SEAN WOLF HILL
Anne Marshak Jernberg originally developed the therapy methods that would become Theraplay through working with children in headstart programs in Chicago. She and colleagues noticed that many of the children they worked with had "failed to make proper early attachment to their parents" (Jernberg 1993b, p. 46). In addition to poor parental involvement in the lives of these children, their home environments were often what could be described as being "deprived"--- deprived of positive stimuli and of an atmosphere in which the child felt "special". In interactions with these children, Jernberg repeatedly found that these were children who seemed to be lost in the shuffle among the adults in charge of their lives. She quickly formed the impression that they "needed a therapy that could bond poorly bonded parent and children at the most primitive (nonverbal) level" (Jernberg, 1993a, p. 47).
Finding her methods successful with these neuro-psychologically normal, albeit deprived children, Jernberg began applying them to the treatment of autistic children. These methods worked well with this population because they were nonverbal and noninterpretive. Theraplay was applied to other types of children who were nonengaged, intellectualizing, too verbal, too ideational or too distractible (Jernberg 1993a). In all cases, the etiology of the problems were thought to be related to poor parent-infant bonding. The aim of the interactions in Theraplay would be to replicate normal parent-infant bonding (Jernberg 1993a).
Jernberg's approach to child therapy became quite popular and she found it necessary to register Theraplay as a trademark due to suspect practices some therapists were using under the rubric "Theraplay" (O'Connor, 1991). She established the Theraplay Institute of Chicago in order to assure that Theraplay practitioners conformed to the correct standards and methods. However, due it's wide applicability and heuristic quality, the right to practice Theraplay is "not restricted to persons with advanced degrees in helping professions" (O'Connor 1991).
Core to the Theraplay philosophy is the belief that parent-infant attachment is a developmental necessity. Theraplay fits into what is known as "developmental child therapy". "Interactive play with the mother has been found to facilitate growth and therefore health... Interactive play enhances the child's intellectual and social-emotional development and the degree to which he finds joy in learning, becomes socially responsive and develops group relationships" (Jernberg, 1993 a, p. 241). The therapeutic kernel of Theraplay is a replication of these "primary healthy conditions" of parent-child attachment.
Theraplay is "based on the notion that normal caretaker/child interactions in the first few years of life are essential in establishing the basis for the child's future mental health and that these types of interactions may be instituted later in the child's life with the same health-producing effects" (O'Connor 1991, p. 30). Jernberg's belief was that healthy caretaker/child interactions 1) maintain the child at an optimal level of arousal; and 2) promote the child's development (O'Connor, 1991). This attachment and bonding is largely set in motion in the child's sensory-motor years. When infants engage in sensory-motor play, a basis is formed for future movement through space and the handling of objects in the outside world. Jernberg described this fundamental play as the basics of cognition and rudimentary memory (Jernberg, 1983). It is the caretaker who has the primary responsibility for ensuring that the infant is appropriately stimulated and relaxed, gently challenged and nurtured. "It is a delicate dance in which the needs of the caretaker and the child must be constantly reevaluated and their interactions renegotiated" (O'Connor 1991 p. 31). Jernberg describes the optimal primary conditions of parent-infant interaction as when the parent is engaged with the child and finely attuned to the child's every internal experience. This fine-tuned resonance that a mother develops for the internal experiences of her baby creates a kind of "cloak" around the dyad. The parent is able to replicate the internal and external experiences of the child, creating new modalities of interaction based on the primary engagement they share. In healthy interactions, the two are having great fun together, they are alert awake and active, and constantly providing feedback on each other's states. "The activity is so memorable to both that, as each is falling asleep that night, each will remember quite clearly what happened, and what the other sounded, felt, smelled and looked like..." (Jernberg 1993 b, 242). At this basic level, the child feels himself or herself to be an extension of the caretaker. The child's behaviors become less guided by reflex and more "built up" from the constant inputs provided by the parent (mother). The need for the mother to maintain the child's level of arousal drops off dramatically in the third year. (O'Connor, 1991). Still, there are times when the "dance patterns" ingrained in child and parent must be called forth to guide the child through developmental crises and turning-points. "Over the course of the child's life, his need to have someone else exercise control over his level of arousal will vary considerably, depending on the situations in which he becomes involved" (O'Connor, 1991, 30). An incident of trauma, which leaves the child overstimulated and overwhelmed and therefore unable to care for himself, is an example of a time when the parent must shift from stimulating input to being more nurturing.
