Transcript: Why attachment matters: in play, SAIA Conference 2014

Theraplay is a child and family therapy aimed at enhancing and building attachment, self-esteem, trust in others, and joyful engagement.

Podcast Episode: Why attachment matters: in play, SAIA Conference 2014

Category: Attachment 


What follows is a transcription of the audio recording. Due to differences between spoken and written English, the transcript may contain quirks of grammar and syntax.

EG - Edwina Grant

Theraplay is a child and family therapy aimed at enhancing and building attachment, self-esteem and trust in others. In this keynote address to the Scottish Attachment in Action Conference in December 2014, Edwina Grant explains the importance of play - the building block of human development, and explains the relationship between Dyadic Development Psychotherapy and Theraplay.

EG A little bit about me and Dyadic Developmental Practice, because DDP and Theraplay have a great deal in common I think. The core attitude of Dyadic Developmental Practice is P-A-C-E, which is PACE. So folks, and in no particular order, what does the ‘E’ in PACE stand for? ‘Empathy’ … a bit louder folks, what does it stand for? Empathy. Thank you, and we certainly need to turn up the empathy, the empathy volume, don’t we? … when we are talking about working with the children that we all connect with. So empathy, let me see … and the ‘A’? Oh come on folks … ‘Accepting’. Absolutely, and that’s about children and young people learning that no matter what they do, we still care for them, we still love them - their behaviour is different from who they actually are. And ‘C’ - ‘Curiosity’ again helps children to really get that we want to know everything we can about their experience, their inner world - hence curiosity. And of course, finally … yes, a bit louder, ‘Playful’, yes - and I think as the day goes on, if you didn’t already know, then that core attitude of PACE really does connect very well with Theraplay.

I think you all know, babies are born relational, aren’t they? They have lots of different ways of, from the moment they are born, indicating that they need something. What sort of things do babies do to say they need something? Cry is the obvious - other things? Smiling, eye contact, yes, imitation, facial expression. But I guess when a baby certainly is in the early months, and probably into the first year actually, crying is the predominant way of saying “I need something from you”. That cry I guess has 2 broad meanings. The first one is comfort - I need feed, I am hungry, I am thirsty, I am sleepy, I need you to cuddle me - and that’s comfort. And the second broad banner of crying, well anybody want to guess what that might be? Comfort me and play with me - comfort and joy. And when we do, babies just love it. Play and playfulness is so important - it’s the building block - one of the essences of relationships.

Many, many of the children that I work with therapeutically, and I think that you work with or you care for or you love, actually have so few experiences of playfulness and joy, never mind comfort. The very people who should actually have looked after them and played with them and been with them are the people who have abused, neglected and abandoned them. So we need to find a way of showing them that it is good, it is fun to be with them, and we are fun to be with too. And of course that playfulness is where both Theraplay and DDP, and more, overlap. And play actually is the building block of so much of human development - play helps development in all areas - physical development, social development, emotional development, neurological development. It’s right there in the moment. So we need to find ways of engaging with these kids that we know of who haven’t had those experiences and who very often are much, much younger socially and emotionally than they are chronologically. And that, of course, is part of the essence of Theraplay and DDP.

I do want to read you a poem - the poem is by Dan Hughes, and it is from his book ‘It was that one moment’. The poem is called ‘The Belly Laugh’, and here is the foreward. “While we stress the therapeutic value of helping the child to resolve past traumas and to discover the experience of safety, we cannot forget the importance of the child developing and truly experiencing positive emotional experiences as well. The abused and neglected child may have seldom had the opportunity to experience happiness and laughter, and even less of an opportunity to experience laughter and joy with another person. This poem also focuses on the positive surprise of this unpredictable event - abused and neglected children so often want, and they need, predictability and structure, since the uncertainties of the past were associated with something bad that was about to happen. When a child is able to be surprised and be open to a possible happy ending to the event, she most likely has been able to establish a degree of safety that leaves her able to experience the positive when it emerges. When she truly gives in to a very special experience, a belly laugh, she has also begun to establish a sense of self that now incorporates the positive”. So ‘The Belly Laugh’.

That winter day when I was helping my adoptive Dad,

Being nervous of course,

I didn’t know that I was, since I always was nervous,

We were bringing in the groceries from the car.

