i

The Treatment Acceptability of Group Theraplay as a

Perceived Effective Intervention for Socially
Disadvantaged Children

By
Emma Kate Marrison

A thesis submitted in partial fulfilment of the requirements for the Degree of Master of Science
in Child and Family Psychology in the University of Canterbury 2022
 ii

Acknowledgements

I would like to acknowledge my primary supervisor Dr Michael Tarren-Sweeney for the guidance

during my journey of completing my thesis. Thank you for taking to time to give me feedback and

direction. I would also like to acknowledge my secondary supervisor Dr Petria Thoresen for

everything you have taught me through my thesis journey. Thank you for all your time, support and

encouragement. I would also like to thank Stand Tū Māia Christchurch, in particular Jocy and Trevor

for all your support and flexibility in aiding the running of my study, as well as all the staff at Stand

Tū Māia who assisted in the Group Theraplay sessions. Without all your support, none of this would

been possible. I would like to thank the children who participated in this study and made this research

possible, I could not have done it without all your valuable input. I would also like to thank my

friends, family and my partner for the endless encouragement and motivation along the way of my

thesis journey, I could not have done it without all your love and support.
 iii

Abstract

The objective of this study was to investigate socially disadvantaged children’s perceptions,

feelings, and attitudes towards the treatment intervention Group Theraplay. The treatment acceptability

of Group Theraplay has largely been un-explored, making this an explorative study. Due to limited

research, the literature review was expanded to include the effectiveness of Group Theraplay. The

literature review identified four studies evaluating the effectiveness of Group Theraplay. Two of these

included an element around treatment acceptability of Group Theraplay. The objective of this study was

carried out through a small qualitative case-study design with nine children who attended the village at

Stand Tū Māia Christchurch, using Interpretative Phenomenological Analysis. The analysis of the

children’s interviews revealed two superordinate themes: enjoyment of Group Theraplay and positive

social emotional skills. Results also identified Group Theraplay activity recall in the children’s

interviews. These themes suggested children’s experience of Group Theraplay was overall positive, and

children enjoyed participating in the sessions, therefore meaning Group Theraplay has high treatment

acceptability among socially disadvantaged children. Study implications and limitations are discussed

with recommendations to future research outlined. This study concluded that Group Theraplay has a

high treatment acceptability in socially disadvantaged children.

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Table of Contents

Title .......................................................................................................................................................... i
Acknowledgements ................................................................................................................................ ii
Abstract ................................................................................................................................................. iii
Table of Contents ................................................................................................................................. iv
List of Tables........................................................................................................................................ vii
Acronyms ............................................................................................................................................ viii
Chapter 1: Introduction.........................................................................................................................1
PART 1: The effects of adverse childhood experiences on child development, particularly self-
regulation......................................................................................................................................1
What is self-regulation? ...................................................................................................2
Attachment Theory...........................................................................................................4
A word on trauma .............................................................................................................4
Interventions available .....................................................................................................5
PART 2: Theraplay ......................................................................................................................7
What is Theraplay?...........................................................................................................7
History of Theraplay ........................................................................................................9
Theraplay for traumatized Children .................................................................................9
PART 3: Treatment Acceptability..............................................................................................10
What is Treatment Acceptability? ..................................................................................10
Treatment Acceptability and Theraplay .........................................................................11
Chapter 2: Research review of Theraplay and Treatment Acceptability .......................................12
Selection Criteria ........................................................................................................................12
Search Strategy ...........................................................................................................................12
Theraplay Effectiveness .............................................................................................................14
Francis, Bennion and Humrich (2017) ...........................................................................14
Siu (2009) .......................................................................................................................16
Siu (2014) .......................................................................................................................17
Wettig, Coleman and Geider (2011) ..............................................................................18
Conclusion..................................................................................................................................19
Chapter 3: Methods .............................................................................................................................20
Research Question ......................................................................................................................20
Study Aims .................................................................................................................................20
Study Design ..............................................................................................................................20
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Selecting a Qualitative Methodology .........................................................................................20

Interpretative Phenomenological Analysis (IPA) ......................................................................21
Setting.........................................................................................................................................22
Group Theraplay ........................................................................................................................23
Group Theraplay Activities ........................................................................................................25
Engagement ....................................................................................................................25
Structure .........................................................................................................................26
Challenge........................................................................................................................27
Nurture ...........................................................................................................................27
Participants .................................................................................................................................28
Selection Criteria ............................................................................................................29
Post Group Theraplay Interviews ...............................................................................................30
Audio Recordings and Transcripts .............................................................................................31
Ethical Considerations................................................................................................................31
Procedure....................................................................................................................................32
Materials .....................................................................................................................................33
Chapter 4: Results ................................................................................................................................34
PART 1: Superordinate themes and Sub-themes .......................................................................34
Theme 1: Perceptions About Group Theraplay..............................................................34
1a. Recognition of what Group Theraplay is. ....................................................34
1b. Enjoyment of Group Theraplay....................................................................35
1c. Likes and Dislikes. .......................................................................................36
1d. Purpose of Group Theraplay. .......................................................................37
Theme 2: Positive Social-Emotional Skills....................................................................38
2a. Peer Relations. ..............................................................................................38
2b. Self-Confidence. ...........................................................................................38
2c. Emotional Regulation. ..................................................................................38
Part 2: Participants Ability to Accurately Recall Theraplay Activities .....................................39
Nurture activities ............................................................................................................39
Challenge activities ........................................................................................................41
Engagement activities ....................................................................................................42
Structure activities ..........................................................................................................42
Chapter 5: Discussion ..........................................................................................................................43
Summary of findings ..................................................................................................................43
Theme 1: Perceptions about Group Theraplay ...............................................................43
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Recognition of what Group Theraplay is. ..........................................................44

Enjoyment of Group Theraplay..........................................................................44
Likes/dislikes. .....................................................................................................45
Purpose of Group Theraplay. .............................................................................46
Theme 2 Positive Social Emotional Skills .....................................................................47
Peer Relations. ....................................................................................................47
Self-Confidence..................................................................................................47
Self-Regulation...................................................................................................48
Participants Ability to Accurately Recall Theraplay Activities .....................................48
Nurture activities. ...............................................................................................49
Challenge activities. ...........................................................................................49
Engagement activities. .......................................................................................50
Structure activities. .............................................................................................50
Implications ................................................................................................................................51
Theme 1: Perceptions about Group Theraplay ...............................................................51
Theme 2: Positive Social-Emotional Skills....................................................................52
Strengths .....................................................................................................................................52
Limitations .................................................................................................................................53
Recommendations for future research........................................................................................54
Conclusion..................................................................................................................................55
References .............................................................................................................................................56
Appendix A: Parent/Caregiver Information Sheet ...........................................................................59
Appendix B: Parent/Caregiver Consent Form ..................................................................................62
Appendix C: Child aged 5-9 Information Sheet ................................................................................64
Appendix D: Child aged 10-13 Information Sheet ............................................................................66
Appendix E: Child Assent From .........................................................................................................68
Appendix F: Human Ethics Committee Approval Letter ................................................................70
Appendix G: Stand Tū Māia Approval Letter ..................................................................................71
Appendix H: Theraplay Group 1 Session 1 Plan ..............................................................................72
Appendix I: Theraplay Group 1 Session 2 Plan ................................................................................75
Appendix J: Theraplay Group 2 Session 1 Plan ...............................................................................78
Appendix K: Theraplay Group 2 Session 2 Plan ..............................................................................81
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List of Tables

