I have asked Shanon Claussen, LISW, RTP-S, EMDR Consultant in Training and EMDR Basic Training Coach,  to share her integration of Theraplay ® with EMDR in her practice.  Shanon is a skilled EMDR therapist and clinical supervisor at Mahaska Health Partnership in Oskaloosa, Iowa. Following is what Shanon has summarized for our understanding to further EMDR work with children and adolescents:

“ Research and Theraplay ®

Theraplay® is a therapist-directed play therapy for children and their parents. It is designed to enhance attachment, raise self-esteem, improve trust in others and create joyful engagement. Theraplay® is based on the natural patterns of healthy interaction between parent and child, and is personal, physical and fun. Interactions focus on five essential qualities found in parent-child relationships: Structure, Engagement, Nurture, Challenge and Playfulness. Theraplay® sessions create an active and empathic connection between the child and the parents, resulting in a changed view of the self as worthy and lovable and of relationships as positive and rewarding.  For more information on Theraplay and to find training, visit www.theraplayinstitute.org.

Theraplay is also a trauma-informed treatment, rated "3-Promising Practice" by the California Clearinghouse for Evidence Based Practice, meaning research evidence supports the efficacy of Theraplay, but not many studies have been done. Theraplay has become known as a particularly effective treatment for children who have been adopted or have attachment issues. It is also one of the few treatment modalities that can be used with very young children (0-4) as well as all ages through the teen years.  http://education.uncc.edu/oeo/upcoming-events/multicultural-play-therapy-center-conference/family-play-therapy-engaging-creative-e

Theraplay® is especially helpful for children with attachment related problems, but can help improve or strengthen any relationship.  It has additionally been shown to raise self-esteem, improve trust in others and create joyful interactions between a parent/caregiver and a child.

There is a growing body of research which outlines the positive impact of healthy physical contact for people of all ages.  Loving touch produces oxytocin and releases endogenous opioids, which are known to solidify infant-mother bonds. Many studies have found that withholding touch can be as damaging as inappropriate touch, as seen in Romanian orphans. Children, especially those with attachment-related issues, need to experience gentle, kind, loving and safe touch. Thus, Theraplay®’s treatment includes many opportunities for healthy touch – whereby the therapist deliberately plans to have the child touched because touch is an important modality for creating relationships. Touch communicates safety, acceptance, playfulness and empathy, and touch helps regulate a child’s out of sync emotions. http://www.sandrawebbcounselling.com/theraplay.htm

Research and EMDR

We know that EMDR has been researched to be an effective modality used to treat trauma.  Since it was discovered by Dr. Francine Shapiro in 1987, it has been used to treat more and more problems such as eating disorders, phobias, attachment disorders, and many others as well.  Both hemispheres of the brain need to work together for new learning to be stored in the conscious brain. Psychological trauma causes disruption of both of these hemispheres to work together                           http://icfd.net/emdr.shtml .  Since  both therapies are  evidenced based practice for the treatment of attachment related trauma, Theraplay and EMDR incorporated together can have a very positive and powerful treatment outcome.

Trauma is a disorder of regulation. Children who have been traumatized cannot modulate their arousal,  overreacting to stimuli and challenged at self-calming.  Because of their poorly developed self-soothing, they have less impulse control and less ability to tolerate stress or frustration. They are more at risk for depression and anxiety. They are more at risk for violence and aggression because of a lack of ability to empathize and connect. They are more at risk for substance abuse and addiction because they self-medicate in attempt to feel better. A review of ACES research www.aces-research.com further expands on the tremendous negative impact of childhood trauma.

When children grow up lacking the circuitry to process painful emotions, their first impulse upon experiencing a feeling is to try to get rid of it. They may develop eating disorders, abuse alcohol or drugs, cut themselves or become suicidal or aggressive. Much pathology is the result of the anxiety, shame and aloneness that come from a lack of access to emotional resources. EMDR allows the patient to access the traumatic memory where it is stored in isolation from adaptive information.  It echoes the early attachment process in that the patient always leads the therapist, and the therapist modulates his/her affect. The therapist attunes to the patient, telling the patient to visualize the disturbing event while using bilateral eye movement, sound or tactile stimulation.

Use of EMDR with Theraplay ®  [All information was taken from materials I received during my Theraplay Training.  Any names used have been changed to protect confidentiality]:

When I was trained in Theraplay ® interventions I learned that the basic assumptions of Theraplay ®, which  are:

1)       the self and personality develop out of the early parent-child interaction as outlined in Self Psychology, object relations theory, attachment theory and research on brain development.

2)      caregiver empathy and sensitivity are essential to the child’s healthy development and secure attachment.