The still, white snow over the ice rose in the sky,

Being drawn up by my father’s rising feet -

He was lying there on his back with startled eyes,

Surrounded by celery, bread and toilet paper.

I thought to help him, hoping to stop any rising rage

And so be safe.

Reaching down, while standing on more snow over ice,

My feet flew too and I landed on my Dad

And the bread, celery and toilet paper.

Waiting for a scream I heard …

I heard a magical, wonderful mysterious sound of laughter.

Dad’s body began shaking,

And his laughter tumbled and rose from him to embrace me.

My body began shaking as I was bouncing with him

And the sounds came from me,

And mixed with Dad’s in the falling snow.

I never knew that I had them, those belly laughs

Until Dad called and they came to him.

I have never been the same since we found them.

So I guess really that is all I have to say just now - I hope you have fun today and that you learn with both your heads and your hearts.

Sheila Lavery - a facilitator who teaches the principles of Theraplay - explains how Theraplay can be used by foster and adoptive parents, inviting the audience to try out some of the techniques.

SL We want to explore the role of play in building trust. Play is a really lovely way to build trust with children, because one of the challenges for children who have trauma histories is learning to trust adults particularly, and specifically to trust the intention of adults to care for them - they just don’t get it that the adults would want to care for them, because their early experiences are that nobody did - the people who should have done it didn’t do it, so why would anybody else bother? And play is a way of getting that message across.

It feels a bit to do it in groups with adults, you know, people that you have never met or only just met and you have got to sit down and do this really quite intimate stuff. So it does feel a wee bit strange to begin with - but we would ask you to kind of bear with us, because it feels strange for the child to have that level of intensity and intimacy with an adult - it feels strange for them as well.

It is integral to Theraplay, and our children need to experience good touch, because of course in their histories they had lots of bad touch or the absence of touch. And we know that the antidote to bad touch is not touching, alright, so it’s getting some good touch in. The foster carers that I worked with in the past struggled with employing Theraplay with their children, and I don’t know if it’s the same for the people in the room - it turned out that they felt if it was written into the care plan that they would be using Theraplay with the children, they would feel more comfortable with it - they would feel, you know, more comfortable with how it fitted in with Safe Care guidelines.

So what is Theraplay and why is Theraplay different from any other kind of play therapy? It is a specific type of play therapy, in that it is relational based - it is based on relationship. The important thing about Theraplay is not how good the game is, or how clever it is, or how sophisticated it is - it is about the fact that you are doing it with another person who is intensely focused on you. It is based on the natural patterns of healthy interaction between a parent and child, so it’s based on that positive intersubjective relationship that an adult has … that a good enough Mum or Dad would have with a very young baby. And it is used to establish or re-establish connection between parents and children following loss, trauma or separation. So you can see why it would be important to use it for children who have come into our homes from … where their family of origin was a hostile environment or a neglectful environment. But also we need to remember to keep using it - because sometimes people learn a bit of Theraplay, and they do a bit, and then they stop. And it is worth keeping practicing it, more or less every day. And what we know from parents who do this with their children, is the children kind of pre-empt it happening - they come in, you know, Mums have come back who have learned how to do Theraplay and said “oh my daughter or my son just come in now and say” … “I’ve got it all set up Mum - I’ve got the cushions ready, I have got everything ready”, because they are so hungry for it - they are like sponges, soaking up all this attention and play.

The other thing about Theraplay of course is that it is directed play - the adult takes charge of the play, in a very playful, empathic, curious and accepting kind of way - but the adult directs the play. And through that the child can learn to take direction from an adult. So we do know that children who have had difficult histories can be very controlling - they have very controlling behaviours - and by the time, you know, they are 3 even, they have developed patterns of controlling their environment and the people in it. And through play they can relinquish that control without even realising it in a way.

