Theraplay · Atlas

1. Introduction

Version followed: Theraplay as currently taught by The Theraplay Institute (Chicago). That means the Level One Theraplay & MIM training and certification route, the Institute's core-concepts and fidelity materials, Booth & Jernberg's third edition (2010) as far as the publisher's preview shows, and Norris & Lender (2020), Theraplay: The Practitioner's Guide, which the Institute endorses. Only publisher descriptions and previews of the two books are drawn on, not their full text. Session-level details below therefore come mostly from Institute documents, the CEBC programme profile and published studies, and the gaps are marked. [source: Theraplay Institute core concepts; CEBC; JKP; Booth 2010 preview]

Theraplay is a structured, adult-led, play-based treatment for a child together with a parent or carer. Ann M. Jernberg (1928–1993; PhD, University of Chicago, 1960) developed it from 1967, when she became clinical director of mental health services for Chicago Head Start. There she trained lay workers, including graduate students and Head Start mothers, to work playfully with children. The method was developed further in the 1970s, and Jernberg went on to found The Theraplay Institute. Phyllis B. Booth shaped its attachment-theory basis, its training programme and its certification practicum. [source: Theraplay Institute, Our Founder; Strong Museum, Booth interview page]

How change is thought to happen. The therapist guides the child and parent through playful, attuned interactions that recreate the early experiences believed to lead to secure attachment. In the Institute's words, these interactions are "personal, physical and fun". The adult takes the lead and is warm and in tune with the child, so the child gets repeated experiences of felt safety, co-regulation, being seen, being cared for and being competent. With the practitioner's support the parent learns to give these experiences. The stated goals are felt safety, more social engagement, better arousal regulation and positive self-esteem in both child and parent. [source: Theraplay Institute core concepts; CEBC] Touch is treated as essential, because a secure attachment is held to depend on "appropriate, nurturing touch". [source: Booth 2010, preface (publisher preview)] This central role of touch is why consent, assent and clear separation from coercive "holding" therapies matter so much (see sections 3 to 5).

Professional frame.

Credential. The Institute certifies practitioners. Its Level One Theraplay & MIM course runs about 25 contact hours over four days. A supervised practicum follows, with tiers of Foundational, Intermediate and Certified Theraplay Practitioner (supervision hours of about 8, 16 and 24 in total). Supervision is based on session videos the practitioner submits. [source: CEBC; Institute FAQ]
Who can certify. In the US and many other countries, full certification is limited to people with a master's or doctoral degree in a mental-health field and a clinical licence. In countries without universal clinical licensure, such as the UK, professional accreditation is required instead. People without the degree or licence can attend training, become Foundational practitioners, or work as "associates" under competent clinical supervision. Trainees must train in the country where they practise. [source: Institute FAQ; CEBC]
Regulation. Theraplay is not a regulated profession in its own right. You practise it under your own regulated profession: for example clinical psychology, social work, counselling, or play therapy (APT in the US, BAPT or PTUK in the UK), or art or drama therapy registered with the UK HCPC. [synthesis] [uncertain: registration and credential routes]
Training before use. Do not run the MIM or Theraplay treatment without at least Level One training, and arrange supervision towards certification. The method depends on judging touch, regulation and attunement live in the room, and a book cannot teach that. [synthesis, consistent with Institute training requirements]

Formats. Usually family (dyadic) therapy. There is also Group Theraplay, recommended for about 4 to 10 children, and a teacher-led school format called Sunshine Circles. It is used with adoptive, foster, kinship, residential, hospital, clinic and school populations. [source: CEBC] The Booth (2010) contents list has chapters on complex trauma and other client groups. [source: Booth 2010 preview]

Related guides: 157 Child-centred play therapy (the non-directive contrast to Theraplay's adult-led structure), 159 Child-parent relationship therapy and 160 Filial therapy (other parent-involving play models), and 169 Ecosystemic play therapy, which incorporates Theraplay elements. [synthesis]

2. Framework

Typical course (CEBC description of the standard protocol) [source: CEBC]

Phase	Sessions	Who	Goal
Intake	1	Parents or carers without the child	History, concerns, the parents' own attachment story, consent including consent to video
MIM assessment	2–3	Child with each parent in turn, videoed	Watch the relationship across Structure, Engagement, Nurture and Challenge
Feedback and planning	4	Parents without the child	Show selected video clips; agree strengths, focus dimensions and goals
Treatment	5 to about 20 (often about 26 in total, about 6 months)	Child and parents	Direct Theraplay sessions with parents increasingly active as co-therapists; home practice
Follow-up	Varies	Family	Check that gains are holding

