Theraplay

1. Introduction

Version followed: Theraplay Institute (Evanston, IL) Level One Theraplay & MIM model as set out in Booth & Jernberg (2010), Theraplay, 3rd ed. (publisher sample: front matter, introduction and opening of Chapter 1) and the Institute clinic's published treatment protocol; CEBC programme profile for structure, training and fidelity. The Institute-endorsed Norris & Lender (2020) Theraplay – The Practitioner's Guide is the other current manual; its contents are not drawn on [uncertain]. UK delivery (Theraplay UK) uses a slightly different certification route (see 2).

Theraplay is a structured, adult-led, attachment-based play therapy for a child and parent(s) together. It was developed by clinical psychologist Ann Jernberg at the Chicago Head Start programme in the late 1960s; she founded the Theraplay Institute in 1971 [source: GoodTherapy (secondary)]. Its stated aims are to enhance attachment, increase self-regulation and promote trust and joyful engagement [source: Booth & Jernberg 2010, ch. 1 sample]. Sessions are fun, physical, personal and interactive and deliberately copy the healthy, playful exchanges between a parent and an infant [source: CEBC; Booth & Jernberg 2010, introduction].

Core idea of change: the child's difficulties are treated as relational and largely preverbal, so they are changed by giving the child many repeated, here-and-now experiences of an attuned, regulating, caring adult, delivered through touch, gaze, voice, rhythm and play rather than talk. The parent watches, is prepared, then joins and takes over these interactions, so the new relational experience is carried by the child's own caregiver at home [source: Booth & Jernberg 2010, introduction; Institute treatment protocol; Tuomi 2011]. The four dimensions of a healthy parent–child relationship (Structure, Engagement, Nurture, Challenge) are the organising grid for assessment and session planning [source: Institute treatment protocol; CEBC].

2. Framework

Format. Conjoint child + caregiver(s) sessions, weekly, 45–60 minutes (shorter for younger children), sometimes more than weekly in severe cases [source: CEBC]. A two-therapist model (one working with the child, one with the parent) is used where possible [source: GoodTherapy (secondary)] [uncertain: not confirmed in a primary source]. Ages 0–18; typical referrals include attachment difficulties, complex relational trauma, foster/adoptive placements, withdrawal, aggression, ADHD, autism spectrum and developmental delay [source: CEBC].

Length. Sources differ; name the one you follow: Institute clinic protocol, 19–28 sessions in total plus four follow-up sessions across the next year [source: Institute treatment protocol]; CEBC, a typical 26-session protocol over about six months, with an illustrative layout of sessions 1–20 [source: CEBC]; UK school/group version evaluated by Foundations, 8 weekly sessions [source: Foundations guidebook]. Foster, adoptive and trauma cases may need more, longer or more frequent sessions [source: Institute treatment protocol]; one secondary source cites 9–18 months for trauma [source: GoodTherapy] [uncertain].

Phases (Institute clinic protocol, with CEBC session numbers):

1. Intake interview (session 1). Goal: history and current concerns, preferably with both parents. Move on once the referral is understood and parents agree to the MIM [source: Institute treatment protocol; CEBC].
2. MIM assessment (sessions 2–3; one session per caregiver if two). Goal: a videotaped structured observation of each caregiver with the child, analysed by the therapist before the next meeting [source: Institute treatment protocol; CEBC].
3. Feedback / planning session (session 4, parents only). Goal: share observations, agree a treatment plan and the dimensions to target [source: CEBC; Enhanced 2014 MIM Analysis Form].
4. Parent demonstration session. Goal: the therapist does Theraplay activities with the parent so the parent knows what the child will experience [source: Institute treatment protocol]. Secondary sources add that the rationale is explained and parents are prepared for the child's likely reactions [source: GoodTherapy].
5. Theraplay treatment sessions (about sessions 5–20+). Goal: dimension-based play sessions; parents first observe while the therapist models, then gradually take over [source: GoodTherapy (secondary)]. After every three sessions, a parent-only session reviews progress and goals and plans home practice [source: Institute treatment protocol].
6. Follow-up. Four sessions over the following year [source: Institute treatment protocol]; repeat of the original measures and booster sessions as needed [source: GoodTherapy (secondary)].

