What is Theraplay?
The Theraplay Institute was founded in 1971. Whilst the therapy has since been expanded into over 28 countries, much evidence for its effectiveness has appeared in the form of case studies – usually in-depth research of an individual person or group – and anecdotes. Although these are valuable in their own right, it is important that controlled, peer-reviewed studies are carried out in order to provide a strong evidence base for the efficacy of Theraplay. This review will discuss in detail the only two pieces of research of this type. Further studies outlined are discussed and these provide additional evidence for the effectiveness of Theraplay in particular circumstances.
Individual Theraplay.
This piece of research aimed to evaluate the effectiveness of Theraplay in the treatment of children who had been diagnosed with both language disorder and shyness/social anxiety.
As the research was the first controlled study into the area (at the time it began), it consisted of a two-stage process. The first stage was a pilot study. This followed
This followed a group of 22 children over a two year period, aged from two years and six months to six years and 11 months. The children in this initial study all lived in just one residential home and received treatment from a single, experienced clinician. They were assessed on a number of behavioural and psychiatric measures in addition to language measures. The control group consisted of 30 children who had not previously experienced language, behavioural or neurological problems. This small-scale pilot study was carried out so that the effects of Theraplay could be examined in order to assess whether a larger-scale study would be useful.
Statistical analyses indicated that the treatment group started with more difficulties than the control group. They scored significantly worse across all scales but one (low self-confidence) prior to the beginning of treatment. On comparison after their Theraplay there were no significant differences between the two groups on measures of overall shyness, over-conformity and mistrust. Therefore Theraplay had a positive impact on the treatment group. Although the group receiving treatment still had higher levels of attention deficit, poor cooperation, social withdrawal and language problems, these had begun to move in the right direction. Both groups of children were followed up after two years, and there were still significant improvements across all behaviours for those who had had Theraplay. At the point of this follow-up, a significant improvement was also recorded in the children’s level of expressive language disorder, which shows an improvement in the children’s ability to make themselves understood. Levels of shyness after Theraplay were equivalent to those of non-disordered control group children, and this was maintained over the two year period. Therefore, the group who received Theraplay ended up with reduced shyness levels – equivalent to the children who never experienced such problems to begin with.
As the pilot study was so positive, the second stage of the research was carried out using a larger sample of children receiving treatment from a number of medical centres and a greater number of therapists. 167 children were selected from a pool of 333 patients spanning nine medical centres in Germany and Austria. The ages of the children were similar to those in the pilot, ranging from two and a half years to six years and 11 months. The second stage of the research used the same measurement scales as the pilot study and a control group of children (who represented a baseline of “normal” functioning against which the treatment groups would be measured). Session structure was similar across the treatment centres and each lasted between 30 to 45 minutes. The average number of sessions required was 18.
Similarly to the pilot, children in the Theraplay group started with somewhat more behavioural, psychiatric and language problems than the control group and they had notably more problems with shyness and lack of self-confidence; therefore, the group receiving the Theraplay started off with more difficulties than the control group. Interestingly, after the Theraplay the treatment and control groups showed no significant difference on measures of shyness, attention deficit, poor cooperation, over-conforming and mistrust. This once again demonstrates that Theraplay has had a significant effect on the children in the treatment group, particularly on levels of shyness. Whilst the positive differences were statistically significant between groups for measures on social withdrawal, low self-confidence and both language disorder scales, there were also trends which indicate that all of the measured problems improved (though not all were statistically significant). This shows that the children who were given Theraplay demonstrated fewer problems after the therapy.
Comparisons of pre- and post-treatment scores showed significant improvements all measures, showing that the children had improved from the beginning of the study to the end. Although not all levels of behaviour and language disorder were reduced to “normal” levels, they were all reduced enough to demonstrate a significant change within the children.
Both studies showed similar levels of improvement, which suggests that Theraplay can be translated to different settings delivered by different therapists. Additionally, the results from the two year follow-up (within the pilot study) showed that positive results lasted over time and in some cases improved over that time.
The improvement in language skills was an interesting and unexpected outcome of Theraplay in this study. The improvements may be due to the language skills used and practiced during the social interaction of Theraplay, or alternatively they may be a side-effect of the decrease in social anxiety that Theraplay delivers.