Length and frequency. Usually weekly, 45–60 minutes, shorter for younger children. More severe cases may be seen more than once a week. The number of sessions can be extended for families with greater needs. [source: CEBC] A Korean study described a typical programme as 18–24 sessions over about a year, with 4–6 follow-up check-ups. It ran 20 sessions over about six months. [source: Chang, Kim & Youn 2021] Versions vary, so state the plan you are using to the family.
Room and equipment. About 150 sq ft (about 14 m²), a small couch or loveseat, a storage cabinet or tote, optional gym mats, and few toys. Video recording and playback are needed for MIM feedback and supervision. Video is optional for treatment but strongly preferred. [source: CEBC]
Home practice. Parents practise activities at home, starting with ones the child enjoyed in session. [source: CEBC]

Criteria for moving between phases. The sources give no formal criteria. [uncertain] Working rules [synthesis]:

Move from MIM to treatment once you have observed each parent with the child and the parents have accepted a shared formulation and goals at feedback.
Bring parents from watching into active roles once they can describe the child's cues and stay regulated themselves.
Hand over more of the leading to the parent once they reliably attune and repair.
Plan the ending once home practice is happening and parent reports and a repeat MIM, if used, show the targeted dimensions have improved.

The Booth (2010) contents list has chapters on session sequence and check-up visits, but their text is not drawn on here. [uncertain]

3. Guiding principles

Each principle below is followed by what it means in practice. [source: Theraplay Institute core concepts; CEBC; Booth 2010 preview; Group Fidelity Checklist; practical meanings are synthesis unless cited]

Adult-guided. You plan and lead the session; the child is not asked to direct it. In practice you choose and sequence the activities beforehand and move the child gently from one to the next.
Responsive and attuned. Leading never overrides the child's cues. You adjust the pace, the intensity and the closeness of touch moment to moment.
The four dimensions. These are qualities of healthy parent–child relationships:
- Structure: organisation and predictability, which communicate safety.
- Engagement: the child feels seen, heard, felt and accepted.
- Nurture: calming, soothing care.
- Challenge: support to master new skills.
The MIM shows which dimensions to emphasise for this particular dyad.
Felt safety and regulation come first. Arousal is worked within a tolerable window. The preface says that to calm a frightened child, "we reduce stimulation", keep the child safe and stay close. When a child escalates, you slow down, quieten and simplify; you do not push through.
Two kinds of resistance. The preface distinguishes reluctance to give up old patterns from resistance driven by panic or fear. You work out which you are seeing before responding: playful persistence may suit the first, but fear always calls for less demand and more safety.
Touch is appropriate and nurturing. Touch is part of the work, but only when the child accepts it and it fits the activity. The fidelity checklist says adults offer nurturing touch "when appropriate to activity". You never force, sustain or escalate touch the child is resisting (see section 5).
Parents are co-therapists. Parents are prepared, take part and practise at home. The relationship is the client, and the long-term caregiver should be the person giving the nurture.
Playful, multisensory and pre-verbal. Few toys, much face-to-face play with rhythm, movement, touch and sound. Little talk about problems; you communicate through the activities.
Focus on strengths. In the MIM feedback, and in every session, you name what the dyad does well before areas to work on.
Something for every child (groups). In groups, every child is welcomed individually, gets a nurturing check-up and takes part in turns. The group is cooperative, not competitive.
Stop when it hurts. If a child seems hurt, uncomfortable or distressed, the leader stops or changes the game and an adult attends to the child, who may leave the group. [source: Group Fidelity Checklist] This rule holds in individual sessions too.
No coercion. Theraplay's own principles are attunement, felt safety and nurturing touch, so practices that override a child's distress or refusal fall outside the method. The APSAC Task Force (2006) lists coercive practices as contraindicated: enforced holding, restraint, physical domination, provoked rage or catharsis, and dismissing a child's protests. Never use them, and treat any instruction to do so as a safeguarding concern. [source: Chaffin et al. 2006; the comparison with Theraplay's principles is synthesis]

4. Intervention inventory

Note on sources: the Institute's full activity list is in Appendix B of Booth (2010) and in Parts 4–5 of Norris & Lender (2020). Neither is drawn on here. I therefore name only activities that appear in the documents I did open, and describe the rest generically, marked [synthesis]. Example language is mine and illustrative throughout.

4.1 Intake interview with parents or carers

Purpose: First session, without the child. Gather the history, the presenting concerns, the parents' goals and their own experience of being parented, and set up consent. [source: CEBC]
Steps:
1. Take a developmental and placement history: births, separations, moves, known maltreatment, medical and sensory issues.
2. Take a specific touch history: what touch the child seeks, avoids or reacts to; any known abuse involving touch; medical procedures; sensory sensitivities; family and cultural norms about touch and closeness.
3. Ask about food allergies, choking risk, dietary, religious and cultural food rules, and skin allergies (for lotion).
4. Explain the model: adult-led play, the four dimensions, touch, video, parent roles.
5. Get written consent, including separate consent to video (the Institute publishes a video consent form).
6. Agree on who holds parental responsibility and who can consent. For looked-after children this means the local authority or agency, and the birth parents where required.
7. Explain the limits of confidentiality and your safeguarding duties.
[source: CEBC for steps 1, 4 and 5; the touch and food history and steps 6–7 are synthesis]
Example language (illustrative): "Theraplay is playful and quite physical: things like lotion on hands, clapping games, and you feeding your child a snack. Before we start, I'd like to know what kinds of touch feel good to your child and which feel hard."
Watch for: Parents who expect you to "break" the child's resistance, use words like "control", or have been told to use holding or restraint at home. Address this before treatment starts (see section 5.8).