Criteria for moving between phases. The sources do not give formal criteria [uncertain]. Booth & Jernberg ch. 5 has a section on guiding the child through the phases of treatment, but its content is not drawn on [uncertain]. Practical criteria [synthesis]: begin conjoint sessions only when the parent understands the rationale, can tolerate seeing their child's resistance, and is safe and not currently abusive (see 5); move the parent from observer to participant once they can follow your lead calmly for a whole activity; hand more leadership to the parent as their attunement improves in the parent-only reviews; plan ending when the presenting problems have eased, the parent can lead a session at home, and the child can accept structure and nurture from the parent without escalating.

Fit with other work. In foster and adoptive families Theraplay is often used early to build attachment, with later processing of past experience in another approach such as DDP; parent support (e.g. TBRI-informed therapeutic parenting) is a major add-on [source: Institute treatment protocol].

Certification and fidelity before using the name. US route: degree (master's/doctorate) in a mental health field and licensure for independent practice (associates may practise under supervision); Level One Theraplay & MIM training (4 days, about 25 contact hours); supervised practicum in three tiers (Foundational 8 hours, Intermediate 16 hours, full Certified Theraplay Practitioner 24 hours) [source: CEBC]. Fidelity: recorded sessions submitted to a Certified Theraplay Supervisor, self-reflection forms at each supervision, a standard session-evaluation form at three practicum levels, mid-term and final reflections reviewed by two supervisors [source: CEBC]. UK route: Level One (4 days) or Group training (2 days), then 40 sessions delivered, at least 8 supervised, with a certified supervisor recommended; no licence fee required [source: Foundations guidebook]. Theraplay is a registered trademark; check with the Institute or Theraplay UK what you may call your work before certification [uncertain: exact naming rules].

3. Guiding principles

Core concepts as listed in the third edition [source: Booth & Jernberg 2010, introduction], with practical meanings [synthesis unless tagged]:

• Interactive and relationship-based. The relationship is the intervention; choose activities that need two people, not toys a child can use alone.
• Direct and here-and-now. Work with what happens between you and the child this minute; leave out stories, histories and toys that pull attention away from the relationship [source: Tuomi 2011].
• Guided by the adult. You plan and lead the session and set its pace; the child is invited in, not asked to choose the agenda. The therapist keeps control of the session's progress while letting the child respond freely [source: Tuomi 2011].
• Responsive, attuned, empathic and reflective. Leading is never rigid: watch the child's arousal and anxiety moment to moment and change the plan to fit; close attention to arousal is linked to fewer out-of-control episodes [source: Booth & Jernberg 2010, preface].
• Aimed at the preverbal, social, emotional level. Talk little; communicate through gaze, touch, voice, rhythm and song; this applies even to older children and adolescents whose development was disrupted [source: Booth & Jernberg 2010; Tuomi 2011].
• Multisensory, including touch. Use caring, healthy touch (lotion, powder, back-drawing, holding hands) on purpose, matched to the child's tolerance, cultural norms and history (see 5).
• Playful. Fun and shared enjoyment are treated as the most important part of the work [source: Tuomi 2011]; keep things light, quick and surprising.
• Modelled on healthy parent–infant interaction. When unsure what to do, ask what an attuned parent would do with a much younger child [source: Booth & Jernberg 2010].
• Structure as a regulating presence. Structure means being a reliable, supportive presence that guides and regulates the child's experience and keeps them safe, not being controlling [source: Booth & Jernberg 2010, preface].
• Work at the child's real developmental and emotional age. Pick activities for the age the child acts in the relationship, not their age in years [source: Tuomi 2011; synthesis].
• Plan from the MIM. Weight sessions towards the dimensions the MIM showed were missing for this dyad [source: Enhanced 2014 MIM Analysis Form; Institute treatment protocol].
• Parents are co-therapists. Aim to give parents a more positive and empathic view of their child, make them competent co-therapists and teach realistic developmental expectations [source: CEBC]; prepare them by discussion, observation and role play, and help them come to terms with parts of their own history that get in the way of responding to the child [source: Booth & Jernberg 2010, ch. 1].
• Convey hope. An optimistic stance tells child and parents there is hope for their relationship [source: Booth & Jernberg 2010, ch. 1].
• Distinguish two kinds of resistance. Resistance that comes from reluctance to give up old patterns is handled differently from resistance driven by panic or fear; with a frightened child, reduce stimulation, keep them safe and stay close [source: Booth & Jernberg 2010, preface]. See 5.
• Therapist and parent are the most interesting thing in the room. Secondary sources describe the adults as the most enticing toys in the room [source: GoodTherapy (secondary)]; keep the room fairly bare and the props simple.