Considering the significant improvements across a number of measures in both the pilot and the main study, this research offers supporting evidence for the efficacy of Theraplay, most notably in the reduction of shyness.
Group Theraplay
This study looked at the efficacy of group Theraplay in reducing internalising problems in young children living in China. The researchers defined internalising problems as behaviours that are turned inward towards the self and may often go unnoticed by others. Examples of these include depression, withdrawal and attention problems.
It was predicted that the internalising scores of children who received Theraplay would decrease more after Theraplay than a control group that not receive Theraplay. 46 children participated in the study, with 22 in the Theraplay group (average age 7.84) and 24 in the control group (average age 7.89). Mothers of the children also took part in the study. The study included children who were; at a “high risk” of having internalising problems, neither the mother nor the child were receiving any counselling or psychotherapy, and the child’s intellectual level was at least within the normal range. Group Theraplay sessions were conducted once per week by certified clinicians over eight weeks. each session lasted roughly 40 minutes.
Statistical analyses showed that there were significant differences in internalising problems between the Theraplay and control groups. This demonstrates a considerable decrease from pre- to post-treatment. These results strongly suggest that Theraplay was effective in reducing internalising problems. Post-treatment interviews revealed an 8.07 satisfaction rating from the mothers who partook (out of a maximum of ten), and 64% were reported to have tried out the Theraplay activities at home outside of the sessions. This provides further evidence for the success of Theraplay – not only considering the satisfaction of those who took part, but also that the techniques lend themselves to use outside of a therapy environment.
Impact of Theraplay on Attachment
An evaluation of the Marschak Interaction Method Rating System (MIMRS), using Marschak Interaction Method (MIM) ratings taken pre- and post-Theraplay. MIM is an integral part of Theraplay, as it is a measure used to observe and assess relationships in order to identify the format and content of Theraplay. Using 11 parent-child dyads, significantly positive results were found on two of the five dimensions of the MIMRS: i.e. increased tolerance of Nurture and Challenge in the child parent relationship. In addition to these results, changes on the Engagement and Separation-Reunion dimensions occurred in the right direction despite not being significant. There was, however, only a slight difference between pre- and post-test scores on the Structure dimension. Although the research did not directly measure the effectiveness of Theraplay, it indicated that the therapy does indeed affect measures related to attachment.
The Kinship Questionnaire, a caregiver-completed measure of attachment in children under six, was used in a pilot study of Theraplay. One certified Theraplay therapist delivered the intervention to ten families, many of whom were adoptive families, and measures on the Kinship Questionnaire were taken before and after therapy. Findings indicated that nine of the ten children showed statistically significant improvement following Theraplay. This research is promising in demonstrating the effects of Theraplay, particularly within those who may be adopted. However there are notable limitations: the study used a small sample size, and employed no control group.
Impact of Theraplay on those with Autism
Findings related to Theraplay and autism are minimal and have thus far been mixed. A study investigating Theraplay with eight children with pervasive developmental disorder (PDD) or mild-to-moderate autism (every week for a two-week period). The study found no significant differences in pre- and post-test autistic scale scores or scores on the Parenting Stress Index. However, there were significant improvements on dimensions of the MIM and parents’ and children’s level of adrenalin reduced, suggesting that stress levels may be reduced by Theraplay. As with the aforementioned study, however, the research used a small sample size of eight children, and there was no control group. Additionally, Theraplay was utilised for a period of two weeks only. The study was replicated with largely the same results: although it also found an improved relationship between parent and child i.e. increases in responsiveness, gaze fixation and positive guidance of the child by the parent. The same normalisation of adrenaline levels was found.
Impact of Theraplay on fostered children
The efficacy of Theraplay with foster children in particular has been investigated. The study involved 20 foster children in long-term foster placements. Findings indicated a decrease in aggressiveness following Theraplay administered by two therapists. As with much Theraplay research, however, the study did not utilise a control group.
Conclusions
The small collection of research discussed above provides convincing evidence that Theraplay can be effective in helping children. Fortunately, an increasing number of controlled experiments are now being carried out that concern different nationalities and clinical diagnoses.
The research suggests that Theraplay is a promising therapy for fostered and adopted children. More research into the area is necessary, however. The aforementioned controlled experiments should pave the way for further research of this type, which would utilise larger groups of therapists and children, in addition to investigating different age groups and clinical diagnoses.