So we know that early interactions between parents and children - a Mum and her baby - a Dad and the baby - create the foundation of the child’s being and their sense of self. We learn who we are and what we are worth through the non-verbal communication with our primary carer - through how they look at us, right? The look in their eyes, the look on their face, the tone of their voice, the joy that they have in seeing us when they meet us when we are tiny babies. If you think about how a parent interacts with a very young baby - it’s all smiles and positive eye contact, yes? Lots of rhythmic movement, lots of good nurturing touch, lots of atunement, reading each other, working with each other, being on the same emotional wavelength, giving matched attention to stuff and having that matched intention. The ingredients of positive inter-subjectivity as divined by Trevarthen & Stern. So, I have a little quote from Colwyn Trevarthen - “the intrinsic regulators of human brain growth in a child are specifically adapted to be coupled by emotional communication to the regulators of adult brains”. So we learn how to regulate ourselves, how to be in the world and who we are in the world from our parent’s faces and how they interact with us. Fostered and adopted children have experienced a lot of negative interaction with primary care givers, so they will have missed out on all of the joy that tiny babies get from good enough parenting. And those are form building blocks in the brain. Foster and adoptive parents generally have more positive experiences of relationships. So foster and adoptive parents are generally better placed to do this kind of work with the children who come into their care. And there is a really good book “I Love You Rituals” - it is a great - it just takes simple little rhymes and adapts them so that you can make the child the focus of the rhyme. “Your fingers are so sleepy” - does anybody know that rhyme? It’s not a Theraplay rhyme, but you use it with Theraplay principles. So you take the child’s hands and you massage … you have got lots of touch and you say “your fingers are so sleepy, it’s time they went to bed - first you, baby finger, tuck in your sleepy head. Ring finger, you’re next, and here’s the tall one - this is just great - pointer finger hurry, you know we can’t be late”, and you massage the finger. “Are we all here and huddled in? Oh no, there’s one to come, move up everyone, here comes thumb”.

Right, so what difficulties respond to Theraplay, and children love to play … the bottom line is children love to play - but sometimes people get hung up about what kind of difficulties will respond? Can I use it with a child with attachment difficulties? Can I use it with a child with autistic spectrum? Can I use it with a fatal alcohol child? All of these children, according to the Theraplay Institute, will benefit from Theraplay.

Theraplay has little bits of challenge, but as we know, our children … children who have experienced trauma, needs tons and tons and tons of nurture, tons and tons of structure and wee bits of challenge, because we don’t want to trigger that sense of failure, that sense of shame that is so up there in them really - bottom line. It doesn’t have to be a complicated activity - it is about fun. You don’t need to get too hung up on “is it or isn’t it Theraplay?” “Are we having fun?”.

What makes it Theraplay? Well first of all it is directive - the adult is in charge, that’s what makes it Theraplay. It is relational - it is not about the activity - it is about the intensity of the relationship while you are doing it. It is responsive attuned interactive play. The adult responds to the child - if the child struggles with the activity, the adult empathises with them. “I can see this is difficult for you - how can we make this easier - let’s try it that way, this way” - the adult is attuned to the child - they are reading the child all the time. And this is particularly important if we are talking about working with children who have experienced trauma - because although children will be resitant to this kind of intimate … it is a very intimate experience, Theraplay. And children who have experienced relational loss and pain will resist intimacy. It is modelled on this ‘good enough’ parenting - it is modelled on being attuned - matching your attention … giving your attention to what the child is giving their attention to, and wanting the same … we both want the same thing, and the same thing is fun - we want to have fun. The focus is very much on the here and now - it is not about “oh I have got to go and put the dinner on in 5 minutes”, or “we will do this and then we will just go and do your homework, okay?” We don’t go there with Theraplay. This is what it is about - we are here right now, looking in other’s faces, holding each other’s hands, moving our bodies in the same rhythmic motion. It is always about the here and now - everything else is forgotten.

Touch is integral, and I think this is why we need to think about, if you are going to do this, your social worker knows that you are doing it - it has to be a part of your care plan.

What I discovered is, if we can play a game when there is tasks to be done - if we can play a game first and everybody is feeling quite positive and connected, and they have learned that I can ask them to do something and it feels okay, then we do “and now we can do the dishes” - and they would do it. It’s amazing, it’s almost miraculous, but it works. So they learn to trust us to make good choices for them. They learn self-regulation - because the adult directs the play in Theraplay, the adult decides whether we go faster or slower, wind down, you know, stack hands on top - the adult structures the play. All Theraplay is structured, even though some activities are specifically structured activities, all of them are structured. So it is a regulatory activity. It improves their self-image - they feel better about themselves. I mean wouldn’t you feel better about yourself if you had somebody looking at you, engage with you as if you were the most amazing person on the planet and not paying attention to anything else? Right? It’s one to one, it is dyadic - two people engaged in this incredibly intense experience.

