Hundreds of broken-hearted parents have enrolled their daughters at Lake House because they felt she wasn’t getting the right level of support at home. Having tried everything they knew to do, they found themselves feeling exhausted and hopeless as to how they could help their daughter to feel better. Fortunately, with the right treatment team in place, and with support and guidance from LHA’s team of dedicated professionals, these families were able to help their daughters find the path to healing and feeling better.
Theraplay is a highly relational and uniquely structured clinical approach specifically designed to support the needs of pre and early-adolescent children and their families. Having the highest evidence-based practice rating by SAMHSA, Theraplay has proven to build and enhance attachment, self-esteem, joyful engagement, and trust in others. This stems from natural patterns of playful, healthy interactions between parent and child. Theraplay is more than just play—it lets the body have experiences while re-training the brain in the process.
Theraplay is a treatment modality created specifically for children and teens. Unlike other “play therapy” modalities, Theraplay is therapist led—not client-driven. It requires no verbal processing from the child. Theraplay helps preteens and teens heal from their very core by targeting the limbic system of the brain. This part of the brain is what helps drive behavioral and emotional responses.
There’s a long list of reasons why a family might need help with their preteen/young teen daughter. They usually boil down to this primary issue: interpersonal challenges within the family system. These challenges may look like:
What happens if these symptoms go untreated?
Early intervention is important when families begin to notice any of these signs or symptoms in their child. Because if these symptoms are left unaddressed, it can result in escalated behavioral issues.
Parents may start to see more acuity in behaviors such as substance use, suicidality, and/or self-harm. These issues often lead to a continued decline of joy and engagement within the family system. The issues will continue to impede on social and academic functioning, and this often results in shame and low self-esteem..
When relationships have deteriorated at home, parents become frustrated and scared. This causes disruption in the family. Disruption in the family then causes the members of the family to not function properly. It becomes a vicious cycle as negative behaviors escalate with age.
For children ages 9-15, the part of the brain that understands logic and reasoning is not fully developed. Yet, many therapeutic modalities used to treat emotional and behavioral issues require a fully developed brain.
Adding anxiety/depression/trauma on top of this stunts brain development. When someone is experiencing depression, their ability to understand logic and reason is not effective—no matter how old they are.
Everyone at their core has a need and desire for connection and security. When there is chaos or disruption, it helps to come back to that core process that is often associated only with early childhood experiences. This can be helpful and relieving in addressing the issues.
Theraplay breaks down into four core dimensions. These are used during the MIM assessment and guide the implementation of Theraplay. The four core dimensions are:
It's best to examine these core elements to develop relational security and regulation. Different games and activities correlate with each one of the four dimensions. These help to organize Theraplay’s MIM assessment and determine how future Theraplay sessions will look like.
1. Theraplay’s MIM Assessment
Theraplay has its own assessment process called the MIM. It helps therapists identify how a parent/child relationship is doing across the four dimensions. A therapist may ask which of the dimensions are real assets, real strengths, and which they are struggling with.
If there are noticeable behavioral or emotional challenges, that's usually because there’s an imbalance across these core components. This assessment helps the therapist understand where things are going right in the family, and where the family can improve.
At Lake House, the family completes the assessment by entering an office with a couch and a table. There are a series of envelopes on the table that contain tasks or games in each. Each of these games or tasks correlate to one of the four dimensions (structure, engagement, nurture, and challenge).
There is no therapist in the room and the parent/child is on their own while we record the interactions. There isn't a time limit because we want to see how the parent/child navigate across these four dimensions. We want to see how they would act in a typical interaction.
The therapist then reviews the recording with another clinician to pinpoint the strong and weak areas. These observations help to structure the future treatment for the child. This treatment will build on their strengths and work on their weaknesses.
2. What does a Theraplay session look like?
A Theraplay session doesn’t start in the office. It starts before with an entrance and ends with an exit that helps the child to organize the experience of the session. The therapist then guides the child through the session. There is a series of games or activities that flow from one to the next for the entirety of the session.
The therapist will focus on whatever ideas were identified in the MIM. Maybe it’s 80% nurture activities for a family that is really struggling with that core dimension. There might be more engagement or challenge activities because the child or family is withdrawn and needs to be brought out a bit.
Just as with all Theraplay sessions, there isn’t any process or dyadic dialogue. There is talking but no verbal processing. It’s play-based. It’s about establishing trust and experiencing connection through play.
If a client is doing Theraplay in a traditional sense, sessions would be once a week. If an hour is too long, we may do two thirty-minute sessions. Parent sessions (described later) are also once a week.
Not too long ago, we had a 13-year-old enroll at Lake House. She had been internationally adopted and experienced abuse and neglect in her early home placements. When her parents enrolled her at LHA, she hadn’t been attending school for over a year. She struggled to build and maintain friendships, had a serious suicide attempt, and when she got overwhelmed or emotionally dysregulated, she fainted.
Her parents had tried everything for their daughter, including talk therapy, DBT, and CBT. Nothing had worked for them. When they enrolled at LHA, we decided to try a Theraplay approach with her. In the Theraplay approach, we didn’t try to get her to tell us about her issues or the trauma she’d experienced in life. Instead, we were trying to build a foundational level of safety and security deep inside her brain to help her calm down, regulate herself, and not constantly operate under extreme levels of anxiety.