4. Intervention inventory

Scope note: the book chapters that hold the full session-sequence rules and the activity appendix (Booth & Jernberg 2010, ch. 4 and Appendix B; MIM task list, Appendix A; Norris & Lender 2020, activity lists) are not drawn on [uncertain]. The inventory below covers every procedure and activity in the sources; activity lists shared by schools and adoption agencies are tagged as secondary, and step-by-step detail beyond the sources is marked [synthesis]. Get the official activity lists through Level One training.

A. Assessment and parent work

4.1 Intake interview

• Purpose / when: First contact, preferably with both parents, to gather history and the presenting problem [source: Institute treatment protocol; CEBC].
• Steps [synthesis]: (1) Hear the parents' main worries and what a good outcome would look like. (2) Take developmental, attachment, placement and trauma history, including the parents' own experience of being parented. (3) Screen for safety: current abuse, domestic violence, caregiver substance dependence, severe dissociation in the child, touch-related trauma (see 5). (4) Explain Theraplay in plain terms: play-based, adult-led, physical, with the parent taking an active role. (5) Book the MIM.
• Example language (illustrative): "In this work you're not in the waiting room. You'll be in the room and, step by step, you'll be the one doing the playing with your child."
• Watch for: parents who expect the child to be "fixed" alone; signs that a caregiver is unsafe or too depleted to join yet.

4.2 Marschak Interaction Method (MIM)

• Purpose / when: Before treatment, and as a repeat measure at the end. A structured, videotaped observation of each caregiver with the child that shows how the pair handles structure, engagement, nurture and challenge [source: Institute treatment protocol; CEBC; Enhanced 2014 MIM Analysis Form].
• Steps: (1) Give the caregiver a set of simple instruction cards for tasks to do with the child; examples include having two toy animals play together [source: Institute treatment protocol], a short separation and reunion, and telling the child a story about their origins (both appear in the analysis form) [source: Enhanced 2014 MIM Analysis Form]. Use the Institute's recommended basic task list (Appendix A of Booth & Jernberg) rather than inventing tasks [uncertain]. (2) Video the session; you stay out of the interaction. (3) If there are two caregivers, observe each one [source: CEBC]. (4) Review the video before the feedback session [source: Institute treatment protocol].
• Analysis (paraphrased structure of the Institute's Enhanced 2014 form, not its items): for each dimension, write separate verbal and nonverbal observations for the child and each caregiver. Structure: does the child accept the parent's lead; does the parent's organising help the child regulate; does the parent drift into a peer role, abdicate, fail to set limits or turn into a rigid teacher. Engagement: can the parent draw the child in; empathy, mutual attunement, pitching stimulation to the child's tolerance, shared enjoyment. Nurture: physical comfort offered and accepted; whether the parent asks the child to care for them; response to the child's stress; the child's self-soothing; behaviour around separation and reunion; content and attunement of the origins story. Challenge: developmental fit of demands, the child's engagement, how mastery is made attractive, focus, frustration tolerance and how the parent helps with frustration. Then answer overall questions about what it would feel like to live with this child and with this parent, and record needs and the main target dimensions for parent and child [source: Enhanced 2014 MIM Analysis Form]. No numeric score.
• Watch for: your own bias towards the parent or child; cultural norms about touch, eye contact and hierarchy [source: GoodTherapy (secondary)]. Training in MIM administration and analysis is part of Level One.