Table A – Summary of studies selected for review

Table B – Participant’s age, gender, and group membership

Table C – Superordinate themes and sub themes

 viii

Acronyms
ACE – Adverse Childhood Experiences
PTSD – Post Traumatic Stress Disorder
PNS – Parasympathetic Nervous System
SNS – Sympathetic Nervous System
GT – Group Theraplay
CT – Complex Trauma
TF – CBT – Trauma Focused Cognitive Behavioural Therapy
DBT – Dialectic Behavioural Therapy
DBT-C – Dialectic Behavioural Theraplay for Pre-Adolescent Children
CBCL – Child Behaviour Checklist
DSM-IV – Diagnostic Statistical Manual fourth edition
DSM-V – Diagnostic Statistical Manual fifth edition
SDQ – Strengths and Difficulties Questionnaire
SRS – Social Responsiveness Scale
MANOVA – Multivariate Analysis Variance
CLS – Controlled Longitudinal Study
MCS – Multi-Centre Study
CASCAP-D – Assessment Scale for Child and Adolescent Psychopathology - German
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Chapter 1: Introduction

PART 1: The effects of adverse childhood experiences on child development, particularly self-

regulation

Many children are exposed to early social adversity during their childhood, this includes

maltreatment. This can have an impact on many aspects of a child’s life, including difficulty with

emotional and behavioural self-regulation. My thesis is concerned with improving emotional and

behavioural self-regulation among children exposed to early social adversity.

Adverse childhood experiences (ACEs) are events that occur in childhood that are potentially

traumatic. ACE was conceptualized by Felitti et al. (1998) after looking at the correlation between

health risk behaviour and illness in adulthood, and childhood exposure to abuse, neglect, and

household dysfunction during childhood. Felitti et al. (1998) then created a questionnaire to measure

ACEs using seven categories of adverse childhood experiences which was then compared to measures

of adult risk behaviour, status of health and disease. There are many kinds of ACEs, such as childhood

maltreatment. This includes childhood emotional, physical, or sexual abuse, and neglect. Another kind

of ACEs is household dysfunction. This includes divorce, exposure to domestic violence, an

incarcerated family member, substance abuse, mental illness and more. All of these ACEs can have a

potential traumatic effect on a child (Felitti et al., 1998).

ACEs can have a negative impact on children’s brain development, with one study by finding

that ACEs predict reduced volume of the inferior frontal gyrus (Barch, Belden, Tillman, Whalen, &

Luby, 2018). This area of the brain is responsible for impulse control and self-regulation. ACEs can

also have a significant psychological impact on children, with many children exhibiting internalizing

and externalizing behaviours. Common post-traumatic stress disorder (PTSD) symptoms exhibited in

children over the age of three who have experienced trauma include avoidance, psychological

numbing and hyper or hypo-arousal (Osofsky, 1997). These impacts may then interfere with

participation and engagement in normal developmental activities in childhood such as social

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engagement and academic success. Long-term effects of ACEs in childhood can cause impact in adult

life such as effects on emotional state including higher rates of depression and suicide attempts, and

higher rates of health risks including substance use and abuse, obesity and more (V. Felitti & Anda,

2010).

What is self-regulation?

Self-regulation is a term that has been around for a long time. The term self-regulation is a

behaviour that reflects feedback control where self-corrected adjustments are taking place in order to

stay on track. These adjustments originate from within an individual (Vohs & Baumeister, 2016).

Self-regulation has been looked at mainly from a behavioural lens. However, further research into

self-regulation has begun to take more of a neurological and cognitive lens. It has started to become

evident that the role of unconscious early experiences has the ability to shape the brain systems

controlling adult behaviour as a mechanism of self-regulation (Posner & Rothbart, 2000). In the

1990’s was when study on emotion and its regulation became more prevalent and widely researched

(Eisenberg & Sulik, 2012). Emotional regulation has been defined as the processes that are used to

manage and change if, when, and how an individual experiences emotions and emotion-related

motivational and physiological states as well as the behavioural expression of emotions (Eisenberg,

Hofer, & Vaughan, 2007).

Emotional regulation as defined by Gross (2013), can span from controlled, conscious effortful

regulation to unconscious, effortless automatic regulation. Emotional regulation is divided into two

types: effortful control and reactive control. Effortful control is often automatic but can also be

consciously controlled. Whereas reactive control is generally an involuntarily motivated approach or

avoidance system of response reactivity. The construct of effortful and reactive control is an ongoing

debate within the field (Eisenberg & Sulik, 2012; Gross, 2013).

It was assumed for a long time that young children had very little capacity for self-regulation.

However, indicators of self-regulation and antecedents of effortful control have been seen in children
 3

which continues to develop through adolescence. A caregiver will help an infant to co-regulate

through soothing or distraction to alleviate the infant’s distress of fear. The co-regulation of their

emotion modulates their exposure to stimulating events. The ability to self-regulate behaviours

develops rapidly as a toddler and in preschool years when children start to seek more independence

from their primary caregiver. This also improve in aspects of executive functioning associated with

effortful control, with further improvement once children reach early school years (Eisenberg & Sulik,

2012).

Measuring self-regulation through physiological processes is an emerging area of research.

Physiological responses appear to be a combination of reactivity and regulation. It is not yet known

exactly what psychophysical responses are involved in emotional regulation. The parasympathetic

nervous system (PNS) and the sympathetic nervous system (SNS) have opposing effects within many

of the body’s organs. In a stressful situation, SNS activity increases and PNS activity decreases in

response to the stimulus causing physiological effects in the body known as fight-and-flight response.

Whereas PNS have the opposite effect on the body, known as rest-and-digest. These responses have

an effect on one’s ability to regulate (Eisenberg & Sulik, 2012). Research suggests PNS influence on

the heart is primarily mediated by the vagus nerve (Porges, 2007).

A child who has experienced trauma can have extreme difficulties with the functions of self-

regulation. A child who has experienced trauma will have difficulty controlling their emotions,

behaviour and attention when faced with a perceived environmental threat, causing the child to

become dysregulated. The inability to self-regulate is a core feature in children who have experienced

trauma. Trauma inhibits the brains ability to develop self-regulation (Saxe, Ellis, Fogler, Hansen, &

Sorkin, 2005). Children and who experience trauma can go on to experience life-long difficulties with

emotional regulation (Lawson & Quinn, 2013)

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Attachment Theory

Attachment is a system that promotes the connection between children and caregivers and

serves the purpose of protection from emotional and physical danger (Bowlby, 1973). John Bowlby

was one of the first to do research in attachment. His first body of research in the area published in

1944, where he examined the history of 44 juvenile thieves. This confirmed his belief of disruption in

the mother-child relationship is a precipitating factor of mental disorder. Bowlby’s research in the area

continued and broadened (Fonagy, 2001). Attachment theory focuses on the relationships and bonds

between people, particularly the bond between a parent and a child.

There is a close link between emotional regulation and quality attachment. Individual

differences in emotional regulation can be influenced by child attachment history (Cassidy, 1994).

Attachment and regulation processes are intertwined meaning an intervention focused on attachment

will help build on a child’s emotional regulation. Insecurely attached children have less opportunities

to learn strategies from a caregiver to emotionally regulate compared to a securely attached child who

may learn these strategies from modelling and support from a caregiver (Smithee, Krizova, Guest, &

Case Pease, 2021).

A word on trauma

Complex trauma (CT) is a term that the traumatic stress field has adopted. It is defined as the

experience of developmentally adverse traumatic events that are chronic and prolonged, happening on

more than one occasion. This is most often interpersonal and begins in early life (Van der Kolk,

2010). Complex trauma symptoms fall into seven different domains of impairment: attachment,

biology, affect regulation, dissociation, behavioural control, cognition, and self-concept (Cook et al.,

2005). Exposure to interpersonal trauma during childhood has been described as the silent epidemic

(Kaffman, 2009). According to UNICEF (n.d), on average a child dies every five weeks in New

Zealand as a result of violence. Worldwide, roughly a third of children have experienced physical
 5

abuse and around one in four girls and one in five boys have experienced sexual victimization

("United Nations," 2006).

