(First Published in The Canadian Association for Child and Play Therapy’s National Magazine – Playground, April 2011)

Lorie Walton, M.Ed, CPT/S, RP
Certified Theraplay® Therapist Trainer Supervisor
Owner of Family First Play Therapy Centre Inc
www.familyfirstplaytherapy.net
Executive Director of Theraplay Canada
www.theraplaycanada.ca

When children experience any type of challenge (emotional, developmental, educational, medical, familial) their emotional regulation systems experience a stress response. Ongoing stress reactions can impact the child’s ability to maintain emotional regulation. Stress hormones such as cortisol and adrenaline, surge thru the child’s body during stressful times. These hormones are negative and can impact the child’s developing regulating system in inhibitive ways. The heart rate increases to power the human body during ‘flight’ or ‘fight’ responses, and it must maintain its rhythmic pulse despite the varying demands placed on it. Thus, regulating heart rate during stress and controlling stress hormones are two critical tasks that require the brain to keep proper time (Perry, 2000).

Because children’s emotional systems are still in the early stages of development (along with their brain and body systems), they require help in being soothed as they are often unable to soothe themselves without an attentive adult’s help. If left unsoothed, the child’s overall emotional development may be negatively impacted long term thus potentially predisposing the child to anxiety and future mental health issues. Disturbances of the brain’s rhythm-keeping regions are often causes of depression and other psychiatric disorders (Perry, 2000). Therefore, if a young child’s primary regulating system doesn’t function well, not only will his hormonal and emotional reactions to stress be difficult to modulate, but other systems like sleeping and eating, learning motor functions, and responding to others in positive ways will be volatile as well.

Most often, children with dysregulated emotional systems require first an intervention which helps their body unconsciously experience soothing and calming from an external source BEFORE they can consciously begin to master their fight, flight, freeze responses in a controlled and motivated way. The regulation of emotions is equal to helping a child securely attach. Attachment researcher has demonstrated that attuned, engaging interactions between a baby and mother leads to secure attachment, positive internal working models of self and world and the capacity to regulate emotions and actions (Sroufe 2005).

When considering which therapeutic modality to use, it is best to consider two important aspects of the child’s presentation: 1. Does the child’s emotional system appear younger than his chronological age? And 2. Does the child have a significant attachment caregiver who can learn how to attune to the child’s internal dysregulated states and provide soothing and nurturing experiences to effectively help the child’s brain and body systems begin to ‘balance’?

Theraplay®(1) is an evidenced-based intervention which helps children experience emotional regulation by participating in playful, attuned experiences with a parent or caregiver. One of its many assets is its ability to assist a caregiver use attuned nurturing and soothing responses to help the emotionally dysregulated child’s body internalize new responses to stress. Below is a brief account on how Theraplay was used to help an anxious child. 7 year old Sara, was referred for Theraplay in order to help reduce the highly anxious behaviours she was presenting with. Sara’s parents spoke honestly of their own anxiety in regard to parenting Sara. They reported her behaviours as very challenging at times especially pertaining to separation when going to school. They also reported her as fearful, nervous and aggressive especially with family members.

Sara participated in 12 Theraplay sessions with her mother and father. The Marschak Interaction Method Assessment was done prior to Theraplay sessions in order to assess attachment and relationship strengths and needs. During this assessment, Sara was observed as hyper-vigilant, controlling, aggressive and rejecting and very anxious about being left alone. This behaviour substantiated reports from home, and strongly indicated Sara’s dysregulated emotional state. Thus, goals for Theraplay treatment were set to decrease her anxiety and hypervigilance, increase Sara’s self-confidence to master challenges and assist Sara in strengthening the bonds of attachment with her parents. Goals were also set to help Sara’s parents feel more confident about their ability to parent Sara.

The Theraplay sessions were structured so that Sara could interact with her father as much as with her mother. Nurturing and engaging techniques were introduced to assist in strengthening Sara’s trust with her parents. Through activities such as measuring, or cotton ball soothe, the parents were encouraged to point out special qualities about Sara to help her feel noticed and to encourage body awareness. Initially, Sara appeared somewhat uncomfortable when receiving positive comments about herself. She would not make eye contact and would often become fidgety and try to change the subject. At times, during more active games she would be rough towards her mom, but once encouraged to use Feather High-5’s(2) she was able to demonstrate her ability to be gentler and more controlled.

During initial Theraplay sessions, Sara sometimes appeared unable to keep up with the pace of activities and she often seemed anxious when too many directions were given at once. She appeared challenged when more than one person was speaking to her or when information was given at a pace which was difficult for her to process. Thus, the following modifications and suggestions were made to address these issues:
• Modeling techniques were used to provide Sara with the opportunity to observe new tasks before it was her turn.
• The parents were encouraged to have only one person speak to Sara at a time, so that she could process information more easily.
• When providing Sara with directions, the parents were encouraged to give no more than 2 step directions at a time, to relieve some of the anxiety for Sara in completing the task.
• Calming and relaxation techniques were modeled for Sara (i.e.: blowing on her fingers) to help Sara, learn how to reduce some of her anxious feelings.
• The parents were encouraged to practice these techniques at home to assist Sara in using them when she most needed to.

During each session, the parents were invited to keep a physical connection with Sara. Sara would be placed on Dad’s knee facing Mom so that Mom could massage lotion into Sara’s hands and arms. Stick-together(3) games were incorporated to help the parents remain ‘physically’ connected to their daughter as much as possible. Nurturing activities such as Magic Carpet Ride(4) and snuggling Sara in a blanket while in mom’s arms were some of Sara’s favourites. It was observed during these nurturing moments that Sara seemed less anxious and much more settled. During one session, after being rocked in a blanket and then put into mom’s arms, Sara almost fell asleep.