4.3 Feedback and treatment-planning session (parents only)

• Purpose / when: After the MIM; share observations and agree the plan [source: Institute treatment protocol; CEBC].
• Steps: (1) Start with positive observations. (2) Give two or three key messages, not a list of faults. (3) Ask the parents what they noticed and wondered. (4) Show short chosen clips of the video. These four elements (positives, key messages, questions, clips to show) are the headings of the form's feedback section [source: Enhanced 2014 MIM Analysis Form]. (5) Agree the dimensions to target for each and the session plan [source: CEBC].
• Example language (illustrative): "Look at her face here, when you started the clapping game: she lights up when you take the lead in a playful way. That's something we can build on."
• Watch for: parental shame. If a parent becomes defensive, slow down and return to strengths [synthesis].

4.4 Parent demonstration and preparation

• Purpose / when: Before the child's first Theraplay session, the therapist does the activities with the parent so they know what to expect [source: Institute treatment protocol], and prepares parents through discussion, observation and role play [source: Booth & Jernberg 2010, ch. 1].
• Steps [synthesis on detail]: (1) Explain why the session is adult-led and physical. (2) Do two or three planned activities with the parent as the "child" (e.g. a lotion hand activity, a back-drawing activity), so they feel being cared for. (3) Prepare them for resistance: the child may refuse, laugh, run, or get silly, and this is expected. (4) Agree their role in the first sessions (watch, then join on cue). (5) Ask how it felt to be cared for; note any difficulty receiving care, since it may link to the parent's own history.
• Example language (illustrative): "Notice how it felt when I took care of your hands. That's the experience we want your son to have with you."
• Watch for: parents who could not accept nurture themselves; CEBC lists parents who were not well parented and need to experience being cared for as a target [source: CEBC].

4.5 Conjoint Theraplay session (core procedure)

• Purpose / when: The main treatment. The therapist plans and leads a session of short activities drawn from the four dimensions, weighted towards the dyad's needs [source: Institute treatment protocol; CEBC; Tuomi 2011].
• Steps: (1) Write a session plan before each session, choosing activities across the dimensions [source: Tuomi 2011]. The book's guidance on the order of a session (Booth & Jernberg ch. 4, "Planning the Sequence of a Theraplay Session") is not drawn on [uncertain]. A workable shape [synthesis]: a structured, engaging greeting at the door; an activity that notices the child's body (e.g. checking freckles or measuring); a few lively engagement and challenge games; a calming nurture activity including feeding a snack (feeding is a named nurture activity [source: GoodTherapy (secondary)]); a predictable goodbye and handover to the parent. (2) Lead each activity with brief, clear directions; keep transitions quick. (3) Adjust the plan in the moment to the child's and parent's reactions [source: Tuomi 2011]. (4) In early sessions the parent watches while you model; then bring them in and gradually hand over the play [source: GoodTherapy (secondary)]. (5) Keep the room fairly bare, and use simple props (lotion, cotton balls, balloons, bubbles, blanket, pillow, snacks) [synthesis from activity sources].
• Example language (illustrative): "Let's see what you brought with you today. Look, two strong arms, and a freckle right here on your nose!"
• Watch for: working signs: more eye contact, longer stretches of joint attention, the child seeking the parent, calmer recovery after excitement. Not working: rising arousal, frozen compliance, or the child taking over every activity. Then change dimension (often towards structure or nurture) [synthesis].