Early childhood is the most vulnerable time in a human’s life when it comes to the impact of

trauma, particularly when it occurs in the home or with trusted caregivers. When a child is exposed to

multiple and intense traumatic experiences such as physical and sexual abuse, it increases a child’s

level of physiological arousal. This means that children who have experienced this level of repetitive

trauma, are often in a hypervigilant state. CT often occurs within the caregiver system. This may mean

that the child may feel unsafe with their primary caregiver. This can disrupt a child’s core sense of self

and other relationships leading to the child expressing mistrust of others. (Arvidson et al., 2011). A

crucial component of treating CT is the participation of a committed caregiver in treatment. This is

due to co-regulation being a critical component of a healthy attachment with a caregiver (Blaustein &

Kinniburgh, 2010).

Van der Kolk (2010) developed a concept called Developmental Trauma Disorder. This disorder

was proposed for the fifth edition of the Diagnostic Statistical Manual (American Psychiatric

Association, 2013). This was due to there being a gap in the DSM-IV around a disorder for children

who have had a maladaptive impact caused by complex trauma but did not meet diagnostic criteria for

PTSD. PTSD also neglects to highlight the developmental effects complex trauma has in childhood.

Developmental trauma disorder is organized around dysregulation triggered by traumatic reminders,

generalization of stimuli and behaviour anticipated to prevent the recurrence of trauma (Van der Kolk,

2010). Complex trauma symptoms can include symptoms of PTSD, however the function of the two

does not necessarily overlap (D'Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012).

Interventions available

There are many common interventions for treating children who have difficulties with regulation

or have experienced trauma. The first of which is Trauma-Focussed Cognitive Behavioural Therapy

(TF-CBT). TF-CBT is an evidence-based, short-term treatment model to help children and adolescents
 6

recover from trauma. This treatment can improve a range of outcomes related to trauma in 8-25

sessions. TF-CBT expands off traditional cognitive behavioural methods that incorporates family

therapy while using a trauma-sensitive approach. TF-CBT can also address many other impacts

related to trauma such as cognitive and behavioural problems and affective disorders ("Trauma-

Focused Cognitive Behavioural Therapy," 2022).

Another treatment intervention is Dialectic Behaviour Therapy (DBT). This behavioural therapy

uses similar aspects to Cognitive Behavioural Therapy, with an addition of mindful awareness and

training in emotional regulation (Gray & Bjorklund, 2014). DBT has more of a focus on both

acceptance and change. DBT is an evidenced based treatment which was originally created to treat

borderline personality disorder. It is divided into four stages of treatment depending on the severity of

maladaptive behaviours. DBT generally consists of weekly sessions for a period of 12 months

(Chapman, 2006). DBT has since also shown to be effective in helping those who have difficulty with

emotional regulation and for treating PTSD (Bohus et al., 2013). Dialectic Behaviour Therapy for pre-

adolescent children (DBT-C) is an adaptation of DBT for children to help treat severe emotional and

behavioural emotional dysregulation. DBT-C only differs to DBT through the presentation and

delivery of the treatment. This is to accommodate for the developmental and cognitive levels of the

child, as well as the addition of incorporating the parental role to achieve treatment goals

(Perepletchikova, 2017).

Another therapeutic intervention for children is Play Therapy. Play Therapy is defined as “the

systematic use of a theoretical model to establish an interpersonal process wherein trained play

therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties

and achieve optimal growth and development.” By the Association of Play Therapy (n.d). This is a

child centred approach. Play Therapy has been adapted for treating trauma, it is called Flexibility

Sequential Play Therapy. This components based model allows for the authenticity of each child while

providing a safe and structured journey toward trauma resolution (Goodyear-Brown, 2009). Findings
 7

suggest Play Therapy can be effective in reducing trauma symptom severity (Reyes & Asbrand,

2005). Another therapeutic intervention similar to Play Therapy is Theraplay.

PART 2: Theraplay

What is Theraplay?

Theraplay is a structured and adult-led form of play therapy. Its relationship-based approach is

designed to help families reconnect and engage with each other. It has an emphasis on attunement and

empathy. Theraplay was designed to help parents and caregivers respond to the child’s needs, rather

than what they think the child may need from their view (Jernberg, 1980). It is adaptable to many

different formats including individual, group, and family (Munns, 2000). Theraplay includes a lot of

physical contact, joyfulness, and fun. Toys are not used, treatment concentrates on the playful

interactions between the child, parent/caregiver, and therapist. Simple materials are often utilised such

as lotion, cotton balls potato chips, slices of fruit and more. A session will be pre-planned, and the

therapist will follow the sessions agenda (Munns, 2000). Theraplay uses a non-verbal level of

learning, where children do the positive social interaction instead of just talking about it. Gradually,

these positive messages start to become a part of the child’s sense of self ("The Theraplay Institute,"

2021).

The core concepts of Theraplay are structure, nurture, engagement, and challenge. These core

concepts are achieved through playful and fun games, developmentally challenging activities, and

nurturing activities ("The Theraplay Institute," 2021). Theraplay was developed for any professional

supporting a healthy attachment in a child/caregiver relationship. Theraplay is directive and therapist

led, it is also interactive (Wettig, Franke, & Fjordbak, 2006). Theraplay targets the preverbal, social,

right-brain level of development. These four concepts make what looks to be a fun activity, purposeful

and meaningful. Structure entails creating an organised and predictable environment for the child

which communicates safety, Structure is particularly important toward the beginning of the session to

build on that predictability for the child to allow them to feel safe. Nurture provides a caring stance to
 8

soothe and calm a child both physically and emotionally, this dimension it utilised in the middle of the

session. The level of nurture depends on the child. Engagement is utilised throughout the session, this

focuses on the adult’s presence with the child in their experience of being heard, felt, seen, and

accepted. Challenge is an element that gets utilised toward the end of the first session and sooner in

the subsequent sessions, this builds on a child’s mastery around new skills, their sense of competency

and confidence. The first session is designed based on the information available regarding the group’s

dimensional needs. The second session is designed based on the existing information and observations

from the first session. An extensive debrief and treatment planning session occurs after the first

session to identify priority needs of the individuals a within the group, as well as the whole group

needs. Theraplay sessions consist of three rules for the children; have fun, stick together and no hurts

("The Theraplay Institute," 2021).

There are three types of Theraplay intervention, also known as tiers. The first tier of

intervention is a universal treatment called Sunshine Circles, which is designed for general

populations. This will most often occur in a classroom or larger group of children. Sunshine Circles is

an adult-directed, structured play therapy-based modality that focuses on the development of healthy

peer relationships (Booth & Jernberg, 2009). Sunshine Circles can be led by a teacher in the

classroom, it requires a small amount of training making it easy to implement in the classroom. The

second tier of intervention is more targeted, called Targeted Theraplay or Group Theraplay

intervention which is for smaller group work. This can be with a small group of children, or a small

group of children and their family/caregivers. This is often more directed and intensive than Sunshine

Circles. The third intervention tier is the most intensive and is called Theraplay therapy, this is dyadic,

being typically one caregiver and child with the facilitator (Booth & Jernberg, 2009)

Theraplay is an evidence-based treatment that focuses on attachment. Theraplay activities promote

attachment between a mother and child. Theraplay also builds on a child’s ability to self-regulate by

using coregulation strategies which leads to self-regulation (Booth & Jernberg, 2009).
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History of Theraplay

A notable name in Theraplay is Ann Jernberg. In the late 1960’s, Jernberg became the director of

psychological services for Head Start. This job involved identifying children in need of psychological

services and referring them to treatment centres. Jernberg soon found a severe deficit of existing

treatment centres to provide children with effective treatment. Facing crisis and recognising this gap

in treatment prompted Jernberg to create a new program. She recognised a need for a more cost-

effective, short-term treatment which could be implemented with little experience required. Due to

urgency, it had to also be an easily understood intervention as it was going to be used by

inexperienced mental health workers. Thus, Theraplay was created. Theraplay is therapist led, this is

where is differentiates from play therapy as play therapy is child led (Jernberg, 1980). Theraplay’s

focus on healthy relationships and attachments was guided by Austin Deslauriers work on treatment of

Autism, which in turn was based on Bowlby’s attachment theory (Booth & Jernberg, 2009).