After each Theraplay session, a co-therapist would take Sara into another room to play in order to allow the parents and therapist to review weekly progress and challenges. During these discussions, Sara’s parents were comfortable in expressing their anxiety around parenting Sara when she exhibited impulsivity and controlling and aggressive behaviors. Parenting strategies were suggested, and the parents were encouraged to attune to Sarah’s younger emotional needs. Over time, the parents reported that they had begun to proactively incorporate Theraplay strategies which included attunement, nurture, and structure as much as possible in order to help Sara feel less anxious and more secure.

The playful interactions within the Theraplay experience creates the opportunity to share one’s bodily reality and ones emotional reality in expanded, dyadic states of preverbal consciousness (Makela, 2003).
Theraplay is tailored to give corrective experiences in physical coregulation through its extensive use of touch, eye contact and the calming and stimulating way of speaking throughout the playful interactions which
include Structure, Engagement, Nurture and Challenge. At the same time, it creates a resonant hum of emotions through attunement – the noticing of the minutest emotional cues of the child and responding to them (Makela, 2003). Being’ noticed’ makes all the difference to an anxious child’s predisposition of insecurity.

There is a growing body of research which outlines the positive impact of healthy physical contact on people of all ages. Barnard & Brazelton (1990) and Field (1993) found that loving touch produces oxytocin and releases endogenous opioids, which are known to solidify infant-mother bonds. During Theraplay, touch is used in playful, nurturing, and structured ways to help connect the child’s unconscious brain and body systems to those of their parent’s calmer ones. Incorporating touch within the Theraplay session helps to reduce the child’s internal emotional stress responses. Oxytocin, opioids and endorphins counter-act the cortisol responses within the child’s body and allow the child to experience pleasure and internal calm. As the child begins to enjoy playful interactions with her parent, the child’s internal blueprint eventually
becomes ‘rewritten’ to include a calmer internal response to external stressors. As the parent becomes the co-regulator of the child, the child begins to feel internal regulation which leads to security within oneself and then eventually with others in her world.

Theraplay helps children to experience the internal capacity of ‘calm’ from their coregulating caregivers at a pre-verbal level, which is lower on the hierarchy of cognitive development than other more cognitively sophisticated interventions. Once a child has cognitively and emotionally matured, more sophisticated interventions, such as CBPT, can then be considered to help anxious children begin to consciously master their internal stress reactions. Thus, Theraplay can be considered a ‘first-step’ in the intervention protocol to help a predisposed anxious child begin to master control over their emotional triggers.

By the end of the 12 sessions, Sara had begun to demonstrate her ability to respond with eagerness instead of with a ‘fight’ response such as aggression. Her parents also reported that Sara appeared less anxious, less controlling at home and appeared more confident in going to school. During a follow-up session, Sara’s parents reported that she seemed calmer and more affectionate with them. Her dad said it best when he stated “Now she wakes up singing in the morning!”

Lorie Walton, M.Ed., RP; is a Certified Play Therapist Supervisor and Theraplay® Therapist Trainer Supervisor.
She is the owner of Family First Play Therapy Center Inc., in Bradford Ontario where children and families who are experiencing attachment issues and emotional trauma receive therapeutic support. She is also the Executive Director of Theraplay Canada, was Past-President of the Canadian Association for Child and Play Therapy (CACPT) and continues to be an active member within the Theraplay and Play Therapy community. She received the 2009 Monica Herbert Award from CACPT in recognition of her commitment to Child Psychotherapy Play Therapy growth and support across Canada.

(1) Theraplay®- www.theraplay.org (2) Feather High-5 – a wiggle of one persons fingers to another persons wiggling fingers instead of a hand-slap (3) Stick-Together Games are Theraplay games which incorporate the parent and child to keep a physical connection with one another at all times(such as linked elbows or a hand on the child’s shoulder, or nose to nose) while participating in Challenges (ie: stick together with nose to nose while getting balloon across the room as a team) Blowing feathers from one pillow to another as a team is also a fun game which promotes togetherness and helps to
exercise deep breath exhales.(4) Magic Carpet Ride – spread a blanket on the floor and have child lay down on it. Parents and Therapist lift the child up in the blanket and move them around the room as if giving the child a magic carpet ride. Move slowly and swing softly so that the child feels a rhythm to the swinging and movement. (take them ‘across the ocean’ ‘over the treetops’ ‘over the mountains’ etc)

References
Barnard, K.E., & Brazelton, T.B (Eds.) ( 1990). Touch: The foundation of experience. Madison,
CT: International Universities Press Inc.
Field, T. (1993). The therapeutic effect of touch. In G. Branningan & M. Merrens (Eds.). The
undaunted psychologists: Adventures in research (pp. 3-12). New York: McGraw Hill, Inc.
Makela, J. (2003). What Makes Theraplay Effective: Insights From Developmental Sciences.
Originally Published in the newsletter of The Theraplay Institute Fall/Winter.
Perry, B.D. (2000) Traumatized children: How childhood trauma influences brain development.
In: The Journal of the California Alliance for the Mentally Ill 11:1, 48-51.
Sroufe, L. A. (2005). Attachment and development: A prospective, longitudinal study from birth
to adulthood. Attachment & Human Development, 7, 349-367.