Jernberg fits her views of early child development into Piaget's quite neatly (O'Connor 1991). In Piaget's Level I or "sensorimotor" level, which lasts until a child is two years old, the infant is constantly taking in stimuli from the environment. He or she is frequently at a high level of excitation. There is no language, just experience. The infant feels completely absorbed--- the "oceanic" feeling. There is little manipulation of the environment and no sense for object permanence until the very end of this level. The acquisition of language marks the child's entry into Level II, or the preoperational stage. Now the child is able to categorize and cognitively organize and manipulate what he or she is learning. By age 6, the concept of object permanence is perfected. Entry into Level III, the concrete operations stage, finds the child able to conserve ideas, classify and serialize. Information storage moves from a body- to a language-based medium. Around age twelve, the child enters Level IV or the formal operations stage where a penchant for more abstract thought takes hold.
In Theraplay, the therapist intervenes at the stage of the child. The goal of Theraplay is to provide corrective experiences at these different levels of development (O'Connor, 1991). The core belief of Theraplay is that both the motivational system and personality derive from interaction with the world and to change over time. The therapeutic intervention seeks to recapitulate earlier developmental issues in later developmental phases. Thus, Theraplay functions much like a time machine, taking the child back to a stage of caretaker-child interaction that was mishandled earlier in their life. Theraplay is therefore a type of play therapy that seeks to provide corrective experiences.
Theraplay is squarely in the realm of a psychoanalytic-developmental view of the world. Jernberg was heavily influenced by Austin DesLauriers' work with autistic and schizophrenic children and Heinz Kohut's concept of healthy narcissism. Since these two approaches to psychotherapy for children and youth are the starting point for Jernberg's Theraplay, a brief exposure to their methods and theories is merited here. Jernberg (1979, p.2) admits that Theraplay is a "direct application of DesLauriers' approach." A psychoanalyst, DesLauriers took a novel approach in working with children with psychotic disorders, an approach that included physical touch and intrusiveness. Her aim during therapy was to establish the therapist as the most important intruding force in the life of the child. The vigorous manner of the therapist would "force the psychotic child to take account of the therapist's human presence" (Jernberg, 1979, p. 2). DesLauriers' techniques placed an accent on the here and now, ignoring bizarre behavior as well as the past and fantasy material. This represented a departure from traditional analytic canon.
The therapeutic use of self employed by DesLauriers suggests somewhat of a paradox: Although "it is a matter of presence: a forceful, insistent, intruding presence of the therapist to the patient, so that the patient cannot escape his presence", emphasis is also placed on the child's health, potential and strength (Jernberg, 1979, p.3). The therapist's intrusive presence is particularly important for issues of failed individuation, where the goal of therapy is to "help...the child to see himself as unique, different, and separate from others" (Jernberg, 1979, p.2). This calls for a focus, through eye and body contact, on maintaining a level of intimacy between the child and therapist. In DesLaueriers' approach --- as in Theraplay--- the therapist takes charge and structures the sessions. The degree to which the therapist is a dominant force in the sessions sets these approaches apart from the "child-centered" therapy of Virginia Axline, where the therapist allows the child to guide the sessions. The reason for this is the presumption of "fixation": DesLauriers' clients, being schizophrenic or autistic, were not likely to "open up" spontaneously in a therapeutic encounter. Likewise, in Theraplay the idea is that the child has come to be "stuck" at some unfulfilled phase of parent-infant/child interaction and is not able to express more developmentally advanced material without a preplanned structured session.
DesLauriers' choice of the word "intrusive" may startle some more "client-centered" therapists. DesLaeriers (1962) insists that this intrusiveness must lead to a "reassuring presence" in which the therapist plays the part of "the benevolent mother" so needed by the child" (p.98). Through holding, touching, persistent eye-contact, the process intends to "foster a maturational process" (p.64). The "intrusiveness" is not a negative experience for the child: DesLauriers advocated "an intense, active, physical joyful therapist-child interaction" (Golden 1986, p.99). The withdrawn child must be drawn out through the parent like manner of the therapist initially by "involving his affective interest in various parts of himself" (p.64). The aim of the therapeutic encounter is to apply a series of corrective experiences which recreate an earlier period of development, but with healthier interaction. This necessitates a high level of activity and direction on the part of the therapist.
In the confused and disorganized world of th e sc hizophrenic patient, the therapist must stand out as a clear-cut, well-deline ated, intruding force. His presence should immediately limit the loose and f luid boundaries of the patient's world, to the actuality of all the stimulating factors involved in this presence, and forcefully directed at keeping alive the patient's awareness of reactions elicited by the therapist. The analogy could be made here to the total pattern of activities adopted by a mother in attending to her small child. ...the comparison to the mother should not be understood primarily in terms of the nursing functions of the mother, but in terms of her overall "contact" and physical communications with the child... The therapist has to become the entire world of the schizophrenic patient. (DesLauriers, 1962, 63-64)
Significant in this passage is the implication that in replicating the mother-child dyad, the therapist is not merely "nurturing" but also must be "intruding" and structuring. Jernberg directly transfers these ideas to Theraplay.