Once Theraplay was first rolled out within Head Start, it was met with a lot of resistance due to its

unorthodox nature. Jernberg made two films about Theraplay in 1969 and 1975 to educate. Theraplay

was then written into the Health, Education and Welfare proposal for psychological services to

Chicago Head Start programs. In 1976, Theraplay was registered as a service mark. In the 1980s other

Head Start centres in the United States and Canada began to receive training in Theraplay to then

implement the intervention. Theraplay is now used widely around the world. In 2016, Theraplay

became recognised as an evidence-based intervention by the Substance Abuse and Mental Health

Services Administration (SAMHSA). This was based on the empirical studies by Siu (2009, 2014)

which demonstrated improvements in internalizing symptoms and autism related symptoms in

children (Tucker, Schieffer, Lenz, & Smith, 2021).

Theraplay for traumatized Children

Complex trauma is exposure to repeated traumatic experiences over a prolonged period. CT

symptoms may overlap with PTSD, particularly in the early stages. However, they do not necessarily
 10

overlap with respect to function (Lawson & Quinn, 2013). Theraplay can be used for all populations

of children, and it is reported to work well for traumatized children (Tucker & Smith-Adcock, 2017).

This is partly due to its adult-led nature. Behaviours that traumatized children exhibit can be traced

back to their negative views of themselves and the world. It is therefore essential to provide a child

with positive experiences that were missing in early years due to complex or developmental trauma.

Theraplay activities align with a child’s current developmental level rather than their chronological

age (Attachment Trauma Network, 2021). Theraplay is an intervention that promotes secure

relationships, executive skills, and emotional resilience. The intervention also supports children’s

growth in self-regulation. Each of these developmental areas are particularly important in a

traumatized child as trauma can have a significant negative impact on each of these areas of

development (Tucker et al., 2021).

PART 3: Treatment Acceptability

What is Treatment Acceptability?

The concept of treatment acceptability was first developed by Kazdin (1980). He defined

acceptability of treatment as “whether treatment is appropriate for the problem, whether treatment is

fair, reasonable, and intrusive, and whether treatment meets with conventional notions about what

treatment should be.” (Kazdin, 1980, pp 259). This conceptualisation was then expanded to include

potential treatment effectiveness, the suitability and likeability of treatment, consumer satisfaction,

and feelings of importance and relevance of the treatment (Calvert & Johnston, 1990). Treatment

acceptability has been traditionally measured through a questionnaire, using a 7-point Likert scale

(Kazdin, 1980). Literature has mostly looked at the parent and the child’s ratings of acceptability of

treatment using structured interviews and questionnaires (Kazdin 2000; Walsh et. al., 2018)

Treatment acceptability has a significant outcome on the effectiveness and success of treatment

making it an important component to examine when considering a treatment type (Kazdin, 2000).
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Feelings toward treatment and treatment acceptability appears to be an emerging area of research, with

little literature on treatment acceptability in many different types of treatment.

Treatment Acceptability and Theraplay

It is evident that there is very scarce literature which looks at the child’s voice when it comes to

feelings of treatment. The research on treatment acceptability appears to focus more closely on the

parent or caregiver’s acceptability of the child’s treatment rather than the child’s feelings of their

treatment (Kazdin, 2000). When looking at a treatment’s effectiveness, it is hard to consider

participants who dropped out of the treatment. Treatment dissatisfaction and views of treatment being

demanding or irrelevant directly contributes to treatment drop out (Kazdin, Holland, & Crowley,

1997). When a treatment is perceived to be more acceptable, then clients are less likely to drop out

(Milosevic, Levy, Alcolado, & Radomsky, 2015). There appears to be some research on treatment

acceptability around the more common treatments such as cognitive behavioural therapy (Walsh et al.,

2018), but there is no literature on treatment acceptability of Theraplay or a similar therapy.

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Chapter 2: Research review of Theraplay and Treatment Acceptability

The present chapter reports a systematic review of research literature on the (1) ‘effectiveness’

and (2) ‘treatment acceptability’ of Group Theraplay. The review aimed to identify research evidence

on treatment acceptability and effectiveness, as well as identifying the gaps in our knowledge. The

purpose of reviewing any prior literature in this area of interest is to summarize and critique research

into Group Theraplay’s effectiveness and acceptability. This literature review focuses on the

effectiveness of Group Theraplay as a whole, while then narrowing in on treatment acceptability of

Group Theraplay.

Selection Criteria

Articles were included in the review if they met the following criteria:

1. The intervention is Group Theraplay

2. Administered in group format

3. Participants are all or predominantly pre-adolescent school-aged children (ages 5 to 13 years).

Studies with age ranges within a year outside the inclusion age range will be included. Studies

must have a majority of their participants within the age range of 5-13 to be included.

4. Article reports treatment effectiveness data, treatment acceptability data or both.

Articles were excluded from the review if they:

1. Focused more on Sunshine Circles than Group Theraplay. This is due to Sunshine Circles

being a general form of intervention whereas Group Theraplay is a targeted intervention.

Search Strategy

Searches were made on electronic databases PsychINFO, Google scholar and CINAHL.

Searches used the following search terms: Group Theraplay*, Theraplay*, group play Theraplay*,
 13

intervention*, treatment acceptability*, child’s voice*, feelings toward*, children*, school-aged

children*, effectiveness of* evaluating outcomes*

Searches were ordered by relevance and there were no limitations on date published.

Treatment acceptability was the first topic to be researched. Searching the phrase “treatment

acceptability of Group Theraplay” on google scholar found 75 results, none of which were relevant to

the inclusion criteria of treatment acceptability of Group Theraplay. The phrase treatment

acceptability was then substituted for “child’s feelings” which found 1,370 results, none of which

were relevant to the inclusion criteria based around treatment acceptability. “Attitudes” toward Group

Theraplay found 961 results in google scholar, this phrase retrieved one relevant article by Siu (2014).

A search on the phrase “qualitative” research on Group Theraplay found 887 results, two were

included in the present literature review (Siu, 2009 & 2014). Each phrase mentioned above was used

in Google Scholar, but no results were found. The above search phrases were used in PsycINFO and

CINAHL, both of which found no results.