4.6 Parent-only review sessions

• Purpose / when: After every three Theraplay sessions: review progress, revisit goals, and plan how to support treatment at home [source: Institute treatment protocol]. In residential and foster work, adult-only meetings use session video and the therapist gives structured advice [source: Tuomi 2011].
• Steps [synthesis on detail]: (1) Watch short clips together. (2) Ask the parent what they saw in the child and in themselves. (3) Link moments to the dimensions. (4) Choose one or two home activities. (5) Explore what was hard for them (e.g. the child's rejection, the urge to scold).
• Watch for: the parent's own history coming up; the book frames helping parents come to terms with this as part of the work [source: Booth & Jernberg 2010, ch. 1].

4.7 Home practice

• Purpose / when: Once the parent can run activities in session. Parents practise at home, starting with activities the child enjoyed in therapy [source: CEBC].
• Steps [synthesis]: a short daily or several-times-weekly slot, 10–15 minutes, at a calm time; two or three known activities, with the parent leading; one nurture activity every time; stop while it is still going well.
• Watch for: parents using play as a reward or withdrawing it as punishment; using too much structure or correction [source: Holt International (secondary)].

4.8 Follow-up sessions

• Purpose / when: After the active phase; four sessions across the following year [source: Institute treatment protocol], with boosters as needed and repeated measures (e.g. a second MIM) [source: GoodTherapy (secondary)].
• Steps [synthesis]: have the parent lead a short session while you observe; review the home routine; troubleshoot new developmental stages or stresses.

B. Activities by dimension

Key concepts per dimension are from the Institute's Level One framework as reported by CEBC; target problems are from a secondary summary [source: CEBC; GoodTherapy]. Named activities come from two secondary lists: a parent article by Holt International (activities said to be mostly from a Theraplay activities flip book) and a council/school group list (no author given). Which dimension each activity belongs to is the reporting source's choice or my inference, marked so [uncertain]. Do every activity with the adult leading, keep it short (a few minutes), and finish before the child tires of it [synthesis].

4.9 Structure activities

• Purpose / when: Safety, organisation and regulation [source: CEBC]: the adult sets clear rules and limits; most useful for impulsive, hyperactive, controlling or dysregulated children [source: GoodTherapy (secondary)].
• Activities (how to do them):
  • Red light, green light / follow the leader – the adult calls go and stop and the child moves and freezes; later, take turns as the caller [source: Holt International].
  • Start/stop band or traffic lights – play instruments or move only on the signal, stop on the other signal [source: Shropshire list].
  • Bubble pop on cue – the adult blows bubbles and the child pops them with a named body part only when told; the list notes it trains self-control and turn-taking [source: Shropshire list].
  • Measuring – measure the child's smile, nose, ears or arms with a tape and comment warmly on each [source: Shropshire list]; this also notices the child's body.
  • Freeze games (e.g. jump then freeze like statues on a call) [source: Shropshire list].
• Steps [synthesis]: give one short, clear direction; demonstrate; use a countdown ("one, two, three, go!") so the child waits for your signal; praise the waiting; slow the pace if arousal rises.
• Example language (illustrative): "When I say 'pop', you pop it with your elbow. Ready... wait for it... pop!"
• Watch for: working: the child waits for the signal and seems relieved by the predictability. Too much: rigid, joyless compliance, so add engagement.

4.10 Engagement activities

• Purpose / when: Connection, attunement, acceptance and widening positive feeling [source: CEBC]; eye contact and synchrony; useful for withdrawn or avoidant children and those on the autism spectrum [source: GoodTherapy (secondary)].
• Activities:
  • Bubbles – blow bubbles and pop them together, more or less structured, for eye contact and laughter [source: Holt International].
  • Sticker match – put matching stickers on each other, then touch the matching spots together [source: Holt International].
  • Thumb wrestling / rock, paper, scissors – brief, playful contact games [source: Holt International].
  • Cotton ball blow / cotton ball hockey – face to face, blow a cotton ball back and forth between you [source: Holt International; Shropshire list].
  • Cotton-ball nose blow – stick a cotton ball to the child's nose with a dab of lotion and blow it off [source: Shropshire list].
  • Magnifying-glass "detective" – look at each other's features through a magnifier; the list says it builds eye contact [source: Shropshire list].
  • Pass the face – pass a silly face back and forth for the other to copy [source: Shropshire list].
• Steps [synthesis]: get to eye level; start where the child can tolerate (side-by-side if face-to-face is too much); show delight; match and then gently stretch the child's rhythm and volume.
• Example language (illustrative): "I'm going to blow this cotton ball to you. Can you blow it right back to me? Whoa, what a strong blow!"
• Watch for: working: shared laughter, the child looking back for you. Too much: giddiness or overexcitement, so slow down and move to a calmer nurture activity.