Heinz Kohut's studies of the development of "healthy narcissism" posited that the process of parent-infant interaction was the starting point for the build up of a person's "self-structure", their view of themselves and their place in the universe (Golden, 1986). Kohut saw the early narcissistic yearnings of infants as children as the fulcrum upon which a healthy personality is lifted. Infants have a great need to experience themselves as grandiose, as the center of the universe. This feeling is substantiated by an idealization of the parent who constantly conveys the message "I know what you need" to the child (Golden, 1986). In Kohut's sessions, it was the therapist, through transference, who became this idealized parent. This is consistent with Jernberg's approaches in Theraplay in which the therapist sets limits, conveys a reassuring presence, is empathic, fun, intense, supportive and defines boundaries to provide an appropriate mix of "structuring" and "nurturing" experiences. In essence, the therapist becomes this omnipotent other, is perceived by the child as good, impactful, assertive, protective and caring. In Theraplay, this power is then handed over to the parents. The goal is for the child to internalize these feelings of being special, which they will use as a foundation for building a sense of self as powerful, optimistic, and impactful. In Kohut's work, and in Theraplay, the therapist is able to communicate to the child that their natural need for nurturance, security and consistency are understood and that they in turn are worthy of having these feelings (Golden, 1986). The purpose is not to "baby" the child, but to provide "phase-appropriate interactions" which contain a mix of nurturance and opportunities for challenge and novelty.
Kohut proffered that a child emerges from the parent-child dance with one of two messages:" I am special, meaningful and unique", or "There is a flaw in the world, which is me" (Golden, p.101). Kohut felt that the all-powerful, perfect, loving aura of a healthy parent allows the child to become immersed in these feelings and thus to develop self-soothing/self-regulating capabilities, a sense of satisfaction with regard to needs being met, the ability to be accommodating and empathic with others, and a stable self-structure. These are the "basic core of healthy later development" (Golden, 1986). Kohut stated that there is "cohesion of the self" by time a child is two years old (Goldberg, 1978). That is, by the time a child reaches this very early age the "self-structure" is crystallized.
Kohut's therapy has been described as "a genetic reconstruction of the patient's psychological development and childhood as they were experienced by the parents and child" (Goldberg, 1978, 7). Here again is the idea of the corrective experience: the therapist and child work through a reexperiencing of the primal parent-child dance, minus the episodes of negative influence. Through transference, the therapist becomes the "idealized parental imago", allowing a mobilization of the client's "archaic grandiose self" (Golden and Kohut, 1987, 64). The client allows this to occur due to the phenomenon of "mirror transference". Mirror transference develops in the therapeutic atmosphere of acceptance and attention and results in an encoding in the patient of the feeling that "others... are needed... as agents for self-confirmation, or self-approval" (Elson and Kohut, 1987, p. 64). Through the therapeutic encounter, the client experiences "transmuting internalizations" which form a bridge between basic archaic narcissistic needs and more realistic social conditions which supply the guidelines to prevent narcissism from regressing into infantile absolutism (Golden and Kohut, 1986, p. 101). By permitting the child to be more accepting of primitive needs and allowing through therapy for some provision of what was actually missed in their development, the child becomes more self-observing and can --- based on a therapeutic encounter which supplied healthy admiration and attention--- enact new behaviors which lead to increased mastery and a capacity for joy (Golden and Kohut, 1986). "The patient is enlisted in his own self-observation in describing the regressive experience" which leads to "a tentative reconstruction of early normal developmental phases" (Elson and Kohut, 1987, 22).
"Health has been measured by the degree to which people are capable of an unencumbered, rich, variegated, profound, intense interest in objects" (Elson and Kohut, 1987, 5). In psychoanalytic parlance, of course, "objects" refers to people, interests, art, pets, ideas, music, etc. Kohut viewed narcissistic fixation in later life not as a regression from this "object" love to narcissism, but as a breakdown of healthy adult higher forms of narcissism and subsequent regression into the primitive narcissism of infancy. Narcissism itself is not necessarily unhealthy, but it must be anchored to a realistic view of the world. Healthy interest in objects transfers in later life into an ability to negotiate the world of objects, a mastery over the use of self and others to heighten feelings of self-esteem. "When the child begins to get a sense of his own value, of his own cohesiveness, of being somebody, he needs other people to confirm this. This is an intense need... [Others] are important only insofar as they serve the heightening or maintenance of self-esteem" (Elson and Kohut, 27). Later, we shall explore how the process of Jernberg's Theraplay is designed to provide this confirmation of self-value.