EMDR protocols can be used during the use of Theraplay ® interventions to strengthen the relationship between a caregiver and a child and improve the relationship.   Since early experiences of co-regulation are the basis for later emotional self regulation, the EMDR therapist can use immediate BLS or ‘tapping in’ (Laural Parnell, Ph.D. www.emdrinfo.com) to strengthen the relationship and strengthen the child’s resources when s/he sees that the child is able to self regulate while engaging in a Theraplay® activity with the caregiver .

Positive and negative interactions result in the child’s inner representation of the self, others, and the world.  If a child has a negative moment of play with the caregiver, the 8 Phase EMDR protocol can be applied.  If a positive interaction occurs during a Theraplay activity, resource tapping can be applied to strengthen the positive interaction, thus reproving the relationship.  Strengthening the positive (resourcing) will allow for a stronger adaptive information system so that when the reprocessing phase is applied, unprocessed memories that are dysfunctionally stored  can be better integrated for healthy functioning.  Positive interactions with others assist the child with development of an improved inner working model of how the child views the self, others, and the world.

Case example of combining Theraplay ® interventions and EMDR interventions (Therapist is trained in both Theraplay ® and EMDR to provide these interventions):

Phase 1.  History taking/Information Gathering:

‘Sal’ is a 6 year old male.  His mom, ‘Sue’, is in her mid 30s.  Sal has 3 other siblings: a sister (10) and 2 brothers ( ages 12 and 8), and he is the youngest in the family.  Sal and his siblings each have a different father.  As a result, Sal has had several different male figures in and out of his life.  Sal’s biological father is not involved in his life regularly.

Sal witnessed domestic violence between his mom and each of the males in mom’s life in various forms (some were physical, some verbal, etc.), including by his biological father.  Sal does not feel safe at times and still wishes his father was a part of his life.  About 2 years ago, Sue left Sal’s biological father and started a new relationship with a man. ‘ Kyle’ is about 8-10 years younger than Sue, which is significant because Kyle is now just reaching an age where full brain development occurs (mid 20s).  Mom is unsure of Kyle’s commitment level to her and the children at times.  Kyle demonstrates fear and anxiety to commit to the children and mom long term.  Kyle talks to mom and the children about getting married to Sue, but will not propose or show signs/behaviors that indicate he truly wants a long term commitment.

Sue has not been able to be emotionally present/stable for Sal or his siblings since their birth due to her upbringing and past abuse but reports she does want a good relationship with Sal and his siblings.  Sue reports a lack of attachment with her parents growing up, sharing that she was abused by them physically, mentally and emotionally.  Her upbringing and past abuse interferes with Sue’s ability to parent positively, have a good relationship and attach positively to the children.

Sal engages in negative behavior to get attention, and verbalizes a longing to be close to his mom, as well as to be close to his biological father who is not involved in Sal’s life.  Sal acts out negatively at school as well.  Symptoms of his diagnoses of ADHD and PTSD interfere with positive relationships at school, at home, as well as with his ability to focus and do well at school academically.  Theraplay ® and EMDR interventions are both being utilized  to help Sal work through past trauma and improve his relationship with his mother so he can have a healthy level of attachment, as well as to enable him to be successful academically and socially at school.

Phase 2. Preparation (Resourcing):

Therapist starts out with utilization of a Theraplay ® intervention: Therapist directs Sal and his mom Sue to sit across from each other on the floor, in a “criss-cross applesauce” seating position.  Therapist can see Sal smiling to get special time with his mom Sue, sitting close to her.  Therapist says to Sal, “You look happy with your mom sitting close by you.  Where to you notice feeling happy in your body?”  Sal replies, “In my head and belly.”  Therapist applies BLS (about 6-8 slow, short sets).  Therapist asks Sal if he notices a pleasant feeling, he confirms yes (As with EMDR protocol and resourcing, we want to make sure the client is not having any disturbing feelings/sensations/experiences when resourcing is occurring).   Therapist continues to be attuned to what Sal is feeling throughout the session and strengthens all times where the child and the mother have positive interactions and/or are experiencing positive feelings with each other such as happiness or joy to prepare Sal for later EMDR phases.

As Sal, or any child, continues to play during Theraplay ® activities, therapist notes times the child is experiencing joy, is proud of himself, is able to master a game, able to work through difficult emotions (such as frustration, anger, joy) and “taps in” each of these feelings.  If possible (I prefer it this way), the parent is asked to “tap in” the positive traits and abilities of the child to strengthen them.   Homework can be given to the parent to help “tap in” any time the parent witnesses the child experience something positive (did a good job, was able to master something difficult, made a good choice, etc.)