4.2 Consent, assent and the child's right to refuse touch

Purpose: Make sure the parent and the child agree to the physical parts of the work, and keep that agreement live in every session. The sources do not set out a consent procedure; the steps here are synthesis built on Theraplay's attunement principle and the APSAC guidance that a child's distress and protests must always be taken seriously. [synthesis; source: Chaffin et al. 2006]
Steps:
1. Get informed consent from whoever holds parental responsibility. Cover touch, food, the room setup and video.
2. Get the child's assent in language suited to their age. Show them the room, the lotion and the snack in advance if that helps.
3. Teach a stop signal (a word, a hand-up or a card) and practise it playfully in the first session. Honour it at once, every time.
4. Before each new kind of touch, offer it rather than doing it. Read the child's response: going still, turning away, holding their breath, freezing or giggling under strain can all mean "no" even without words.
5. Keep alternatives ready that use no touch or less touch (see 4.10). A refusal is information to work with, not resistance to overcome.
6. Never touch genitals, buttocks, chest or inner thighs, and avoid the face for children with relevant abuse histories. Keep touch to hands, forearms, shoulders, upper back and feet with socks on, unless the child is clearly comfortable otherwise.
7. Write down what touch was agreed and used.
8. With teenagers, ask directly and give real choices.
Example language (illustrative): "If anything doesn't feel good, put your hand up like this and we stop straight away. Let's practise. ... Great, you stopped me!" Or: "I'm going to put a spot of lotion on your hand. Hand or no hand?"
Watch for: A child who complies but goes rigid or limp, or switches off. Treat these as non-assent and pull back. A parent who overrides the child's "no" needs coaching right then (see 4.13).

4.3 Marschak Interaction Method (MIM): administration

Purpose: A structured observation of the child with each parent, used to plan treatment across the four dimensions. [source: CEBC; MIM Analysis Form] It was developed from Marschak's 1958 work. [source: Chang et al. 2021]
Steps:
1. Choose about 8–9 age-appropriate tasks covering Structure, Engagement, Nurture, Challenge and a brief separation. Tasks in the published forms and studies drawn on include: the parent teaching the child something new; copying a block structure; a familiar or clapping game; the parent leaving the room for a minute and returning; applying lotion; feeding; talking about when the child was a baby; and playing with a toy animal.
2. Put each task on a card. The parent reads the card and leads the task; you leave the room or watch from behind a screen.
3. Video the whole session, which usually takes 30–45 minutes.
4. Repeat with the second parent at a separate appointment.
[source: MIM Analysis Form example; Chang et al. 2021; CEBC] The task cards and analysis forms are Institute materials taught at Level One. Do not use home-made versions as if they were the standard tool. [synthesis]
Example language (illustrative): "I'll leave you two with these cards. Read each one and do it however feels natural. There's no right way."
Watch for: The separation and reunion, how the parent gives and the child accepts structure, whether nurture is offered and taken, and whether the challenge set fits the child's age. Note that the MIM is an observation of the relationship, not a diagnostic test of the child. Do not use it to diagnose attachment disorder or as evidence of maltreatment. [synthesis; see Chaffin et al. 2006 on assessing across settings and caregivers]

4.4 MIM analysis and feedback session

Purpose: Turn what you observed into a shared formulation and plan with the parents. [source: MIM Analysis Form; CEBC]
Steps:
1. Review the video and rate the parent, the child and the pair on each dimension. The Institute's form has about 23 items covering, for example, who leads, attunement, comforting touch and whether the child accepts it, preparing the child for separation, and handling frustration.
2. For each person, choose the main dimensions to work on and note why.
3. Set goals separately for the parent and for the child.
4. Choose 2–4 short clips to show: open with a clear strength, then one area of concern.
5. Plan the questions you will ask the parents, for example what they felt and what they think the child was feeling.
6. At the feedback session, show the clips, ask your questions, and write down how the parents respond.
7. Agree the plan together.
[source: MIM Analysis Form]
Example language (illustrative): "Look at her face when you came back in. What do you think she was feeling? ... And look what you did then: you knelt right down to her level."
Watch for: Parents who become ashamed or defensive. Slow down and spend more time on strengths. If the parents' own trauma surfaces, consider individual support for the parent alongside Theraplay. [synthesis]