Kohut's psychoanalysis is set apart from classical oedipal-regression analysis in that there is "a shift in emphasis from the drives to a more holistic approach--- to the developing personality as the child experiences his body, his mind, and to the larger more complex and more completely nuanced emotional environment into which he is born and in which he is raised" (Goldberg and Kohut, 1978, 310). This emphasis on the attentional environment into which the child is born is also the core of Theraplay. Both therapies posit that the normal parent-child scenario is one in which the child develops the conviction that the surroundings which are part of him or her are unshakable, providing pleasure, bliss and satisfaction, due to the parents' ability to "out-balance anxiety... by empathically responding] to the child" (Elson and Kohut, 1987, 40-41). Regardless of the details of the nature of the external world, the parent creates a healthy world through his or her ability to sense empathically and intuitively the needs of the child. "Various combinations of parental intrusiveness and parental neglect fail to provide the proper and fitting availability of the parent as part of the patient's narcissistic matrix" (Goldberg and Kohut, 1978, 8). The parent requires an intuitive sense of the needs of the child. Good timing, appropriate dosing and accuracy of the empathic responses is important.
The problems Jernberg observed working with children of Headstart programs in Chicago were largely resultant of poor timing, overstimulation, understimulation and inaccurate parental responses. These lead to an internalized feeling on the part of the child that "there is a flaw in me" (Golden, 1986, p.101). Kohut is sensitive to the correct and timely application of mother-child play, as evidenced by this elegant description: The correlating game in terms of self-cohesion and self- fragmentation is "This-little-piggy-went-to-market"... If you play it at the right time, and if you play it with the right kind of empathy for the child, then what do you do? You tak e him apart, toe by toe... Finally, when the child, with excitement and anxiety, has been all taken apart, what comes then? The mother embraces the child and, in a laughing and mutually enjoyable embrace, the child is put back together again, united with himself and with the idealized mother in a blissful experience of being a self-object all in one. (Elson and Kohut, 1987, 50)
Parent and child are immersed; "...each individual movement, each cooing, each swallowing, each precursor of a thought process, each little recognition is there all by itself... intensely enjoyable" (Elson and Kohut, 1987, 25). Through the intuitive provision of the right mix of structuring, challenging, intruding and nurturing responses, the healthy parent facilitates the "development of a global self-acceptance" (Golden, 1986, 101). Jernberg (1979) describes in great detail the play between mother and child--- the mimicking, the eye-contact, the stimulating tone of voice, the tickling, the rocking, the singing ---- that is so definitive of what she calls the "nursery environment". All this has a physio-developmental aspect, of course, but Jernberg is concerned with how these parent-child interactions sculpt a child's self-image. In a home where the parent is caring, trustworthy, fun, interesting, warm, appealing, lively, strong, competent, responsive, talented, wanted, needed, resourceful, engaged, focused, pleasure-providing, attuned, empathic and loving, the child will develop a healthy self-view that "I am beautiful; I am special; powerful; nifty; talented; fun to be with; extraordinary lovely; fun-loving; coordinated; courageous; curious; lovable". The child will come to see world as safe, joyous, predictable, fun, exciting, varied, "focused on me", trustworthy, secure, colorful, happy and loving.
In a home where the parent is unable to interact with the child empathically, or interacts in negative ways (neglect or abuse), the child develops the sense that they are unattractive, hopeless, unpleasant, unworthy, dull, ugly, incompetent, unlovable, inadequate, unappealing, ungiving, misunderstood, helpless, inferior, lacking, empty and cold. This child will see the world as painful, rejecting, distant, unempathic, dull, cold, hostile, cruel, overstimulating, selfish, "invalidating of me", conditional, punitive, uncaring, dangerous, unpredictable, untrustworthy and chaotic (Jernberg, 1993a). The mother is the mirror which tells the child that they exist and who they are (Elson and Kohut, 1987). Kohut equated a person's ego-structure with the level of development of their "self-functions" (learning, studying, talking, thinking, etc.) and the degree of their self-esteem (Elson and Kohut, 1987). For Jernberg, these are all directly related to the quality of the early parent-child interactions.
Given the influence by the work of Kohut and DesLaureiers it is not surprising that Jernberg's Theraplay embeds the process of children's play in a therapeutic approach designed to maximize empathic relations and therefore enhance attachment (Jernberg, 1983). Deprived of the healthy infant's "view of the world as a caring, admiring, pleasurable, and invested place in which other people regard them as unique, special, handsome and wonderful", a children will "come to see themselves as ordinary and drab, if not burdensome, and the world as a place that is unloving, discounting, rejecting, painful and not to be trusted" (Jernberg, 1993b, 45). These relational deprivations and deviations result in children who are aggressive, obsessive-compulsive, psychosomatic, suicidal, substance abusing, depressed and antisocial--- to name just a few of the undesirable outcomes. These unhealthy children have problems in areas covered by Kohut's "self-functions" discussed above. The desired outcomes of Theraplay are to enhance attachment capacities, reduce stress, to guide purposeful behavior, to sensitize the customer to the environment and to instill an ability to be playful.