As we started to play with her, we realized that she was showing up in play as a 3-to-5-year-old, not a 13-year-old. The games she enjoyed were early childhood games. When there is trauma or developmental needs that aren’t met, it stunts development and becomes problematic later on. With the Theraplay model, we’re able to “go back in time”, in a sense, and help the brain heal at the limbic level.
Over time, this student began to feel safe, participate more in our Theraplay sessions, and engage in reciprocal activities. She started attending school again and after only 6 months of Theraplay, she had completely stopped fainting when she felt overwhelmed.
While Theraplay is something that we use here at Lake House, it is still used on a case-by-case basis. Some kids first starting treatment have challenging behaviors and we need to avoid putting a parent and child in a room if we believe it could lead to an unsafe situation. We start with providing organization and regulation.
It might not be a structured Theraplay interaction all the time, but we always interact with our students and families with these principles in mind. Some questions we may ask are:
Our clinical model is a developmentally sensitive attachment model. Theraplay is one of the interventions that we use because it is a clinically proven method to increase positive attachment. It is a unique therapy that is not widely used, and Lake House is privileged to use it as a tool for young girls and their families.
Theraplay was developed as an outpatient model of treatment, so it requires a lot of involvement from a parent or parental figure. Lake House doesn’t have the parents there every week since it is a residential treatment center. We’ve taken this outpatient modality and we figured out how to adapt and integrate it into a residential treatment setting.
We integrate Theraplay in the “way of life” at Lake House. All the aspects are built into our academic classrooms and our academic approach. All the way down to informing how the students at Lake House transition from class to class.
One of the key concepts behind the structure is organization, pattern, and repetition. Repeating things over and over again is comforting and regulating. The girls all move in the same pattern every day. They move in the same direction throughout the school building. That was informed from Theraplay and the four dimensions.
In addition to pattern and repetition, our teachers will incorporate Theraplay games and activities into the classroom setting. Regarding the student life process, our girls in their residential life are frequently engaged in play-based activities that support their continued growth and development. They continue to enhance their relationships, and this “way of life” approach has been something that allows parents to see how to put Theraplay into action.
Lake House also does Theraplay groups and uses Theraplay to foster friendships between the girls, which hasn’t been done before. There’s a paradox within Theraplay where it’s all about connection, relationships, and security in relationships, but most of these girls who come to Lake House struggle with relationships. By facilitating intentional games between the girls, it provides some reciprocity. It allows them to interact and spend more time with one another.
It helps build a connection between the girls. For example, two girls who fight a lot were put into a Theraplay group three times in a week. After that week, we didn't see an issue anymore.
There are times when we introduce other modalities in addition to Theraplay. One example is dialectical behavior therapy (DBT). Everyone still participates in an MIM and everyone’s case gets looked at through the four core dimensions. Using the four dimensions helps provide a guide for communication between parent/child and therapist/child.
Not all girls and families will participate in Theraplay sessions all the time, but the four core dimensions are still taught to the girls at Lake House and their families. This allows them to give their parents feedback such as “I feel like I need more structure” or “that felt like too big of a challenge for me”. Parents can then use the same language to provide a nice communication tool for the parents and the child to go back and forth.
The Theraplay modality requires parents to be involved. The MIM is the first piece where the parents are participating in the assessment. Parents continue to receive coaching in learning the skills and techniques from the therapist. Since the girls are so young at Lake House, it is important that we are focusing on helping the parents feel confident in parenting their child and reconnecting and developing that relationship with their child.
We involve parents in Theraplay sessions when they’re on campus visiting. They lead and participate in games with their child. Lake House has adopted many of the Theraplay games for video chat so even during family therapy calls they are able to engage in Theraplay's foundational ways. At the end of the day, the ultimate goal for Lake House is that parent and child have made progress in their connection with each other.
We show parents clips from the MIM assessment so they can see and watch their interactions back on video. We also show them Theraplay sessions to help them understand and learn how to better engage with their child.
Theraplay is something that can be implemented in the home—and it’s highly recommended! At Lake House, our transition plans incorporate the four dimensions and how to effectively use these processes in the home.
5 tips for parents who haven’t done Theraplay before:
For families who haven’t done Theraplay before, it’s best to be organized and consistent and engaged with their child. Having a routine, having a schedule, not necessarily using threats, and focusing on taking care of one another is critical.
It’s key for development. Having time where you sit down and be playful with them. It releases wonderful neurotransmitters in the brain and helps foster connection.
Sometimes there is a behavior that brings the response of “go take a time out and think about what you did”. However, Theraplay would say the opposite such as, “do a time in”. This allows the parent to try to understand what the child was really saying, needing, or wanting in that moment and why they acted out that way. If a parent can figure that out with them, it is very powerful for the child to have someone be present with them during that process, versus disengaging.
If a parent is frustrated, it’s best to consider the expectations that they have for their child and consider how much of the frustration may be coming from unmet expectations rather than their child.
Is the parent creating an environment that is consistent, predictable, and fair, that builds on connection? If the answer is yes, then there’s one path to take, and if the answer is no, then the parent can adjust accordingly.
Frustrations usually result from unmet expectations. Not every 9, 12, 13, or 15-year old is going to be the same. Just because they’re that age, doesn’t mean their brain is. Really considering this question is something parents can actively do at home.
If you have noticed any emotional or behavioral challenges with your daughter, she may need additional help that Lake House can provide. Please don’t hesitate to contact one of our mental health professionals to see how Theraplay can help you. We want you to build a strong relationship with your daughter and we know how to help.