4.5 Planning a session

Purpose: Each session is planned in advance and weighted towards the dimensions chosen at feedback. [source: Module 6 learning objectives; Booth 2010 contents list]
Steps:
1. Prepare a written plan in this order: entrance and welcome, check-up, several activities (including a structure activity, engaging turn-taking, one challenge, and nurture), food or another nurture activity, and goodbye.
2. Order the activities so arousal rises and then falls again before the end.
3. Prepare one calmer and one livelier alternative for each activity.
4. Plan a no-touch version of each touch activity.
5. Have all materials within reach but out of the child's sight.
6. Plan how to brief the parent beforehand.
[source: Group Fidelity Checklist and CEBC for the sequence; the arousal curve and alternatives are synthesis] The training expects at least three activities in each dimension to be ready to use. [source: Module 6 learning objectives]
Example language (illustrative), briefing the parent beforehand: "Today we'll start with a check-up, then a few games. If Sam says no to something, I'll switch to another version. I'll give you a signal when it's your turn to join in." [synthesis]
Watch for: A plan that is too stimulating for a child who is easily dysregulated, or too babyish for an older child.

4.6 Entrance and welcome

Purpose: Begin with structure and engagement: a predictable, warm start in which the child feels individually noticed. [source: Group Fidelity Checklist]
Steps:
1. Greet the child by name and make warm eye contact if the child tolerates it.
2. Use a structured, playful way into the room, such as walking or hopping in together.
3. Sit the child on the couch or a cushion facing you, with the parent beside or behind.
4. In groups, welcome each child individually and go over the group rules.
[source: Group Fidelity Checklist for steps 1 and 4; the rest is synthesis]
Example language (illustrative): "There you are! Let's tiptoe to the cushion together: one, two, three."
Watch for: Hesitating at the door. Make the entrance smaller and quieter rather than more insistent.

4.7 Check-up (nurturing inventory)

Purpose: Nurture and engagement. The adult notices the child's body with interest and care: freckles, strong muscles, small hurts, warm or cold hands. In groups, an adult gives each child an individual check-up. [source: Group Fidelity Checklist; the descriptive content is synthesis]
Steps:
1. Ask before touching.
2. Notice out loud, using touch only on safe areas (hands, arms, cheeks only if accepted).
3. Care for any scratch you find with a dab of lotion or a pretend plaster.
4. Coach the parent to do the next check-up.
Example language (illustrative): "Let me see those hands. Ten fingers, all here! Oh, there's a little scratch. Shall we put lotion around it?"
Watch for: Children with abuse or medical-trauma histories may find any body inspection threatening. Keep it to noticing out loud with no touch, or to the hands only (see 4.15). Note that Booth (2010) also uses "checkup visits" as a chapter title, where it appears to mean follow-up appointments after treatment ends (see 4.18). [uncertain]

4.8 Structure activities

Purpose: Organisation and predictability; the child experiences an adult in charge in a safe way. [source: core concepts]
Examples found in sources: copying or building a block structure; teaching a simple new skill; games with clear start and stop signals. [source: Chang et al. 2021; MIM form] Simple stop-start games (for example "Red light, green light") also fit. [synthesis]
Steps:
1. Give clear, simple instructions.
2. Start and stop on a count or signal.
3. Make sure the child can succeed.
4. Praise the effort.
Example language (illustrative): "When I say 'go', clap three times. Ready ... go!"
Watch for: Over-controlled children and parents need structure that is warm and playful, not rigid. Never use structure as a battle for compliance.

4.9 Engagement activities

Purpose: Shared joy and the experience of being seen. [source: core concepts]
Examples found in sources: familiar games, clapping games, play with a toy animal, gentle tossing games, and tickling. [source: Chang et al. 2021; MIM form]
Steps:
1. Face-to-face, rhythmic turn-taking.
2. Match and slightly extend the child's level of excitement.
3. Build in surprise, then come back to calm.
Example language (illustrative): "Pat-a-cake ... faster ... now soooo slow!"
Watch for: Tickling deserves particular caution. It can be overwhelming and is hard to refuse while laughing. APSAC lists tickling among the coercive practices used in attachment therapy. Avoid tickling with children who have trauma histories. Where you use it at all, keep it very brief, light, invited and stopped at the first sign of distress. [source: Chaffin et al. 2006; synthesis]

4.10 Nurture activities: lotion, caretaking, songs

Purpose: Calming, soothing care that helps the child feel good physically and emotionally, and practises accepting care. [source: core concepts] Examples in the sources include applying lotion, hugging, feeding and talking about the child's infancy or birth. [source: Chang et al. 2021; MIM form]
Steps (lotion):
1. Show the child the lotion. Use one that is unscented and hypoallergenic, after checking for allergies.
2. Ask before applying.
3. Apply slowly to the hands or forearms, perhaps with a quiet song.
4. Hand over to the parent to do the same.
[synthesis on the safety steps]
No-touch and low-touch alternatives: The parent sings to the child; the child puts lotion on their own hands while the parent copies; a blanket swing or cuddle only where the child invites it; a soft song using the child's name. [synthesis]
Example language (illustrative): "Mum is going to rub the lotion in, slow and gentle. You tell her if you want it softer."
Watch for: Nurture is often the hardest dimension for children who have been hurt by caregivers. They may become silly, push it away or go "babyish". Offer less nurture, more briefly and less directly, and do not insist. [synthesis] Never use bottle-feeding, nappies or deliberate regression to an earlier age with older children. APSAC lists age regression as contraindicated. [source: Chaffin et al. 2006]