The goal of Theraplay is to enha nce the chi ldren' s view of themselves and to increase their joy in the world. This could not be mad e to happen quickly without the intensely personal, physical, and eye-con tacting nature of the relationship between child and therapist. To the extent that this is possible, all Theraplay activities are carried out in a joyous, playful, lighthearted spirit, while conveying empathy and extraordinary interest in every feature, every gesture, and every mood of the child. Through activities modeled on the healthy, attachment-enhancing behaviors between parent and infant, the primary goal of Theraplay is to enhance attachment between the parent and child. It is this attachment that will make possible the child's view of him- or herself as unique and wonderful and allow him or her to see his or her world as pleasurable and trustworthy. (Jernberg, 1993b, 48-49) Theraplay therefore proceeds in an atmosphere that is "lively, positive, physical, personal and engaged" (Jernberg, 1993b, 46). The key to this approach is the creation of a corrective interactive condition that allows the child to experience himself or herself as the "natural, expressive infant she had never felt able to be" (Jernberg, 1993b, 52-53). The child must "come to see, reflected in the therapist's eyes, the image of himself as both lovable and fun to be with" (Jernberg, 1979, p.3). The process is therefore an application of Kohut's ideas of "mirror transference, in which the child experiences their 'grandiose self' through the positive attentions of the parent" (Goldberg and Kohut, 1978, 6), and of the "transmuting internalization" that happens when a child introjects the healthy responses of the parent (Golden, 1986, 102).
The process of Theraplay hinges on Jernberg's delineation of four core categories of interaction that occur between parent and child (O'Connor,1991 and Jernberg, 1979):
1. Structuring behaviors occur when the caretaker engages in interactions that somehow create boundaries for the child. Structuring interactions tend to diminish in frequency and intensity as the child grows older. Examples of structuring behaviors are: "baby proofing" a home, actions to prevent or minimize injury, general vigilance around toddlers, controlling bedtime, diet, managing weaning, coaching teeth-brushing and other hygiene activities, and so on. The effects of the internalization of Structuring interactions are to teach the child how to regulate his or her own behavior and to create an atmosphere of safety and security.
2. Challenging behaviors of the caretaker encourage the child to perform at the upper end of their present abilities. Verbal mimicry, reflex grabbing, sports, teaching new skills and hobbies, balancing and jumping games are all examples of challenging interactions.
3. Intruding caretaker behavior has the effect of keeping the child's level of arousal at an optimal level. Any sort of intrusion into physical or psychological space exposes the child to new or surprising stimuli. In early childhood, a mother may drip breastmilk onto the child's lips to encourage nursing. Tickling games, tossing games, and so on are other examples. "Healthy intrusions are characterized by the fact that they occur when the child needs them, not when the caretaker's needs dominate" (O'Connor, 1991, 32).
4. Nurturing activities provide for physical and emotional needs. Interactions between a mother and a very young infant are almost completely nurturing in nature and include feeding, changing, soothing, kissing, bathing and hugging. As the child grows older, more time is spent on meeting emotional needs and the caretaker must negotiate a fading process in which the child comes to provide resolution of physical needs more autonomously.
Problems arise when a parent is unable to provide these four interactive experiences (SCIN) in the right mix, in the right amount and at the right time. "The mother ideally should convey, 'I am in charge. I know what's best for you, and I can provide you what you need'" (Jernberg, 1979, 15). A caretaker requires empathy and sensitivity to provide these interactions and there are many opportunities for the process to break down. Environmental factors such as intruders, resentments of the family from others, competing demands, external stress and strain, lack of time, and lack of freedom may present barriers for a healthy mother-infant relationship. There may not be a "good fit" between caretaker and child which creates a disengaged relation. There may be "an early and mutual turnoff" between the two (Jernberg, 1979, 7). One or the other partner may not adjust to the new role of parent and may respond with avoidance or aggression. Likewise, one parent may not be able to adjust to the other parent's adjustment to the new situation, creating stress and estrangement. A parent may simply not be able to provide certain types of experiences, whether structuring, challenging, intruding or nurturing. A mother may resist the idea of "self-as-mother" or the "baby-as-baby". The parent may have "heroically denied their own regressive longings" and so is unable to identify with the healthy narcissism of the baby (Jernberg, 1979, 9). The parent may fear taking charge or being in a position of such power over the fate of another. The infant may present with a difficult temperament, a physical deformity, lethargy or hyperactivity which prevents them from engaging in the feedback loop of the parent-child interaction (Jernberg, 1993a). The parent may be immature, depressed, ill, a substance abuser, abusive, ambivalent or resentful, which prevents them from initiating the behaviors necessary for the engagement of the self-organizing system of the interactions. Some parents' behaviors may be skewed due to unrealistic expectations of the child, the need to develop a "superbaby", being it "in it for themselves" more than for the child or by being oversensitive to perceived rejection coming from the child.