Searching effectiveness of Group Theraplay in google scholar found 1,660 results, two of

which were relevant to this study and met the inclusion criteria. The above searches were used in

psycINFO, 13 results were found under effectiveness of Group Theraplay, two of which were relevant

and included. Other search phrases used returned no results. CINAHL returned one result which was

using the phrase “effectiveness” that was already included from PsycINFO. Two additional studies

were identified meeting the inclusion criteria for this present chapter’s literature review, bringing the

total to four studies. Table A below summarizes the four studies that have been included in this

literature review.
 14

Table A. Summary of studies selected for review

Article Study 1. Francis, Bennion, Study 2. Siu (2009) Study 3. Siu (2014) Study 4. Wettig, Coleman,

and Humrich (2017) and Geider (2011)

Research To explore the impact of To evaluate the To test the To improve the social
group or individual effectiveness of effectiveness of a interaction ability of infants
Objective Theraplay interventions on Theraplay on reducing school-based Group and toddlers and to prepare
the child’s relationship with a internalizing problems Theraplay program them for the subsequent
key adult at school among young children. in increasing the treatment of their
To explore whether there are social skills of communication disorders.
changes in the child’s children with To strengthen shy children’s
engagement with education, Developmental self-confidence, their self-
such as their self-confidence, Delay when esteem, and build a feeling of
attention, and concentration comparing with a self-efficacy while improving
skills. control group. their social competence, and
willingness to interact with
others.
Participants 20 looked after children (11 46 elementary school 38 students from a 251 randomly selected
girls and 9 boys) between the aged children (25 boys special needs school children who completed
age of 5 and 11 referred from and 21 girls) who met ranging from age of Theraplay treatment during the
9 different primary schools. at least the cutoff point 6 and 13 (35 boys years 2000-2003. 125 of those
in the CBCL for and 3 girls). children diagnosed with
internalizing problems. communication disorders and
clinically significant shyness
Findings Quantitative results show a Children in the The SRS Data The results show that after
post intervention reduction in Theraplay condition showed that students treatment with Theraplay the
the children’s total SDQ found significantly from the Theraplay target symptoms were both
scores. Qualitative feedback fewer internalizing group had significant clinically and statistically
shows changes in the symptoms when improvement in the reduced. About 18, 30-minute
children’s relationship skills, compared with the subscale “social sessions were needed to
confidence, and engagement waitlist group. communication” achieve the desired therapeutic
with education. compared to the outcome.
comparison group.
Limitations The quantitative measure Based on mother’s Low generalizability. Low generalizability.
used proved weak report which may Small sample size, Low internal and external
Small sample size present bias. meaning potential validity, precision (statistical
Lack of control group. Small sample size risk of Type-1 error. validity), and reliability in
impacting on external repeated measurements.
validity. No comparison group.
Future Exploration of gender Implementing an A larger sample size. More research replicating both
differences in looked after attention control A better designed the controlled longitudinal as
Research children placebo condition. comparison group well as multi-centre studies
Look to empower looked 1 to 6 month follow such as a placebo are needed to confirm the
after children by gathering ups to find long term group. effectiveness of Theraplay.
their views. changes.

Theraplay Effectiveness

Francis, Bennion and Humrich (2017)

One study sought to measure the effectiveness of Theraplay in schools. Francis et. al, (2017)

researched a population of 20 looked after children from 9 different primary schools. The study
 15

conducted 30-minute Theraplay sessions weekly over the course of 8 months. This study used the

Strengths and Difficulties Questionnaire (SDQ) as a pre and post measure as reported by each child’s

significant adult at school. This was a mixed method study design, the qualitative phase used related t-

test to determine the significance of the pre- and post- measure scores and the quantitative phase used

semi structured interviews with the same significant adult at school.

In the qualitative phase of this study, the researcher stated that 100% of schools rated the

Theraplay valuable or very valuable. Schools rated the intervention as valuable or very valuable and

100% of children rated five out of five on a scale of how much they enjoyed the sessions. It is an

interesting finding that all 100% of children rated enjoyment at five out of five. It raises some

questions as to how this data was collected, as some variation in answers would often be expected.

Children tend to report what they think the “right” answer is in order to please the adult, or in this

case, the observer (Einarsdóttir, 2007). Due to 100% of children reporting five out of five, it is

possible that an observer expectancy bias has occurred. I think this is an area that needs to be explored

in more depth in order to effectively report on a child’s enjoyment of Theraplay. This finding,

however, is a relevant starting point to my study.

In the quantitative phase of this study found no significant differences between pre and post

mean scores, with all t-test scores coming back as not significant. It is important to emphasise that the

small sample size (N=20) had insufficient statistical power to identify meaningful effect sizes. The

study was further hampered by the lack of a control group. Regarding Theraplay’s effectiveness, this

study’s quantitative phase failed to find any statistically significant results using the SDQ as their pre

and post measure.

Limitations mentioned in this study included the quantitative measure used, the study

suggested additional standardised tools to capture subtle changes that the SDQ may have failed to

measure. Small sample size and lack of a control group were both limitations to this study. The study

concluded that staff and children enjoyed and benefited from this intervention, with 100% of children
 16

scoring this at the maximum rating (Francis et al., 2017). However, it is important to question how

this information was collected and whether there was an influence from some type of observer

expectance bias. Future research suggested researching Theraplay as a preventative model for looked

after children. This study also highlighted the use of the child’s voice for future studies to empower

children by gathering their views.

The qualitative phase of this study received positive feedback from both teachers and children

who participated in the study. Incorporation of the child’s voice post intervention is very relevant to

my study. This study received all positive feedback from the children who were involved in the study.

This study acknowledged the importance of gathering the views of the children who participated in

the study, citing that it can be empowering. Francis et. al, (2017) also demonstrated that it is possible

to gather the views of primary aged children.

Siu (2009)

Siu (2009) studied the effectiveness of Theraplay for reducing children’s internalizing

problems. This was a randomised control trial with an intervention group who received Theraplay and

a waitlist control group. Participants consisted of 46 children displaying internalizing symptoms who

were described as at high risk of developing an internalizing disorder as based on the Child Behaviour

Checklist (CBCL). Children in the intervention group participated in one 40-minute Theraplay session

a week for 8 weeks. Results found that in comparison with the control group, the intervention group

showed a statistically significant reduction in the mean CBCL internalizing t-score. Some limitations

of this study included a small sample size making results less generalizable and solely using mother

self-report to see effects from the intervention creating a potential bias of perspective (Siu, 2009).

In the study by Siu (2009), a treatment satisfaction questionnaire was completed post Theraplay

intervention. This satisfaction questionnaire had a mean overall evaluation being 8.07 out of 10 (1=

very dissatisfied and 10=very satisfied). 68% of children rated the activities as fun and 72% rated

them as happy (Siu, 2009). These findings appear to have more accuracy when compared to the
 17

Francis et. al, (2017) study above. This study has some variation in responses suggesting the

satisfaction questionnaire responses likely were not produced as a result of possible observer

expectancy bias. Results found a positive response toward the Theraplay intervention with a large

portion of children rating the activities as fun and happy, and rating the intervention a high mean

satisfaction score. This study provides some research toward treatment acceptability by gathering the

client’s feelings toward Theraplay, making it very relevant to this present study.

Siu (2014)

The study by Siu (2014) researched the effectiveness of Theraplay in children with developmental

delay. This was a randomised control trial with 23 participants randomly assigned to the intervention

group (Theraplay) and 15 participants to the control group (attending whichever class was scheduled

at the time). This study used the Social Responsiveness Scale (SRS) as a pre and post measure. The

intervention group was taken out of class to participate in 30-minute Theraplay groups weekly for a

duration of 20 weeks. Using Multivariate Analysis of Variance (MANOVA) on the SRS subscales

after Theraplay intervention, no significant difference was found. However, the researcher then

separated the t-tests for each of these groups and found that there were significant pre-post reductions

in the mean SRS scale scores in the intervention group, but not the control group. Specifically,

improvements were seen in picking up social cues and reciprocal social behaviour (Siu, 2014).