4.11 Challenge activities

Purpose: Support the child to master new skills, building competence and confidence. [source: core concepts]
Examples found in sources: block matching; teaching the child something slightly beyond them. [source: Chang et al. 2021; MIM form] Balancing a beanbag, or cooperative "keep it in the air" games. [synthesis]
Steps:
1. Pitch the task just above what the child can already do.
2. Help them enough that they succeed.
3. Celebrate the effort.
4. In groups, include at least one challenge activity each session.
[source: Group Fidelity Checklist]
Example language (illustrative): "Can you balance it on your head for three steps? ... Four steps! Your legs are getting so strong."
Watch for: Watch closely for frustration. Make the task easier before the child fails, and avoid competition.

4.12 Sharing food

Purpose: Nurture through being fed. In groups, a food-sharing activity is expected, or a replacement nurture activity. [source: Group Fidelity Checklist; feeding listed in Chang et al. 2021]
Steps:
1. Choose a small snack that has been checked for allergies, is culturally acceptable and is safe for the child's age.
2. The parent feeds the child one small piece at a time while making eye contact, if the child accepts it.
3. Or the child and parent feed each other.
4. The child can always choose to feed themselves.
[synthesis on choice and safety]
Food safety [synthesis]:
- Check allergies at intake and with the parent each time.
- Wash hands and wipe surfaces.
- Avoid whole nuts, whole grapes, hard sweets and popcorn with young children.
- Sit the child upright, and never feed a child who is laughing hard or lying down.
- Respect religious and dietary rules.
- Never withhold food or use it as a reward or punishment. APSAC lists withholding or forcing food or water as contraindicated. [source: Chaffin et al. 2006]
- For children with feeding histories (neglect, food hoarding, eating disorders, tube feeding), adapt the activity or drop it, and liaise with whoever manages the child's feeding.
Example language (illustrative): "I've got a little cracker here. Would you like Mum to give you a piece, or would you like to take it yourself?" [synthesis]
Watch for: Gagging, refusing, or signs of shame. Offer to switch roles at once ("You feed Dad").

4.13 Parent involvement: preparation, coaching, the interpreting role

Purpose: Parents are co-therapists. They are prepared through discussion, observation and role play, and then take an active part in sessions. [source: Booth 2010 preview; CEBC] Guiding parents through the four dimensions during sessions is part of the training. [source: Module 6 learning objectives]
Steps: These are synthesis. The Institute's description of the parent-observer and interpreting-therapist roles is not drawn on here [uncertain]
1. Before the session, show the parent the plan and practise each activity with them, adult to adult, so they experience it themselves.
2. Early on, the parent may watch while you or a colleague names what is happening.
3. Bring the parent in for activities where they are likely to succeed.
4. During the session, coach the parent briefly and quietly.
5. Afterwards, talk it over: what they noticed, what they felt, and what to practise at home.
Example language (illustrative): "Did you see him look at you when the bubble popped? That was him checking you were with him. Try doing it again, slower."
Watch for: Parents who are triggered by their child's rejection or by caregiving. Give them their own reflective space. A parent who uses touch coercively or keeps overriding the child's "no" needs direct coaching, and if it continues, a safeguarding review (see 5.8).

4.14 Goodbye and transition out

Purpose: A predictable ending that brings arousal down, using structure and nurture. [source: Group Fidelity Checklist: planned transitions, closing song or activity]
Steps:
1. Give a warning before the end.
2. Choose a calming last activity.
3. Sing a goodbye song or use a ritual that is the same every week.
4. Hand the child over to the parent to leave.
5. Make a brief note of what to practise at home.
Example language (illustrative): "Last one. Let's sing our goodbye song, and then Mum will carry you to the car like a sack of potatoes, if you'd like."
Watch for: Children who fall apart at endings. Make the goodbye longer and give them a transitional object to take, such as a sticker.