4.11 Nurture activities

• Purpose / when: Regulation, a secure base and a sense of being worth caring for [source: CEBC]; gentle touch, feeding and calming interactions, useful for anxious, aggressive, traumatised or neglected children [source: GoodTherapy (secondary)].
• Activities:
  • Weather report on the back – draw pictures or letters, or act out sun, rain and wind with fingertips on the child's back; it can calm a child [source: Holt International].
  • Feeding – feed the child a small snack, a named nurture activity [source: GoodTherapy (secondary)]; steps below are synthesis.
  • Lotion or powder hand care – for example, powder a hand and press a handprint on dark paper [source: Shropshire list]; lotion is used in the nose-blow activity above.
  • Manicures and pedicures (older children) – take turns; healthy touch that feels less intrusive for teens [source: Holt International].
  • Blanket swing (two adults) and hot-dog wrap in a blanket [source: Shropshire list].
  • Songs – predictable songs about the child, which travel across carers and placements [source: Tuomi 2011].
• Feeding steps [synthesis]: check allergies and family food rules first; use small, safe pieces; hold the snack, make eye contact, and place it in the child's mouth or let them take it from your fingers; go slowly and notice their pleasure; let the parent take over feeding as soon as possible.
• Example language (illustrative): "I've got a snack for you. Let me give you a piece... and another, when you're ready."
• Watch for: working: the child relaxes, slows, leans in, lets themselves be cared for. Not working: freezing, flinching, giggling to escape, or regressing too far. Then move to less intimate nurture (e.g. side-by-side, through clothing or a blanket) and see 5 on touch.

4.12 Challenge activities

• Purpose / when: Competence, confidence and support for exploration [source: CEBC]; developmentally fitting tasks the child can achieve with help; useful for low self-esteem, anxiety about trying, developmental delays [source: GoodTherapy (secondary)].
• Activities:
  • Balloon games – keep a balloon in the air, only with a named body part, or carry it between you without hands [source: Holt International; Shropshire list].
  • Newspaper punch – hold a sheet tight while the child punches through on a count [source: Shropshire list].
  • Row boats / partner pull-ups – sit facing, hold hands and pull each other up or rock back and forth [source: Shropshire list].
  • Beanbag balance – balance a beanbag on a body part, then do it harder [source: Shropshire list].
  • Cotton-ball or feather blow onto a target [source: Shropshire list].
• Steps [synthesis]: pick a task just above what the child can manage alone; make it cooperative rather than competitive; ensure success, adjusting difficulty quietly; celebrate effort and success together.
• Example language (illustrative): "I'll hold the paper really tight. On three, punch right through. One, two, three!"
• Watch for: working: pride, persisting after a miss. Too hard: frustration or giving up, so make it easier at once.

C. Adaptations named in the sources

4.13 Older children and adolescents

• Purpose / when: Theraplay is adapted for older children and teens [source: Booth & Jernberg 2010 TOC, ch. 11; GoodTherapy].
• Steps: keep the preverbal focus even with teens whose development was disrupted [source: Tuomi 2011]; use age-acceptable versions: hand or nail care, temporary tattoos chosen for each other, guessing games (a phone held to the forehead with others giving clues), take-turns building a silly face, story or drawing [source: Holt International]; give the teen some choices and turns as leader [source: Holt International].
• Example language (illustrative): "You pick which tattoo goes on my arm, then I get to choose yours."
• Watch for: embarrassment; keep it light and private, and do not push nurture a teen experiences as babyish [synthesis].