Each of these distortions of the normal parent-child interactive double-feedback loop result in some form of being out of pace, out of phase, or otherwise out of sync with the needs and continuing development of the child. Jernberg (1979) harkens back to Freud's metaphor of das Reizschutz (barrier or membrane) to highlight the high level of empathy necessary for a parent. The image is that of a barrier or semi-permeable membrane that surrounds the child, filtering out too much excitement, yet keeping the baby stimulated. This barrier prevents the baby from being overloaded or bombarded by heavy stimuli yet admits the positive pressures from without. If incoming stimuli are too painful, a "thin-skinned" baby can develop a thick skin. On the other hand, the membrane may be too permissive and allow all manner of stimuli to impact on the infant. The parent can influence the development of this barrier in a positive or negative manner. In a sense the parent becomes an adjunct to this quasi-biological membrane by periodically modulating its threshold of penetrability, empathically sensing when "enough is enough" and when the child needs challenged rather than nurtured, etc. The mother's responses to her child cushion him or her from blunting traumas and shaking them from stultifying mundaneity. Again, the message is "I am in charge. You can count on me to anticipate what you need. I will keep you protected."
Theraplay operates on such a primal level. It aims to "increase self-esteem by engaging the child in activities which, regardless of age, duplicate the essential parent-child interaction which should normally transpire with a six month old infant" (Golden, 1986, 99). Theraplay requires and active role of the therapist: The process is designed to insistently extricate the child from their own world (Jernberg, 1979). The therapist establishes a caretaker like relationship with the child and implements those activities that promote the experience of positive interpersonal interaction. The treatment goal is to help "overcome those behaviors that prevent the child from having the kind of interpersonal relationships he needs to function optimally in the world" (Jernberg, 1979, 34). Finally, by transferring this relationship to the parents, the child is helped to generalize these interactions in the world outside the playroom. The therapy is conceived as being "compensatory": "Theraplay's bonding and attachment-enhancing properties are a form of treatment. It's treatment strategy is to replicate the early parent-child relationship in all its aspects" (Jernberg, 1993a, 254-255). Theraplay employs corrective experiences--- the experiential aspect, largely unanalyzed/uninterpreted, is "the essential aspect of the treatment process" (O'Connor, 1991, 101).
Theraplay is suitable for a wide range of children (O'Connor, 1991). It is generally thought to have a minimal risk of iatrogenic effects. It is useful especially for problems that present themselves through interpersonal relationships and applicable to aggressive "tough guy" children (who do not need intrusion or challenging but structure and nurturing), passive "poor baby" children (who require challenging experiences), children who are withdrawn (nurturing and challenging activities prescribed), obsessive-compulsive children (who require the surprise of intrusive interaction), as well as the hysterical child (who needs structure and challenge) (Jernberg, 1979). Further applications for specific disorders will be discussed later in this paper. It is generally accepted that Theraplay is contraindicated for children who are sociopathic, traumatized, fragile or abused (Jernberg, 1979), yet certain modifications such as a longer introductory phase have allowed it to be successfully used for these types of problems (O'Connor, 1991). The role of the Theraplay therapist is to apply preconceived techniques that are individually tailored to specific customers to attain the goals described above. The therapist assumes the primary responsibility for the activities that are carried out in a session and these are not limited to what the child "wants" so much as to what the child "needs". A play therapy approach that uses almost none of the traditional play therapy equipment, "more than any other 'prop' is the therapist himself" (Jernberg, 1979, 389). "Matter-of-fact confidence, high self-regard, and firmness are required. The child must feel the therapist's 'Thereness'... Never must the adult come across as merely a shadow, a spirit, a fleeting vagueness" (p.315).
O'Connor (1991) states that the therapist is there to lead the child in constructive interactions and that the following qualities of a Theraplay therapist are crucial:
Golden (1986, 198) adds that the Theraplay therapist must accept the proposition that "physical contact is not only appropriate, but therapeutically mandated, if the child is functioning at or below [Piaget's] Level III"). As suggested above, the Theraplay session is always characterized by a beginning, middle and end. Within this structure, there are always moments of spontaneity, but there is a need for time to be sequenced, planned and finite and for space to be ordered and safe. The therapist, therefore, must be able to both "emphasize the inclusion of elements of fun" (O'Connor, 1991, 36) and provide activities in a pre-determined way based on a carefully considered plan of treatment.