4.15 Adaptations for children with trauma histories

Purpose: Booth (2010) gives a chapter to complex trauma, and its preface describes hands-on, rhythmic, soothing activities as a possible first step. To calm a frightened child it says to reduce stimulation, ensure safety and stay close. [source: Booth 2010 preview] Reviewers present Theraplay as suited to traumatised children. [source: JKP page] The chapter's content is not drawn on, so the steps below are synthesis. [uncertain]
Steps [synthesis]:
1. Get a touch and trigger history (see 4.1), and agree a safety plan with the carers and the child's social worker.
2. Start with structure and engagement before nurture. Begin with touch at a distance: passing a ball, mirroring, clapping in the air.
3. Use the stop signal from the very first session.
4. Keep stimulation low. Sit side by side rather than face to face if eye contact is threatening. Avoid tickling, lying down, being covered by blankets, holding the child from behind, and any touch near the face or neck for children with relevant abuse histories.
5. Offer nurture through the safest attachment figure first, which usually means the carer rather than you.
6. Move gradually towards more contact only if the child invites it.
7. Watch for dissociation: a fixed stare, slowed responses, a flat face. If you see it, stop, orient the child to the room, and slow everything down.
8. Work alongside trauma-focused treatment where it is indicated.
Example language (illustrative): "We're going to keep our hands to ourselves today and play mirror. Whatever I do, you copy."
Watch for: Compliant children who freeze, and children whose "silly" behaviour rises when nurture is offered. Both mean you have gone past their window of tolerance.

4.16 Home practice

Purpose: To carry gains into daily life. [source: CEBC]
Steps:
1. Give one or two activities the child enjoyed in session.
2. Agree a short daily time slot.
3. Ask about it at the next session.
[source: CEBC; the details are synthesis]
Example language (illustrative): to the parent: "Pick one game Sam enjoyed today and try it for five minutes after tea. If he isn't keen, let it go and just tell me how it went next time." [synthesis]
Watch for: Parents turning play into a demand or a test of the child's compliance. Reframe it as optional and fun.

4.17 Group Theraplay and Sunshine Circles

Purpose: Groups of about 4–10 children in clinic, school or residential settings, with all the adults present taking an active part. Sunshine Circles is a teacher-led classroom format. [source: CEBC; Group Fidelity Checklist]
Steps (as checked by the Institute's group fidelity checklist):
1. Welcome each child individually.
2. Review the rules.
3. Give each child an individual check-up.
4. Run cooperative games across the four dimensions, including at least three turn-taking games and one challenge game.
5. Share food or do a replacement nurture activity.
6. Plan the transitions.
7. Close with a song or activity.
Throughout, adults keep children engaged, invite back any child who leaves, help children take part, offer nurturing touch when it fits the activity, and stop or change any game in which a child is hurt or distressed. [source: Group Fidelity Checklist]
Example language (illustrative): "Welcome, Maya, I'm so glad you're here. Let's remind ourselves of our group rules before we start." [synthesis]
Watch for: Peer touch needs its own rules and close supervision. Never pair a child who has shown sexualised behaviour for touch games without a safety plan. [synthesis]

4.18 Ending and follow-up check-up visits

Purpose: Consolidate gains and check they hold. The Korean protocol described 4–6 follow-up check-ups. [source: Chang et al. 2021] The Booth (2010) contents list includes "Doing Checkup Visits". [source: Booth 2010 preview; its content uncertain]
Steps [synthesis]:
1. Tell the family the ending is coming several sessions ahead.
2. Plan a celebration session made up of the child's favourite activities.
3. Consider a repeat MIM to compare with the first one.
4. Book check-up visits at widening intervals.
Example language (illustrative): "We have three more times together. On our last day we'll play all your favourite games, and later we'll meet again to see how you're getting on." [synthesis]
Watch for: Regression around the ending. Normalise it and keep the structure the same.

4.19 Video review and supervision

Purpose: Video is needed for MIM feedback and for certification supervision. [source: CEBC]
Steps:
1. Get separate written consent to video.
2. Store recordings securely and agree how long they are kept.
3. Use clips only for feedback and supervision.
4. Explain to the child, at their level, that the camera is there.
[source: CEBC; the Institute's own video consent form exists but is not drawn on; storage steps are synthesis]
Example language (illustrative): "That camera helps me remember our games so I can get better at helping you and Dad. Only the people who help me with my work will see it." [synthesis]
Watch for: a child or parent who becomes self-conscious or performs for the camera; acknowledge it and place the camera discreetly. If consent is withdrawn, recording stops. [synthesis]

5. Handling problems

All of 5.1 to 5.7 is synthesis built on Theraplay's published principles of attunement, felt safety, reducing stimulation and stopping when a child is distressed, unless a source is cited. [synthesis]

5.1 The child refuses or resists an activity

First, work out which kind of resistance it is (from the Booth 2010 preface):
- Reluctance to give up an old pattern: for example, the child insists on leading. Stay warm, keep the structure, make the activity more playful and briefer, and try again later.
- Panic or fear: reduce stimulation, ensure safety, stay close and do not press. [source: Booth 2010 preview]
Refused touch: always offer the no-touch version immediately. Never hold the child in place to complete an activity.
Illustrative wording: "OK, no lotion today. Want to put some on my hand instead?"