4.14 Group Theraplay and Sunshine Circles

• Purpose / when: Groups of 4–10 children; Sunshine Circles is a teacher-led classroom version [source: CEBC]; a UK school version for 7–9 year olds runs 8 weekly sessions of under an hour with parents [source: Foundations guidebook]. Requires Group training [source: Foundations guidebook].
• Steps: a leader-led circle with cooperative games such as passing a message or silly face, hand-holding movement games, bubble pop, newspaper punch, cotton-ball blows and group blanket games [source: Shropshire list]; a hug-based game note in the list says it is "more about the hug than the right guess" [source: Shropshire list].
• Watch for: in groups, check every child's consent to touch and give non-touch alternatives [synthesis].

4.15 Residential care and foster transitions

• Purpose / when: Children in residential care moving to foster care [source: Tuomi 2011].
• Steps: weekly 20–30 minute sessions, about 10–20 across a 6–12 month stay [source: Tuomi 2011]; phase 1: child, primary nurse and therapist; phase 2: 2–4 meetings where the new foster carer joins after adult-only meetings; phase 3: 2–4 meetings with the new carers, sometimes at the foster home; a second carer may watch on video; use songs that move with the child between carers [source: Tuomi 2011]. In residential settings, house parents or other caregivers may join sessions [source: CEBC].
• Watch for: the child becoming selective with staff, jealousy among staff, regression when the key worker is away [source: Tuomi 2011].

4.16 Foster/adoptive families and integration with other work

• Steps: expect more, longer or more frequent sessions; strengthen attachment with Theraplay first, then process past experience with another approach such as DDP; add therapeutic-parenting education (e.g. TBRI); refer on for services you cannot provide [source: Institute treatment protocol]. Children with severe dissociation may need stabilisation first [source: GoodTherapy (secondary)].

5. Handling problems

The book's sections on resistance and countertransference (Booth & Jernberg ch. 5) are not drawn on [uncertain]; only the preface's reframing of resistance is drawn on. Everything else here is my synthesis unless tagged.