Prior to the application of any "corrective interactions" (therapy sessions), every Theraplay customer is involved in "an extensive pre-treatment phase" which begins with a good developmental history, the gathering of general information, intake procedures, an investigation of caretaking behaviors, information abut family's sexuality, socio-cultural assessment, and so on (O'Connor 1991 and Jernberg,1979). This fairly standard intake interview helps the therapist understand the following types of questions (Jernberg, 1993b, 47-48):
The second part of this diagnostic pre-treatment phase involves bringing the family in for two separate sessions which employ the Marshak Interaction Method (MIM), a technique of analyzing parent-child interactions modified by Jernberg (1991) from an earlier tool known as the Controlled Interaction Schedule. CIS was developed to discern affection-giving from direction-giving (Marshak, 1960). MIM is administered first to one parent, then to another.
In a MIM session, the parent and child sit together at a table. The therapist selects a series of interactive tasks from a range varying along several dimensions: giving affection, giving direction, alertness and playfulness. The specific parent-child tasks are selected according to information gained during the intake. As each is presented in turn, observing along with the second parent behind a one-way mirror, the therapist takes notes on the style and quality of the interactions. Typically, 7-8 structured tasks ("Teach the child something new", "Feed each other M&Ms", "Tell the child about when he or she was a baby", "Play dress up") are performed (Jernberg, 1979). "The interactions are coded for the presence or absence of structuring, challenging, intruding and nurturing" (O'Connor, 1991). Afterward, the therapist discusses the interactions with the participating parent to gain a fuller sense for his or her perceptions of what was happening in the sessions. The following week, the same procedure is performed with the second parent. A week or ten days later, both parents are invited back to attend a feedback session regarding observations during MIM. Modeling empathy, the therapist focuses on the positive aspects of the observed interactions. At this time the therapist begins to instill the Theraplay philosophy, to explain the rationale for the therapy to follow, and to introduce the treatment plan.
Treatment itself is thought to proceed in six phases: An Introduction Phase in which the ground rules are explained, the child's expectations structured, and the therapist begins to develop an appreciation for the specialness of the child; an Exploration Phase in which the parties actively get to know each other by focusing on mutual explorations like eye or hair color or name similarities ("The goal of this phase is for the child to become aware of the therapist's existence and for this awareness to be a positive one" (Jernberg, 1979, 37); a Tentative Acceptance Phase in which the child pretends or actually tries to accept the interactions and appears to be deriving enjoyment from them; a Negative Reaction Phase where the child resists further attempts at intimacy; a Growing And Trusting Phase where the interactions are positive and when the therapist begins to introduce the parents into the equation; and finally the Termination Phase --- subdivided into Preparation, Announcement and Parting--- where the child's growth is celebrated. These phases are typically accomplished in eight sessions.
Theraplay sessions are thirty minutes long. The first four sessions involve no expectations on the part of the parents, who observe behind the mirror the interactions of the therapist and child. A second "interpreting therapist" sits with the parents and talks them through what is occurring, keeping in mind the assumptions about the parents-child interaction style that is guiding the interventions. After these sessions, there is a general discussion/orientation about what went on with all four, therapists and parents. The final four sessions begin like the first, but with one variation: during the last fifteen minutes, the parents join the child and the participating therapist. "It is the parents who ultimately become the full-time Theraplay therapists. Therefore, it becomes as important to train the parents as it is to treat the child" (Jernberg, 1993b, 54). During the transitional sessions, when the parents are increasingly introduced into the interactive feedback loop, there is constant communication between the observing parent and the therapist.
Theraplay sessions are pre-planned. Session greetings and closures are structured in such a way that they experientially are joyful and engaging, not merely symbolic and formal. Partings are used as opportunities to encourage flow-through form the session to real life. Throughout the working stages of therapy, the therapist inserts "checkup activities" which provide both therapist and child with a period to get reacquainted, to provide a temporal bridge between previous sessions and to convey to the child a sense that he or she is capable of growth and of growing. The same processing is done with parents, as the therapist acknowledges their growing awareness of the impact that reciprocal activities have on the child's psychic and social life. The therapists' job is to clarify the purposes of the different modes of activity and to model these for the parents (Golden, 1986). Practice between sessions is encouraged.
Although the activities within the sessions are sequentially executed according to a pre-planned course, there is always room for improvisation. The therapist must be attuned to the possible need to rethink a plan arising from situations such as physical discomfort, fear, over excitement, eroticized perception, blatant requests from the child for enlightenment, unhappy experiences, genuine expressions of anger, ethnic and cultural differences and socioeconomic issues. The therapist must be prepared for these inevitabilities since the primary method of Theraplay is to provide encouraging, joyful experiences, not therapeutic anxiety and frustration. Furthermore, there is no prohibition in Theraplay canon to the incorporation of the child's ideas about activities. Resistances must be dealt with through action, not through attempts to produce insight. Resistances are seen simply as tactics to avoid SCIN experiences. The therapist must engage in on-going assessments of the intensity and quality of interactions. Ultimately, "the child must experience the therapist as available, engaged, consistent, providing security, and as giving care on a noncontingent basis" (Golden, 1986, 100).