5.2 The child becomes overwhelmed or dysregulated

Stop the activity and lower your voice.
Make the space bigger: move back, sit lower.
Offer the carer's lap or side if the child wants it, or a quiet spot with the carer close by.
Breathe slowly and rhythmically and hum.
Return only to calm, structured activities.
If the child is at risk of injuring someone, use only your setting's approved safety-intervention procedure, briefly, and record it. Never use a holding technique as "therapy". APSAC excludes brief safety-based restraint from its list of contraindicated practices, but distinguishes it sharply from therapeutic or enforced holding. [source: Chaffin et al. 2006]
Debrief the carer afterwards and revise the plan to lower intensity.

5.3 A frozen, compliant or dissociating child

Treat compliance without pleasure as a warning sign, not as progress.
Switch to orienting and choice-based activities.
Reduce touch and eye-contact demands.
Check in with the carer about triggers you don't yet know about.
Consider whether trauma-focused work should come first.

5.4 Silly, chaotic or over-excited behaviour

Usually this is too much arousal or too much nurture too soon.
Shift towards structure: short, clear, rhythmic games with clear endings.
Cut the number of activities.
Lower your own energy.

5.5 Parent difficulties

Parent can't play, is critical, or competes with the child: prepare them more adult to adult, and give them a smaller role in sessions.
Parent becomes tearful or triggered: pause, offer them nurture too (a drink, a calm moment), and offer separate reflective sessions.
Parent skips home practice: shrink the task to one activity for three minutes, and ask what got in the way.
Parent uses coercive touch or ignores the child's "no": coach them in the moment ("Let's wait for her signal"), then review it in a separate session. If it continues, or happens at home, apply section 5.8.

5.6 Ruptures with the child

When an activity misfires (for example the child is startled or hurt), name it briefly, take responsibility and repair.
Repair through action as well as words: offer something soothing.
Illustrative wording: "Oops, that was too fast. I'm sorry. Let's do it slow."

5.7 Older children and teenagers

Use activities suited to their age, more choice, open explanations of what each activity is for, and less nurturing touch.
Get explicit agreement for each activity. A refusal ends that activity.
Group formats and peer-based challenge often suit them better.

5.8 Safeguarding, mandatory reporting and the line between Theraplay and coercive "holding" or "attachment therapy"

Safeguarding and reporting [synthesis].

Apply your profession's and your setting's child-protection procedures throughout.
Mandatory-reporting duties vary by jurisdiction and change over time. In the US, every state has reporting statutes for named professionals. In the UK and elsewhere, duties are set by law and by statutory guidance that you must check yourself.
Know your local thresholds and the contact routes: the child-protection service, the local-authority designated officer, or the police.
Explain the limits of confidentiality at intake.
If a child tells you about abuse during play or touch work, stay calm and listen. Don't question them in a leading way. Record their words exactly and refer the same day.
Do not treat play, MIM behaviour or a child's response to touch as evidence of abuse, and do not try to gather forensic evidence. That is for specialist investigators.
APSAC advises treating caregiving practices that would otherwise count as abuse or neglect as suspected abuse, even when they are labelled "attachment treatment": withholding food, water or toilet access, extreme control, restraint, and deliberately provoking distress. [source: Chaffin et al. 2006]

What coercive attachment therapy involved. The APSAC Task Force (Chaffin et al., 2006) documented these practices [source: Chaffin et al. 2006]:

forced or scheduled holding and restraint, including several adults holding or lying on a child, and holding a child's face for prolonged eye contact, sometimes in sessions of 3–5 hours;
tickling, pinching, knuckling of the ribs, and licking;
"rebirthing" and compression, in which the child was wrapped in blankets, held down and told to fight free;
provoking rage for "catharsis";
regression and reparenting with bottles or nappies;
home regimes that controlled food, water and toileting, forced fluids, isolated the child, imposed meaningless chores or prolonged motionless sitting, and demanded instant compliance.

Children's protests were treated as resistance or manipulation, to be overcome by more coercion. Children were also described in pejorative terms and predicted to become psychopaths.

Documented harms.

Candace Newmaker. Candace was 10, adopted, and diagnosed with attachment disorder. In April 2000, in Colorado, she died after a 70-minute videotaped "rebirthing" session. She was wrapped in a blanket and pillows to simulate a womb and told to push her way out while four adults leaned on her, applying several hundred pounds of pressure. She said she was suffocating, and the pushing continued. She was unwrapped cyanotic and not breathing, and died the next day of asphyxiation. Therapists Connell Watkins and Julie Ponder were convicted of reckless child abuse resulting in death and each sentenced to 16 years. Colorado then passed "Candace's Law", banning this kind of therapy; the BMJ reported that the law bans active restraint in psychotherapy. [source: Deseret News 2001; Josefson, BMJ 2001; Chaffin et al. 2006]
Other deaths. APSAC also reports the death of Krystal Tibbets, at her parents' hands, involving compression techniques used at therapists' suggestion. It reports a death linked to forced fluid intake on therapists' instructions, and other deaths where parents said they were following therapists' advice. Critics allege at least six deaths. [source: Chaffin et al. 2006]

APSAC's contraindications.