• Fearful resistance (panic, freezing, fight or flight). Treat it as fear, not defiance. Reduce stimulation, make sure the child is safe, and stay close enough to remain sensitively connected [source: Booth & Jernberg 2010, preface]. In practice [synthesis]: lower your voice, slow down, offer distance and a simple structure or nurture activity (e.g. a back-drawing activity through clothing), and name the feeling briefly: "That felt like too much. We'll go slower." (illustrative).
• Resistance from old patterns (controlling, testing, refusing, taking over). The preface distinguishes this from fear [source: Booth & Jernberg 2010, preface]. [synthesis]: stay warm and in charge; turn the child's move into the game ("You're running! Let's see how fast you can run back to this cushion on three"); give choices inside your structure; do not argue or lecture. Expect resistance to rise early on and prepare parents for it in 4.4.
• Overexcitement / dysregulation. Close attention to arousal reduces out-of-control episodes [source: Booth & Jernberg 2010, preface]. [synthesis]: move from engagement or challenge to a structured or nurturing activity; slow your rhythm; have the parent hold or sit close if the child accepts it; shorten the session.
• Touch problems. [synthesis]: Theraplay uses touch on purpose, so get informed consent from the caregiver and assent from the child; ask about sexual abuse and other touch trauma before choosing nurture activities; start at the child's comfort level [source: GoodTherapy (secondary)] and with less intimate touch (hands, back, arms, through clothing or blanket); never touch private areas; never use holding or restraint to overcome refusal; video sessions and keep the caregiver present. Respect cultural norms on touch, eye contact and family hierarchy [source: GoodTherapy (secondary)]. Coercive "holding" or "rage reduction" attachment therapies are a different, discredited practice; keep Theraplay clearly distinct from them [synthesis].
• Parent cannot join in (shame, depression, own history). CEBC names parents who were not well parented and need to be cared for as a target [source: CEBC]; help them come to terms with what gets in the way [source: Booth & Jernberg 2010, ch. 1]. [synthesis]: give the parent nurture in the demonstration and review sessions; give them small, sure roles first (holding the lotion, counting); refer for their own therapy if needed.
• Parent critical or over-structuring. Parents often lean on structure and correction [source: Holt International (secondary)]. [synthesis]: in review sessions, point to video moments when the child responded to playfulness; give them engagement and nurture tasks for home; model rather than correct in front of the child.
• Non-adherence at home. [synthesis]: shrink the routine to one short activity a day; link it to an existing routine (bedtime, after school); have the parent rehearse it in session first; review in the parent-only sessions every three sessions.
• Stuck (no change after several sessions). [synthesis]: repeat or revisit the MIM findings; check the dimension balance (often too much challenge or too little structure); check the parent's role (still observing only?); look for unaddressed trauma, dissociation, sensory issues or a mismatch between developmental and age level; consider adding DDP or other trauma work [source for DDP option: Institute treatment protocol]; take it to a Certified Theraplay Supervisor [source: CEBC].
• Ruptures. [synthesis]: if an activity hurt, startled or shamed the child, stop, notice it aloud, offer care (a nurture activity), and carry on; this repair is itself a corrective experience. With parents, a rupture after MIM feedback is repaired by going back to strengths.
• Contraindications and safety. Not recommended with abusive caregivers unless protection is in place, or with caregivers with substance dependence; severely dissociative children may need stabilisation first; significant intellectual disability needs adapted approaches [source: GoodTherapy (secondary)]. [synthesis]: if you suspect abuse or neglect, follow your local child protection procedures; Theraplay does not replace a safety plan.
• Allergies, food and sensory issues. [synthesis]: check allergies, choking risk and family food rules before feeding; for sensory-sensitive children, introduce lotion, powder and textures one at a time [gradual sensory introduction: GoodTherapy (secondary)].
• Multiple carers or placement moves. Use predictable songs and activities that can move between carers, bring the new carer in through video watching and adult meetings, and plan for regression when a key adult is away [source: Tuomi 2011].

Sources

Sources:

• Treatment Protocol – The Theraplay Institute
• Level One Theraplay & MIM – CEBC programme profile
• Enhanced 2014 MIM Analysis Form – Theraplay Institute
• Booth & Jernberg, Theraplay 3rd ed., publisher sample (front matter and introduction)
• Booth & Jernberg, Theraplay 3rd ed., publisher sample (introduction and ch. 1 opening)
• Module 1 Learning Objectives – Theraplay Institute
• Theraplay – Foundations guidebook
• Tuomi, K. (2011). Supporting interaction in the context of residential child care. Scottish Journal of Residential Child Care 10(1)
• Theraplay activity list – Shropshire Council (secondary, no author given)
• How you can play, connect and beat the winter blues – Holt International (secondary)
• Theraplay – GoodTherapy (secondary)
• Theraplay – The Practitioner's Guide – JKP Digital Hub (description only)

Books cited:

• Booth, P. B., & Jernberg, A. M. (2010). Theraplay: Helping Parents and Children Build Better Relationships Through Attachment-Based Play (3rd ed.). Jossey-Bass/Wiley.
• Norris, V., & Lender, D. (2020). Theraplay – The Practitioner's Guide. Jessica Kingsley. (Not drawn on beyond the description.)
• Booth, P., Lindaman, S., & Peacock, F. (2025). Theraplay: An attachment theory-based treatment for relational and developmental healing. In Crenshaw, Stewart & Ray (Eds.), Play Therapy: Theory, Research, and Practice. Guilford. (Cited by CEBC; not drawn on.)
• Hong, R., & Coleman, A. R. (Eds.) (2023). Theraplay: Innovations and Integration. Jessica Kingsley. (Cited by CEBC; not drawn on.)