Although the study found some effect in the t-tests of the intervention group when compared with the

control group, this is not enough to show treatment effectiveness as the MANOVA found no

significant treatment effect. Given the large effect sizes in the pre-post mean score reductions for the

treatment group, it is likely that with a larger sample size, a significant treatment effect would be

identified.

This study also included qualitative feedback from teachers at four stages throughout the

intervention. Findings from this study were in line with previous study done by Siu (2009), the study

suggested that Theraplay is an effective form of Therapy that could be integrated into regular
 18

classrooms. A limitation of this study was its small sample size of only 23 participants meaning a

potential risk of a Type-1 error in analysis, the study stated that a larger sample size is required to

increase statistical power. Results were not generalizable due to the skewed population. Future

research endeavours a larger sample size (Siu, 2014).

This study showed promise regarding effectiveness of Group Theraplay through improved social-

emotional skills. The study by Siu (2014) was a well-executed randomised control trial. It provided

relevant literature towards the field in terms of building the evidence-base of Group Theraplay.

However, its low sample size and skewed population proved to be significant limitations to the

validity and reliability of results.

Wettig, Coleman and Geider (2011)

Wettig et al. (2011) researched the effectiveness of Theraplay in treating, shy social withdrawn

children. This controlled, longitudinal study (CLS) included 60 children who had diagnosed

communication and behaviour disorders. Children were assessed using the Clinical Assessment Scale

for Child and Adolescent Psychopathology (CASCAP-D), 22 of these participants displayed clinically

significant shyness and comorbid communication disorders. This study found that after 18, 30-minute

Theraplay sessions on children with clinically significant shyness, that shyness was both clinically and

statistically significantly reduced two years post treatment. There was no pre-post control group.

However, the study measured normative shyness in a sample of normally developing children at the

two-year follow-up, in order to demonstrate the extent to which the treated sample’s shyness at 2-year

follow-up resembled normative shyness. This effect was seen through parent interviews of the

participants. However, this study had low external validity due to the sample group not being

representative of the total population (Wettig et al., 2011). The symptoms of being “mistrusting” and

“socially withdrawn” are left out in the results section of this study, because in both the CLS and

multi-centre study (MCS) the decrease of these two symptoms was not statistically significant.
 19

This longitudinal study provided literature towards the use of Theraplay long term. Although

results are not generalizable, this study still made a relevant contribution toward researching the

effectiveness of Theraplay within a population of children with various internalizing problems.

Following up this research with a representative population of children would be beneficial for further

research in the field. In terms of my study, this study by Wettig et al. (2011) has found some

promising results toward the effectiveness of Theraplay. (Wettig et al., 2011).

Conclusion

The literature above shows that Theraplay can be implemented with children who have a range

of different developmental, emotional, and behavioural difficulties. The literature focusses on

evaluating the effectiveness of treatment. Literature around Theraplay as a treatment therapy is

emerging due to its recent increase in popularity. However, the review of this literature also highlights

that there is very little research that considers the child’s perceptions, attitudes, and feelings toward

the treatment Theraplay. Two of the above studies that were reviewed included a qualitative

component based around treatment acceptability and the child’s voice which proves extremely

relevant to my study (Francis et al., 2017; Siu, 2009). The study by Francis et. al, (2017) encouraged

further research into the child’s voice to empower the child. A common limitation among studies

reviewed includes a small research population and low external validity.

 20

Chapter 3: Methods

Research Question

How do socially disadvantaged, school-aged children attending Group Theraplay perceive

their experience of this intervention?

Study Aims

The aim of this study is to research treatment acceptability of Group Theraplay for socially

disadvantaged children.

Study Design

Given there is no prior research on the treatment acceptability of Group Theraplay, the most

appropriate study design for researching a novel research question is a qualitative case study

conducted with a small number of child participants. An initial qualitative study aims to identify

themes that generates content for subsequent quantitative surveys (Gomes, Appleton, & Lyons, 2006).

Selecting a Qualitative Methodology

This study sought to find an appropriate qualitative methodology for analysis of semi

structured interviewing. Due to the nature of this studies aim, the methodology was required to

analyse each individuals’ authentic experience in order to capture the child’s voice. Two

methodologies identified that meet this criteria were Grounded Theory and Interpretive

Phenomenological Analysis (IPA) (Alase, 2017; Glaser, Strauss, & Strutzel, 1968). Grounded Theory

is described as “an inductive, theory discovery methodology that allows the researcher to develop a

theoretical account of the general features of a topic while simultaneously grounding the account in

empirical observations or data” (Glaser et al., 1968). IPA has more of a focus on personal lived

experience, providing a detailed examination in its own terms rather than one prescribed by other

theoretical preconceptions (Smith & Osborn, 2015). I decided IPA was the most relevant methodology

for my study as it had more of a focus on personal experiences.

 21

Interpretative Phenomenological Analysis (IPA)

IPA is a newly developed qualitative approach to psychological research. A core feature of

IPA is its focus on lived experience (Smith & Shinebourne, 2012). IPA has three primary theories it

identifies with: phenomenology, hermeneutics, and ideography. Phenomenology is the component

concerned with human lived experience. IPA draws on an individual’s own contribution to a holistic

account of human experience. Hermeneutics is the interpretation component which influences IPA.

This involves a certain level of interpretation and engagement from the researcher when considering

an individual’s lived experience. The ideographic approach guides IPA to be based around a case-by-

case basis where generalizations are only made after careful examination and analysis of each

individual case by the researcher. This is why IPA is most commonly used among case-studies or in

studies involving a small number of cases (Smith & Shinebourne, 2012). IPA has been chosen for this

study due to its core feature regarding an individual’s lived experience. This feature is deemed

essential as this study aims to get an authentic view on each child participants individual thoughts and

feelings about Group Theraplay.

There are seven stages to IPA data analysis (Charlick, McKellar, Fielder, & Pincombe, 2015) .

The first stage involves reading and rereading the interview transcripts, the purpose of this is for the

researcher to become immersed in the raw data. This is where the researcher will start identifying

themes and recurring patterns in the transcript. The second stage is identifying themes. At this stage,

the researcher will start to identify and label both major and minor themes and patterns within the

transcripts, this is often done by making notes in the margin. The third stage is structuring the analysis

or developing emergent themes. This is where the researcher will start to focus more on listing all

relevant pieces of transcript and emergent themes and patterns. This is often done on a separate piece

of paper. The fourth stage is searching for connections among the emergent themes and clustering

these themes. This is where the researcher will begin integrating the themes. The researcher will also

use extracts and quotations from the original transcript. The fifth stage is where the researcher will
 22

begin grouping the themes into the most important and relevant and the less important themes. Stage

six is where the researcher will take steps one to five and repeat them for each individual transcript.

The researcher must aim to remain as open minded as possible for this process. After stage six is

complete, the researcher will then begin stage seven where they will construct a cohesive narrative,

combining all themes from all transcripts and ranking them from the most important to the least

important (Charlick et al., 2015).

Setting

This study was conducted at Stand Tū Māia Christchurch. Stand Tū Māia is an organisation that

provides an intensive child wrap around social service response for children. This service is designed

for children aged 5-12 and their whānau who have experienced trauma or hardship in their lives. Stand

Tū Māia’s vision is to have a world strong with tamariki. Their mission is for tamariki and whānau to

be safe, recover from past trauma, develop secure base relationships and create a positive future

("Stand Tu Maia," 2018). A child’s feelings around treatment relates directly to one of Stand’s

strategic goals; “We enable New Zealand’s most vulnerable children to be seen and heard, in safety,

and have their dreams and hopes nurtured” ("Stand Tu Maia," 2018). Listening to the child’s voice has

been something that Stand advocate for, which aligns well with this research idea. Stand Tū Māia

Christchurch began implementing Theraplay around 5 years ago. This has continued to work well

within Stand Christchurch; however, they were interested in learning more around the child’s voice

and child’s perceptions of Theraplay.