And what we know from neuroscience at the moment is that things … what changes the brain is experience. It is not talking about stuff, necessarily, it is not knowing stuff intellectually, because our children can know lots of stuff intellectually - it is about experiencing it. So what they experience is feeling loved and valued, which of course is exactly what they missed out on. It is dyadic, it is two people - although we can do group Theraplay - it is pre-verbal, it is unmistakable … the body doesn’t lie in the way that the mouth does, yes? So how children … how we experience things, how we look, how we move, all of those things are unmistakable. So play allows us to have that honest and intimate relationship.

Anybody out there who has got adopted children or fostered … they have a fairly negative view of themselves, don’t they, yes? Very negative - fear of failure, big, shame-based identity, don’t think that they are loveable, don’t think that they can achieve, question all the time our motives to care for them - “why would you want to care for me, because I’m not good, and I will do everything I can to prove to you I am no good”. So what Theraplay does is gives them the experience of feeling that they are good, that they are valuable and they are valued. So it is good for them and it is good for the relationship. It is also really good, I might say, for parents who have lost the joy in parenting, and we can all get there if we are parenting difficult children. So it is a very clever and acceptable way for parents to re-parent children, without the children feeling ‘patronised’, if you like. And it is a perfect way for parents to connect with the child as if they were much younger children.

So we want to challenge their negative internal working models of themselves and of others - their internal working model of how the world is - so that they can accept what we have to offer. Because we can give and give and give and give, but if the child isn’t able to receive, it is just a one-way exhausting trip.

When children get older it can be harder to maintain that kind of playful, interactive relationship with them, so if we can introduce Theraplay while they are quite young and maintain little bits of it as they get older … the real benefit from Theraplay is to keep using it - not to use it once or to use it every day for 6 months and then drop it - but to just keep using it. And I think also the knock on benefit of that is that we tend to just become more playful in our interactions with our children and have a more playful way of resolving difficulties.

Theraplay with traumatised children … I mean what do we mean by ’trauma’? This is the big question when we talk about trauma, because lots of parents will say “oh my child isn’t traumatised” - what do we mean by ’trauma’ when we are talking about children who have come to us via adoption or fostering? What would be traumatic for a tiny, helpless, dependent baby? Separation? Not to be fed - to be starved - to be left hungry would be traumatic, wouldn’t it? Not to be picked up, not to be comforted, not to be regulated - to be shouted at, living with domestic violence, left crying - all of those things.

This kind of feeling is triggered again by minor stresses that remind the child of the early trauma. And of course, trauma has a physiological response in the body - it is not that the child remembers “oh I remember not being fed - oh that wasn’t night” - they react as if they will starve to death if they don’t get fed.

If you think about the attachment and trauma model - the thing that protects us from traumas is attachment, isn’t it? Yes? Having a key person that you can talk to, that can keep you safe, that can soothe you when things go wrong? Attachment … secure attachments mediate all other traumatic experiences. But for our children, the lack of attachment was traumatic, and of course the traumatic experiences were perpetuated by people who should have been keeping them safe. So that does something really, really complex and difficult and damaging to how your brain works and how you perceive the world, other people, and yourself. We talked about the responses are in the body, right? Alan Shore talks about “the body keeps a score” - it is not about remembering stuff, it’s about feeling that it is happening all over again. Your nervous system responding to the trauma, as if it is happening all over again. Children whose trauma is triggered by sometimes very minor stresses, and often repeatedly, go into fight, flight and freeze. Now when you work with children who are traumatised, you do Theraplay with them - they will be resistant, as I said, and we do have to have empathy for their resistance.

Traumatised children often resist conventional therapy, or conventional therapy doesn’t necessarily work for them, because if their trauma was pre-verbal, they are not going to go in and talk about it, you know? As Besel Van Der Kolk says, “we have got to find better ways than simply moving our tongues about if we are going to help these children recover from trauma”. They often see the world as threatening and overwhelming, so giving them a little bit in the day … like Theraplay is great when they come in from school - hide and seek is great when they come in from school, peek-a-boo, all that stuff, when they have been separated from their primary carer. And they have a very poor sense of permanency, so when they are away from you, that can be really difficult for them to be away at school for 6 hours. Do something that is reconnecting when they come in.