Theraplay has applications in many settings: school, head start programs, private schools, training the handicapped, special ed facilities, outpatient, CMHC, Speech clinic, child guidance center, private-fee clinic, crisis hotline, home-based, institutions, foster care and adoption. Because the shape and feel of each series of sessions is shaped specifically for the needs of the child and family, Theraplay's techniques can be tailored to deal with many different problem behaviors (Jernberg, 1979).
Underactive Children. The children require vigorous, cheerful and fun Theraplay. The therapist needs to always be in charge. Usually sessions with underactive children are highly intrusive in nature. If there is depression, nurturing interactions are in order. There is no room for structuring with these children. Jernberg admits that at times sessions with such children may appear foolish, contrived, artificial or manipulative due to heavy affective investment of the therapist.
Overactive Children. These children are evidenced by attention seeking, always being "on the move", always discharging rather than delaying tension, and as impulsive, distracted and excitable. In such cases, challenging behaviors (which are designed to help a child "grow up") are out of place. The goal is to provide nurturing interactions which have a calming effect. The goal is to allow these children to regress to a more infantile stage of receptivity to nurture. They need structure, not intrusive surprise.
Avoidant Children. Children who run away from intimacy, figuratively or literally, need to be "caught" and hugged. The adult must be intrusive. This echoes DesLauriers therapy with schizophrenic adults.
Theraplay is well-suited for handicapped children, especially those deprived of or not receptive to some stimuli. It has been used with success with blind, deaf and language-impaired children. DesLauriers pioneered work with autistic children. While the "normal mother-child dyad is viewed as a reverberating circuit", autistic children have an inability to send out signals or cues which parents can respond to (Jernberg, 1979, 300). DesLauriers (1969) characterized these cut-off, ritualistic children as "asleep". The goal of Theraplay is to intrude, supplying the child with ample external stimulation and an assertive "Here I am" therapist presence. "Mirroring is perhaps the most intrusive Theraplay of all... In mirroring, the adult deliberately places himself in direct visual range and adopts the child's frame of mind... He behaves exactly as the child does" (Jernberg, 1979, 320). In Speech Theraplay, which is based on the parent-child interactions that are postulated to activate articulation acquisition, "target phonemes are embedded into spontaneous interactive play both in isolation and in meaningful exchange" (Kupperman, 1980540). Rambling/wild children need structure while overly organized children need intrusion. Children who give up easily must be challenged.
Adolescents can benefit from infantile activities if that is what they need. The primary concern is a consideration of the adolescents sexual development. Adolescents with adjustment problems need to be focused upon closely; during interaction, the therapist must keep a constant, running commentary, focusing on the positives. Upbeat comments and spontaneous new activities maintain an atmosphere of empathy. Adults can benefit from Theraplay "because many... were deficient in early mother-child attachment-fostering and autonomy-handling experiences" which are recreated in the Theraplay session (Jernberg, 1979, 386-387).
Jernberg cautions that there is some enhanced possibility of countertransference acting out that must be monitored: Issues of anger, dependency and sexual arousal are important red flags for a therapist. To check these possible countertherapeutic occurrences, Jernberg (1979) recommends therapists ask the following questions:
Theraplay is a developmental play therapy with psychoanalytic undertones. Unlike Axline's child-centered play therapy, the Theraplay therapist calls the shots. It is similar to Levy's Release Therapy in that it uses standardized situations for a specific goal (Landreth, 1991). Theraplay's strategic approach makes it somewhat similar to Minuchin's and Structural Systems theory, however the element of playfulness is a clear contrast (Jernberg, 1979) It bears some resemblance to the Relationship Therapy of Jessie Taft and Frederick Allen which was developed in the late thirties in that the accent is on the here and now and it "de-emphasiz[es] the importance of past history and the unconscious and stress[es] the development of the therapist-client relationship as critical" while accentuating "the curative power of the emotional relationship between therapist and child" (Landreth, 1991, 31). Theraplay understands the influence of past experiences on the present, but does not have as a goal uncovering that past.
Golden (1986) states that Theraplay "offers a level of intimacy not evidenced in previous forms and child therapy" (p.99). He also highlights these significant differences:
Theraplay does not provide props to act out the unconscious
Jernberg (1993a and 1993b) suggests these crucial differences between Theraplay and other play therapy approaches:
Jernberg (1979, xi) stated that while "child-centered approaches worry about the 'the client's dignity', Theraplay's 'taking charge' is just one aspect of its more general aim, which is to replicate the healthy parent/infant relationships".
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