Stand Christchurch is open to all children referred in the Canterbury region and, in some cases, the

wider South Island of New Zealand. The duration of therapeutic intervention in the residential service

for each individual child at Stand is generally five weeks, this is broken up into one to two week

increments at a time. This is to ensure the intervention they receive at Stand is not too intensive,

allowing children to have a break between their time at Stand. Children either come to Stand during

the school day or do a village stay overnights in the Stand residential facility from Monday to Friday.
 23

Children get the opportunity to stay nights if they do not live locally, or if they are capable and able to

do night stays. Stand start the school day with a Theraplay Sunshine Circle with all children every

morning. Many children will participate in more intensive Theraplay sessions with their social worker

and family outside of the residential service.

Stand Tū Māia Christchurch agreed and helped facilitate this study and have given permission

to be named in this study (See Appendix G). I am employed at Stand as a Therapeutic Care Worker,

so I am familiar with the running of Stand. I am a familiar face to the children who stay. This Group

Theraplay intervention was run by a verified Theraplay Practitioner at Stand.

Group Theraplay

The Group Theraplay sessions were facilitated by an experienced and certified Theraplay

practitioner. This practitioner has been certified for 5 years. The practitioner is a registered

psychologist with more than 20 years’ experience working with children and families. Assisting her

was the Mana Ake Practice Team Leader, an Occupational Therapist and two Registered Social

Workers from the Community Social Worker team. All of whom were experienced in Sunshine

Circles and Group Theraplay.

The Group Theraplay session comprised of a mix of upregulating and down-regulating

activities as modelled by the facilitators for children to follow. These activities are designed to expand

on a child’s window of tolerance and to support the growth of self-regulation through the use of co-

regulation (Booth & Jernberg, 2009). The Group Theraplay involves the four dimensions of

Theraplay; Nurture, Challenge, Structure and Engagement. The Group Theraplay Sessions will

include elements of all four dimensions, starting mostly with Engagement followed by Structure and

then begin to bring in Challenge and Nurture.

 24

The beginning of the group starts with a welcome and the three rules of Theraplay that all

children are familiar with from Sunshine Circles. These rules are “have fun, stick together, and no

hurts” ("The Theraplay Institute," 2021).

The beginning of these GT sessions started with an upregulated activity followed by a down

regulated activity. The entrance activity aims to work on engagement by meeting the upregulated

energy of the children who are potentially anxious about the group. The purpose of this is to increase

connection and enjoyment through shared joy. The next activity is to down regulate children as they

enter the circle in order to bring them into optimal arousal. Each child then has a spotlight moment

during the welcome this activity is based around engagement, this aims to assess and increase

tolerance of intensity. A structured game integrating some challenge is then incorporated using safe

and predictable eye contact with the development of secondary intersubjectivity in mind. This is

followed by one of the key activities in this group called “check-ups” where each child is paired with

an adult, using touch to nurture and soothe the child. This is often used with lotion, cotton balls, or

powder, and has a focus on skin-to-skin touch. This can also provide an element of challenge

particularly for older children through prolonged engagement. A challenge focused activity then

follows this to build on the child’s confidence, and to provide a success and mastery experience for

the children. This is followed by another nurture activity which works on self-worth, internal

regulation through co-regulation and to increase a sense of secure base. After this, is another

engagement activity to build on group connection and expand on engagement. This uses co-regulation

to remain in optimal arousal. This was followed by another structure activity which aims to assess

body organisation within safe and predicable structure, which then goes into experiencing up-

regulation through safe, predictable co-regulation. Another challenge activity to build on success and

mastery followed by a structured activity to downregulate while moving into the next nurture activity

which is the second key activity of the Theraplay Group: feeding. This is where the adult then feeds

the child an item of food such as a potato chip or cracker to help the child increase their capacity of
 25

nurture. The group is then concluded with a structured activity which is an exit song. This is focused

around down regulating, self-worth, and empathy. The outline for each GT session can be found in

Appendices H, I, J and K.

Group Theraplay Activities

Engagement

The beginning of each GT session is about focusing on engagement to both increase

connection, and to assess the child’s ability to engage and their tolerance of intensity. The activities

and their order of implementation were chosen according to the identified needs of the group.

Activities based around engagement which were implemented in the Group Theraplay include the

entrances activities. One of these was where the children were instructed to pick an animal and move

like this animal. Another activity was the tightrope walk where children had to follow a line of tape to

the GT room. And the last activity was the bubble pop walk using bubble wrap while entering the

room. One of these activities was used for the entry into each GT session. The next engagement

activity is the “welcome to you today” song where each child has a moment in the spotlight, another

welcome song used for more of an older audience is a welcome to the “we will rock you” tune.

Engagement is also implemented in the check-ups toward the end using noticing where the adult

notices positive things about the child.

Some co-regulation engagement activities include beans – where children follow the leader’s

action for each bean called out such as “baby bean” the children crouch down, or “broad bean”

children jump up and spread their limbs, etc. Another engagement activity is “beep honk” this is

where the adult makes a special noise specific to a body part when they touch it. This engagement

activity is designed to activate the social engagement system through moments of surprise. Children

verbally copy an adult’s pattern and then do their own combination of three. Another activity was

“blanket pass” where this gets passed around the circle, adding more to increase the challenge. One or

two of these activities were implemented in each session.

 26

Structure

A structure activity is implemented during the welcome of the GT sessions designed to

increase predictability to provide a sense of safety and allow for outer state regulation and body

organisation in the children in order to reach optimal arousal. Activities used during this stage include

freeze/go or pass a move, this is where children follow the leader’s instruction. For example, when the

leader moos, sit down. Another version of this is dance dance freeze using big movements and loud

noises and freezing on the leader’s command. Another activity is thumbs away this is where everyone

seated in their circle place their hands facing each way towards the next person, hands flat facing

upwards. Each person takes their thumb on their left hand and places it downwards onto their

neighbour’s hand. When the leader cues using ‘bippity boppity boo’ (or alternatively colours,

numbers, flowers, etc.) everyone tries to lift their thumb free from capture while trying to capture the

other thumbs.

Structure activities utilized during the session include ‘Simon says’ following the leader’s

instruction. Another structure activity that incorporates challenge was zoom/erking, where children

must pass a zoom around the circle or use an “erk” to change the direction of the zoom. Another

structure/ challenge activity was ‘karate chop’ where the child karate chops or punches a string of

crepe paper that the staff member is holding. Another structure/challenge activity was pass around the

pup where the child balances a toy puppy on their hands while progressively building up to five. The

last structure activity was measuring, where the staff member would use crepe paper to measure out

parts of the child’s body.

Structure is also implemented in the closing of the group after the goodbye song when children

exit the room. One type of exit was going through favourite colours to be released to the line, or

favourite animals to be released to the line. Children then follow the leader back down to the

classroom. The purpose of this is to achieve outer state regulation in the children by providing safety

through predictability.
 27

Challenge

Challenge is a dimension that was brought in toward the end of the first GT session. The first

session was designed based on what information available on the children and then the second session

was designed after a thorough debrief resulting in targeted treatment plan. For the second session,

challenge was brought in about halfway into the session. In the second session of the GT groups, an

activity incorporating challenge at the end of the welcome was thumbs away. This also incorporates

structure, as mentioned above.

A challenge activity that can be incorporated during check ins is a pea knuckle war. This

brings in an element of challenge while maximising nurture. Other activities that incorporate

challenge include some structure activities mentioned above such as zoom/erk, karate chop, and pass

the puppy. These were progressive activities where the level of challenge increases if the children are

capable allowing for children to experience mastery through safe and predictable structure.