To create the safe/calm/happy place, the therapist can ask the child to think about a place he feels calm and good inside to create a safe/calm place.  The child will describe (or can draw) the place.  The calm/safe place protocol should be followed to create it.

Phase 3 Assessment: Assess the target for EMDR processing y stimulating primary aspects of the memory:

Therapist assists the family to decide targets to reprocess in EMDR.  Standard EMDR protocol should be followed.  The Negative Cognition and Positive Cognition should be identified, as well as the SUD and VOC.  Emotions experienced should be listed and the therapist should find the location for disturbance in the body.

Sal had difficulty coming up with specific examples of times he has not made good choices, but was able to identify a time at the bus stop, at school, and at home where he did not make good choices.  Therapist will target each of these times in the Desensitization phase.

Phase 4: Desensitization: School, Home, and Bus stop were all reprocessed with the NC “I am not making good choices” and the PC “I am able to make good choices” for all three.  Sal reprocessed each target quickly and completed all 3 targets in the same session.  Therapist had Sal and Mom sit by each other.  Therapist asked Sal to bring up each target, the NC, to notice the location in the body, and coached mom on speed and number of sets to help Sal “tap out” the messed up feelings until his SUD reduced to zero.

Techniques from Joan Lovett’s book Small Wonders can be used to have the parent tell the story while the child processes the disturbing event/memory, or the child can tell the story when the parent is not present.  For example, the therapist can have Sal tell the story on the bus where he did not make a good decision while BLS is applied by the parent or the therapist–whether the parent or therapist does the tapping will depend on what best meets the needs of the child and parent.  The parent may not understand how to apply the tapping, or may not want to.  In addition, the child may or may not want the parent to do the tapping. [ In some cases, the child may tap on their own body during this phase or the therapist may use alternate tactile BLS  such as the ‘buzzies’ from Neurotek (www.neurotekcorp.com).]

Theraplay ® techniques can be used in between BLS sets to titrate the work.  If a child has difficulty reprocessing for a long period of time, 2-5 minutes of reprocessing can be done, followed by a Theraplay ® technique such as balloon volley or bubble popping.  These techniques can be used to soothe and ground the child.  Blowing bubbles and popping them can be a form of deep breathing when instructed to use the diaphragm, and the touch of the bubbles can assist the child with staying grounded and in the present while eliciting the sense of touch.  Other activities such as “feeding” assists the child on many levels with building the relationship and taking care of needs related to nurture.

Phase 5: Installation: Utilize EMDR protocol.  You can use play therapy techniques for this phase as well.

Phase 6:  Body Scan  Utilize EMDR protocol to clear body scan. Can use play therapy techniques like a magic wand [or Ana Gomez’ magnifying glass (www.anagomez.org)]  to scan the body to “find” the disturbance in the body.

Phase 7: Closure Follow EMDR protocol. Therapist can review container or calm place, or engage child in another resourcing technique at the end of the session.

Phase 8: Re-evaluation Follow EMDR protocol. Therapist can have the child draw how the situation feels or looks to them now.

References of Interest:

        Barnard, K.E., & Brazelton, T.B (Eds.) – Touch: The foundation of experience. Madison: International Universities Press Inc., 1990.

      Field, T. – 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., 1993

      Harlow – The nature of love. American Psychologist, 1958, 13, 673-685.

      J. Makela. – What Makes Theraplay Effective: Insights from Developmental Sciences. Originally published in the Theraplay Institute Newsletter Fall / Winter, 2003.

    The Theraplay Institute, Chicago. www.theraplay.org

         Books

       Bundy-Myrow, S. (2000) Group Theraplay for children with autism and Pervasive Developmental Disorder

        Munns, E. (2000) Theraplay: Innovations in Attachment – Enhancing Play Therapy

      Jernberg, Ann. (1979) Theraplay®       

      Jernberg, A & Booth, P. (1999) Theraplay: Helping Parents and Children Build Better Relationships though Attachment-Based Play

      Jernberg, A. & Jernberg, E. (1993) Family Theraplay for the family tyrant

Thank you, Shanon, for sharing your expertise in utilizing Theraplay ® and EMDR for healing of trauma with children and adolescents. For more information or to contact Shanon for EMDR consultation, her email is sclaussen@mahaskahealth.org, #641-672-3159.  Through Shanon’s leadership, Mahaska Health Partnership is cosponsoring, with the EMDR Institute,  Deb Wesselman’s workshop “Integrating Team Treatment  Attachment Trauma in Children: EMDR and Family Therapy” in Oskaloosa August 27-29, 2014.  See Training Events page of this blog for details and registration.

Bonnie the Blogger