Physical coercion, enforced holding, restraint or domination, provoked catharsis, age regression, humiliation, withholding or forcing food or water, prolonged isolation and exaggerated control are all contraindicated.
Children's distress must always be taken seriously.
First-line treatment should rest on stability, safety, sensitivity and nurturance, with short-term, behavioural, sensitivity-focused work with parents.
Ordinary time-out, safety-based restraint and offering physical comfort are not covered by the contraindications. [source: Chaffin et al. 2006]

How Theraplay differs (in practice, as an attuned therapist would show it) [synthesis comparing Theraplay's published principles with the APSAC criteria]:

Touch. In Theraplay, touch is brief, nurturing and offered to the child, who can refuse it. In coercive therapy, the child is held, pinned or wrapped against their will.
Distress. Theraplay reduces stimulation when a child is distressed and stops when a child is hurt. Coercive therapy provokes distress deliberately and keeps going.
The parent's role. Theraplay coaches the parent to read and respond to the child's cues. Coercive therapy trains the parent to dominate the child and enforce compliance.
Sessions. Theraplay sessions last 45–60 minutes, are playful, and are reviewed in supervision. Coercive sessions ran for hours and aimed at "breaking" the child.
Food. Theraplay uses food to nurture. Coercive regimes withheld food or forced it.

The sources do not include an Institute statement setting out this distinction, or describing Theraplay's own history in this debate. [uncertain]

Red flags that a service or colleague is using coercive methods:

holding or restraint described as therapeutic, or holding a child until they "give in";
several adults holding a child down, or wrapping a child in blankets, pillows or sheets;
forced eye contact;
rib "stimulation" or forceful tickling;
rage reduction, rebirthing or compression techniques;
sessions lasting hours, or intensive programmes lasting several days;
treating the child's protests as manipulation;
predicting that the child will become a psychopath or a predator;
unvalidated attachment-disorder symptom checklists (for example, ones listing lying, stealing and poor eye contact);
home rules controlling food, water or toileting, prolonged motionless sitting, or meaningless chores;
claims to be the only treatment that works, and marketing based on testimonials.

[source: Chaffin et al. 2006]

What to do if you see or hear of these practices:

Treat it as a child-protection matter and follow your reporting route.
Report professional misconduct to the practitioner's regulator.
Support the family to stop the practice and to move to a safe treatment.
Assess the child for trauma reactions linked to restraint, touch, food or confinement, and adapt any later Theraplay heavily (see 4.15).

[synthesis; source: Chaffin et al. 2006 for treating these practices as suspected abuse]

5.9 Materials and physical safety [synthesis]

Room: a clear floor, soft surfaces or mats for active games, no furniture with sharp corners nearby, and space between you and the child for movement games.
Lifting, swinging and carrying (where used): keep the child low, check your own back first, never swing a child by the arms, and lift only with consent.
Small items: cotton balls, beanbags and balloons are choking hazards for young children; uninflated or burst balloons are a particular danger. Supervise them, and use alternatives with under-threes and with children who mouth objects.
Lotion and powders: check for allergies, use fragrance-free products, and avoid the eyes and broken skin.
Food: follow the guidance in 4.12.
Blankets: don't use them for wrapping or covering the child's head. Avoid blanket swings with children who have trauma histories or poor body awareness.
Hygiene: wash hands before and after, and clean materials between families.
Video: store recordings securely according to the consent you obtained (see 4.19).

Sources

Sources

Books cited (publisher pages or previews only)

Booth, P. B., & Jernberg, A. M. (2010). Theraplay: Helping Parents and Children Build Better Relationships Through Attachment-Based Play (3rd ed.). Jossey-Bass/Wiley. The bibliographic details are [uncertain]: the preview shows the running title, the 2009 preface and the contents, but not the full title page.
Jernberg, A. M. (1979). Theraplay: A New Program for the Treatment of Problem Children and their Families. Jossey-Bass. [source: Institute founder page]
Norris, V., & Lender, D. (2020). Theraplay® – The Practitioner's Guide. Jessica Kingsley Publishers.
Booth, P., Lindaman, S., & Peacock, F. (2025). Theraplay®: An attachment theory-based treatment for relational and developmental healing. In D. A. Crenshaw, A. L. Stewart & D. C. Ray (Eds.), Play Therapy: Theory, Research, and Practice. Guilford Press. [cited by CEBC; not drawn on]
Hong, R., & Coleman, A. R. (Eds.) (2023). Theraplay®: Innovations and Integration. Jessica Kingsley Publishers. [cited by CEBC; not drawn on]

Further reading (not drawn on): the full Booth interview PDF and the Institute's Consent to Videotape form.

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