Key concepts for trauma then is you work at a slower pace with a child who is clearly resisting, or struggling with the level of intimacy, the parent taking control of the relationship. With teenagers, of course, you would need to speed up a bit, because teenagers don’t really manage working slowly - they like to work quickly. We always respect and work with the child’s coping mechanisms - we always have the empathy. Always use pace or place - that’s your model for interaction with the child. And as we said, Theraplay combines with all other trauma work - especially life story work - other types of therapeutic intervention - Theraplay fits perfectly with anything else that you would be using.

Roberta Manners of the Theraplay Institute explains the structure and dimensions of Theraplay: engagement, attainment, nurture and structure. She also demonstrates an activity ‘caring for hurts’.

RM Theraplay is a joy. If you don’t quite know what to do next because the vibe isn’t great, you just start doing - that is my lesson to myself. On the sofa, legs up, cycling, just messing with a cotton ball, messing with anything - hands, faces. It is right there, you have got it all the time. So the thing is to do it, not to think too hard, but always have something up your sleeve, especially if you are using it every day in a planned way, then a plan is always good - you have prepared yourself. When you are thinking about what you would do any day, every day with your children - think back to your own past, what did your parents do with you? And if they didn’t, what did we do at school? What did our grandparents do? What did we do as, particularly girls, we were always skipping ropes, all the rhymes … and as I would say, rhythmic interactions. But if you think of just something like “the old lady who lived in a shoe” - some of our stories and some of our rhymes are really pretty scary. “There was an old lady who lived in a shoe - she had so many children she didn’t know what to do - and she beat them, and she battered them, and she put them to bed and she gave them some water without any bread”. Oh that’s lovely, that is going to be really comforting to your child as you put them to sleep! So the good old Theraplay Institute - they have managed to develop new words - “There was a wonderful woman who lived in a shoe - she had two children … four children … however many children you have in your family - and she knew exactly what to do … Yes! She held them, so nice actions, she held them, she rocked them, she put them to bed “I love you, I love you, I love you, she said”. Now what a different experience.

Theraplay has been divided up into four dimensions - so if you are thinking about your children you can think about “right, what is going to be most helpful for my kid - the one I am thinking about at the moment?” I think I have found some pretty good tips. If you have a very controlling child, a child who finds structure, the word “no”, instructions, really offensive and frightening - if you are going to help your child accept those structures, accept your rules, what happens in your family - they need a huge amount of nurture. Most of our children, most of our kids who have experienced relation trauma, they absolutely need to know what is going to happen next. They absolutely need to be able to accept some boundaries. But they can only accept it through kindness - they have to feel your good will towards them. They have to feel that you know them and there is absolute good intention in everything that you are doing. And they can only really feel that in the nurture.

The other side of engagement and attunement is really also knowing when not to be engaging your child, when not to be getting their attention and letting them rest. You can always be initiating if you are not careful - “let’s get going”, “let’s get going”, “let’s get going”, “I’m here”, “I’m here for you”. But actually, a lot of what you will be doing is slowing your child down, getting them into a smoother rhythm, and also just letting them rest, like a baby does. When you think of … if you have a babe in arms, a babe in front of you, and you are doing the tongue thing or the smile thing, and the baby is responding, or the baby just does the thing with its face which makes you do the same thing with your face, a smile. And then suddenly, all babies do it - they will turn away. And there is a bit of processing going on, and they are needing to just get out of that intensity. And that is part of attuning with your child - when to just let them rest a bit. Let their body take it all in. So not to be keep, all the time, boom, boom, boom.

And the last thing I was thinking of as a tip - oh the older the child is, the more they like a challenge. So with teenagers, try and get a bit of challenge in, in virtually all that they are doing, because they will respond - because they want to beat you. So the purpose of engagement - to establish and maintain a connection with the child, to focus on the child in an intense way and to surprise and entice the child into enjoying experiences. Think of just how babies rely on their carer’s face, just to know who they are. If they had a depressed mother, had a mother who was absent, who’s absent physically or emotionally absent - how are they ever going to get a sense of who they are? They were, I think in the most extreme cases, children felt they were invisible - that they didn’t really exist - that they had no sense of where their body began, where their body ended, and what internal structural sense they began to develop was pretty worthless, pretty nothing.

