, 3rd Edition, is the program manual. It gives the full description of the treatment and how to implement in its basic form at as well variations for specific populations such as autism, adolescents, complex trauma, adoption, and more. The manual is available at https://theraplay.org/store/?product-page=2

After completing Level One Theraplay and MIM training, participants can then purchase the Practitioner’s Guide which provides additional resources about implementation and sustainability. The guide is available at https://theraplay.org/store/?product-page=2

Research on How to Implement the Program

Research has not been conducted on how to implement Theraplay.

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Siu, A. F. Y. (2009). Theraplay in the Chinese world: An intervention program for Hong Kong children with internalizing problems. International Journal of Play Therapy, 18(1), 1-12. https://doi.org/10.1037/a0013979

Type of Study: Randomized controlled trial
Number of Participants: 46

Population:

  • Age — Mean=7.8 years
  • Race/Ethnicity — 100% Chinese
  • Gender — 25 Males and 21 Females
  • Status — Participants were children recruited from an elementary school whose internalizing score on the Child Behavior Checklist for Ages 6-18 (CBCL/6-18) reached a clinical cutoff point.

Location/Institution: Hong Kong

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The purpose of this study was to evaluate the effectiveness of Theraplay on reducing internalizing problems among young children. Participants were randomly assigned to either Theraplay or to a wait-list control group. Measures utilized include the Child Behavior Checklist (CBCL). Results indicated that children from the Theraplay condition showed significantly fewer internalizing symptoms when compared to the waitlist group. Limitations include lack of follow-up, small participant size, and reliance on self-reported measures.

Length of postintervention follow-up: None.

Wettig, H. H. G., Coleman, A. R., & Geider, F. J. (2011). Evaluating the effectiveness of Theraplay in treating shy, socially withdrawn children. International Journal of Play Therapy, 20(1), 26-37. https://doi.org/10.1037/a0013979

Type of Study: Pretest-posttest study with a nonequivalent control
Number of Participants: 189

Population:

  • Age — 2-6 years
  • Race/Ethnicity — German and Turkish
  • Gender — 64% Male and 36% Female
  • Status — Participants were children with language disorders, behavioral problems, and shyness/social anxiety referred from German and Australian medical centers.

Location/Institution: Germany and Australia

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study assessed the efficacy of Theraplay for dually diagnosed children with language disorders and shyness/social anxiety. Participants were assigned in two waves to treatment conditions or a no-treatment control group. Measures utilized include the German version of the Clinical Assessment Scale for Child and Adolescent Psychopathology (CASCAP-D). Results indicated that children improved significantly on assertiveness, self-confidence, and trust. Social withdrawal was reduced. Expressive and receptive communication improved. Many behaviors normalized compared with neurologically healthy controls. Improvements were maintained over a 2-year period without relapse. Limitations include a lack of randomization, generalizability due to ethnicity and reliance on self-reported measures.

Length of postintervention follow-up: 2 years (Wave 1 only).

Siu, A. F. (2014). Effectiveness of Group Theraplay® on enhancing social skills among children with developmental disabilities. International Journal of Play Therapy, 23(4), 187-203. https://doi.org/10.1037/a0013979

Type of Study: Pretest-posttest study with a nonequivalent control
Number of Participants: 38

Population:

  • Age — 6-13 years (Mean=10.34 years)
  • Race/Ethnicity — Not specified
  • Gender — 35 Male and 3 Female
  • Status — Participants were children with developmental disabilities.

Location/Institution: Not specified

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study assesses the efficacy of a group Theraplay program in a special school for children with developmental disabilities. Measures utilized include the Social Responsiveness Scale (SRS). Results indicated that data from the SRS showed that students from the Theraplay group had significant improvement in the subscale of social communication when compared with the comparison group. Limitations include a lack of randomization, small sample size, and lack of follow-up.

Length of postintervention follow-up: None.

Hiles Howard, A. R., Lindaman, S., Copeland, R., & Cross, D. R. (2018). Theraplay impact on parents and children with autism spectrum disorder: Improvements in affect, joint attention, and social cooperation. International Journal of Play Therapy, 27(1), 56–68. https://doi.org/10.1037/pla0000056

Type of Study: One-group pretest-posttest
Number of Participants: 8

Population:

  • Age — 3-9 years (Mean=5.38 years)
  • Race/Ethnicity — Not specified
  • Gender — 6 Male and 2 Female
  • Status — Participants were children with mild to moderate autism.

Location/Institution: Not Specified

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The goal of the study was to evaluate Theraplay using a sample of autistic children. Measures utilized include the Marschak Interaction Method (MIM). Results indicated that both parents and children significantly improved across session according to the therapist evaluation. These findings suggest that as the intervention progressed, both children and parents became better at interacting during the therapy sessions. Significant changes were observed in the MIM interaction tasks. Overall, caregiver–child dyads scored significantly higher on the MIM interaction task from pretest to posttest. Further, dyads scored significantly higher on several specific dimensions. Limitations include a lack of randomization, lack of control group, small sample size, and lack of follow-up.

Length of postintervention follow-up: None.

Additional References

Bentzen, M., & Hart, S. (2015). The limbic compass and Theraplay. In Bentzen, M., & Hart, S. Through the windows of opportunity: A neuroaffective approach to child psychotherapy. 67-94. Karnac. 

Tucker, C., Schieffer, K., Willis, T., Hull, C., & Murphy, Q. (2017). Enhancing social-emotional skills in at-risk preschool students through Theraplay based groups: The Sunshine Circle Model. International Journal of Play Therapy, 26(4), 185-195. https://doi.org/10.1037/pla0000054

Weir, K. N., Lee, S., Canosa, P., Rodrigues, N., McWilliams, M., & Parker, L. (2013). Whole family Theraplay: Integrating Family Systems Theory and Theraplay to treat adoptive families. Adoption Quarterly, 16 (3-4), 175-200. https://doi.org/10.1080/10926755.2013.844216

Contact Information

Mandy Jones, LCSW, RPT, JD
Title: Program Director
Agency/Affiliation: The Theraplay Institute
Website: www.theraplay.org
Email:
Phone: (847) 256-7334
Fax: (847) 256-7370
Joseph Serrano, PsyD, LPC
Title: Clinic and Business Development Manager
Agency/Affiliation: The Theraplay Institute
Website: www.theraplay.org
Email:
Phone: (847) 256-7334

Date Research Evidence Last Reviewed by CEBC: October 2019

Date Program Content Last Reviewed by Program Staff: March 2020

Date Program Originally Loaded onto CEBC: December 2009