Engagement is very much the surprise element - how to rev the child up, but not to the point where they get over-excited, but where they are at their optimum attention, they are right with you - they are in the room, they are not thinking about the past, they are not thinking about the next thing. And very often with many of the children I work with, they are always telling me what is going to happen next - their idea of what would be good to play next and “we could do it slightly differently - we could do it this way - I know, this way” - or completely random … something completely … suddenly they hear everything out of the window. With engagement you can hold the child in that moment, and generally our kids aren’t in the moment. They are never, never in the here and now. It’s too difficult.

The purpose of nurture - nurture does everything for us that makes us know that we are loveable. It’s such a fundamental part of their sense of who they are, that many of them have known, as part of an integral part of themselves, that actually they are unlovable, they are not worth it … they weren’t touched in the right way, they weren’t looked at in the right way, they weren’t spoken to in the right way, so there must be something wrong with them. And to be able to enable a child to accept your nurture, I think it does mean a lot of patience, curiosity, acceptance - I think acceptance is the big one when it comes to really being able to … not to take it personally if your child can’t manage this very well. Because if a child is defended against nurture, against loving touch, against loving looks - they don’t know it - it’s a completely automatic response. You replicate what you might have done with a tiny baby, and you do that with your child - whether they are 12, they are 18, they are 4 … through Theraplay you can have these interactions. You can show them - it is showing and doing - that they are worthy of the care that you want to give them.

Let’s doing ‘caring for hurts’ - this is a classic Theraplay activity - kids absolutely love it. It is one of those things where you might have the trickiest child in the school and they are part of a nurture group because they could find it so hard to be in the classroom. They will ‘care for hurts’ with one another. And you think this is going to be the least likely thing they are ever going to do. It recognises that the child within has hurts, but it has huge symbolism and children will find hurts absolutely everywhere once they get into what you are doing. And it is that paying attention, it’s the touch, it’s the defining body boundaries - it has got so many things to it that are so helpful for our kids.

If I was with Sheila I would probably start with her hands … feet are great - if you get a chance to get to children’s feet, the smellier the better, and you can take their socks off in the most enticing ways - you can find that they have got sausages in their feet, sausages in their socks, they have got candy … little bits of Smarties in their socks - and they looking at you? But you get their socks off and then you can do their feet and their legs. But I tend to start with hands because it is less intrusive.

Again, firm touch, and I will be looking at her hands and just tender, sweet … oh that just looks like a little, little nick there - I think that needs a little bit of attention, don’t you?

Very often, children will point things out or their parents will point things out “oh something hurt” - and I would just stop whatever we are doing and attend to that hurt. Again, it’s the symbolism of it, but it’s noticing. So we might be in the middle of a game, but if someone gets hurt of just noticing something about themselves, I would stop it or say “we must attend to that after” - but always do it.

“You have so … what beautiful little freckles you have got - beautiful freckles - one there, one there, one there, one there … oh those nails … how did you get those nails? Those nails are absolutely gorgeous”. You are not general at this point - so we do other things with massage. But with caring for hurts you are really, really specific. Each little thing - you are finding, and you are talking about it, and you are doing.

The next dimension is structure and I think along with nurture these two are key - particularly thinking about children whose internal world is so disorganised and the efforts they make to try and control their outer world, just to try and feel safe - their efforts are, obviously fruitless unfortunately, but nevertheless they try very, very hard - and really, cannot even begin to think that the adults around them will organise their world and that they can relinquish that responsibility to manage in the day to day, in the relationship.

You need to show some authority - not being authoritarian, but to be experienced as someone who not only wants to be there with you, with their child, but knows exactly what they are doing, knows how to have fun, is very sure that they understand you well enough to know that what we are about to do is going to be fun - and even if they are struggling with it and coming up with all sort of other ways to do things, and say “what a fantastic idea - I didn’t know it could be done like that - maybe we can try that tomorrow”, or sometimes you go with what the child suggests. Structure, with some flexibility, is what we need - and kindness and certainty for me, is the other.

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