Other challenge specific activities include the cushion/couch jump where children rely

physically on the staff member while standing on a cushion. Another challenge activity was ‘tap tap

pass’. This is a progressive pass around with a cup where children tap their cup on the ground twice in

front of them and then passes the cup to their right in front of the person next to them. This rhythm is

maintained by saying ‘tap tap pass’ together. The pace of this can be altered to create more challenge.

Another activity was newspaper punch, which was a similar idea to karate chop. This was followed by

scrunching up the newspaper and doing a basketball toss into the bin. Feather drop was a one-to-one

activity where the staff member drops a feather for the child to catch. Feather blow is an adaptation to

feather drop, except the adult and child both blow a feather and then they must catch each other’s

feather.

Nurture

The nurture dimension is introduced during the “check-ups” section of the session. This is one

to one and uses skin to skin touch through using lotion, powder, or cotton balls on a child’s hands. The
 28

purpose of this is to increase a sense of being cared for while using touch to nurture and soothe the

child.

A Nurture activity after check-ups included the lotion print activity where the children used

lotion and powder to make their own handprint on a black piece of paper. This activity was

implemented in one of the GT sessions. Another nurture/structure activity that followed on from the

structure activity was ‘measuring’, where the adult then uses the pieces of crepe paper to decorate the

child giving the child a sense of self-worth and increasing the sense of secure base. ‘Making pizzas’

was another nurture activity where the staff member would ‘make a pizza’ on the child’s back, using

various different massage techniques for the different ingredients on the pizza. This activity used

proprioceptive pressure to help regulate, soothe, and calm the child, while keeping children in optimal

arousal.

The next nurture focussed activity is the feeding component of the group. This was where

children were fed a chip or cracker from the staff member and then asked to gues the flavour. In the

first session, this is used to assess each child’s comfort with receiving food and the subsequent session

aims to increase the capacity of nurture in the child.

The last nurture activity for the session is the concluding goodbye song where the staff sing an

adaptation of ‘twinkle twinkle’ to the children. This focuses on the children’s self-worth and empathy.

It also down regulates the children to conclude and close the GT session.

Participants

Participants were children who did a five-week intake stay at the Stand village. These children

were between the ages 5-13 years old, and they participated in two Group Theraplay sessions. We

aimed to have five consenting/assenting children in each Group Theraplay group across two weeks to

allow for a buffer in order to achieve the minimum number of 8 participants.

 29

There were five children in each GT session on each week. One of the children in week one

decided not to proceed with the interview, so they were excluded. The children who participated in the

Group Theraplay sessions and subsequent follow-up interview consisted of 2 females and 7 males

ranging from 6 to 13 years of age (M=9.6 years, SD=2.45 years). The age, gender and group

membership are summarised in table B.

Table B. Participant’s age, gender and group membership

Age Gender Group

Child 1 12 Male Week 1

Child 2 12 Male Week 1

Child 3 11 Male Week 1

Child 4 7 Male Week 1

Child 5 13 Female Week 2

Child 6 9 Male Week 2

Child 7 9 Male Week 2

Child 8 8 Male Week 2

Child 9 6 Female Week 2

Selection Criteria

The children who participated in the study will be those who are already receiving support

through therapeutic intervention in the village at Stand Tū Māia Christchurch. The children who

attend Stand are all children who have experienced trauma. Stand’s focus is to protect children from

further trauma, support their recovery and enhance their wellbeing ("Stand Tu Maia," 2018). Children

and whānau must be referred to Stand through a health practitioner. Children had to be willing and

able to take part in other Theraplay activities that Stand run, such as Sunshine Circles to meet criteria

to be involved in the study. Children who struggled to participate or who found Sunshine Circles
 30

overwhelming were excluded. This is due to not wanting to cause any undue stress on children.

Children from outside the Canterbury region were excluded due to uncertainty of their stays as this

study look place during Covid-19 alert level 2. All children in this study also participated in Sunshine

Circles five times a week. It was particularly important to see consistent participation and involvement

in Sunshine Circles as Group Theraplay is a more intensive type of Theraplay compared to Sunshine

Circles. Children must complete two Group Theraplay sessions in order to meet inclusion criteria of

this study. Children needed to have parental or caregiver consent to participate in the study. Each child

also had to give their assent for participation both ahead of the GT sessions and right before the

interview.

Post Group Theraplay Interviews

Children participated in two Group Theraplay sessions in one week, on a Tuesday and

Thursday. Upon completion of the two Group Theraplay sessions, a follow-up interview was

conducted on the Friday. This interview was semi-structured, using open ended questions giving

children a chance to express their thoughts and feelings of Group Theraplay. The purpose of this was

to record any common themes among children’s responses.

Semi structured interview questions were open ended and focused on the child’s thoughts and

feelings of Theraplay. During the interview, children were taken to a familiar room for the interview

to ensure they felt comfortable.

The interview questions were:

- How do you feel about doing group Theraplay?

- Is there anything you like about group Theraplay?

o Which parts?

- Is there anything you do not like about group Theraplay?

o Which parts?
 31

- Is there anyone you can think of who you think should be doing group Theraplay?

o How come you think they should be doing it?

- Do you feel group Theraplay helps you?

o How so?

- How do you feel when you’re doing Theraplay?

- Does it make you feel any different?

o How so?

- How do you feel after you’ve done group Theraplay?

Audio Recordings and Transcripts

Interviews were audio recorded. These audio recordings were used to create a written

transcript for each interview. Once these written transcripts were created, the audio recordings were

destroyed.

Ethical Considerations

This study was approved by The Human Ethical Committee prior to the commencement of this

study (HEC 2021/83) (Appendix F). For this study I needed to consider the children’s needs and

remain sensitive to them as this is considered a vulnerable population. I remained mindful of this to

ensure no emotional distress was caused.

This study maintained confidentiality and privacy of participants by ensuring all data is secure.

Physical data was kept secure in a locked filing cabinet, and electronic data was secure on a password

protected computer that only I had access to. Data will all be destroyed upon completion of the study.

I created a child information sheet and a parent information sheet outlining all information about the

study and what it involves as well as privacy and confidentiality (See Appendices A, C and D). I

explained this in an age-appropriate manner to the children to ensure understanding.

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Parental informed consent and child assent was obtained without causing any perceived duress

to participants. This was done by making it clear that participation is completely voluntary and does

not affect the village stay if they do not wish to participate. Participants were all also made aware that

they can withdraw at any time without any penalty. Consent and Assent forms can be found in

Appendices B and E.

Procedure

Dates of the study were arranged by the Therapeutic Care and Education (TCE) Team Leader.

The TCE Team Leader also arranges dates of children’s stays. Once dates were confirmed for the

study to take place, I followed this procedure:

- Access the Stand database and select all children who will be attending Stand in the week that

the GT sessions are planned for.

- Email each child’s social worker to send out the Information Sheets and Consent forms to their

caregivers a week before the Study commenced. Social workers were asked to exclude the

children who were unable to participate in other Theraplay activities such as Sunshine Circles

as part of the exclusion criteria.

- When the children and whānau arrived onsite, caregivers were given a hard copy of these

Information and Consent forms and a staff member with an understanding of the current study

explained the study, answering any questions caregivers had. Caregivers were then given an

opportunity to fill out consent if they chose to. For children who required transport to Stand,

the same process was undertaken, except the staff member took the Information and Consent

forms with them upon pick up.

- Once consent was achieved, the team leader on shift then went through the Assent form with

the children who had informed consent from their caregivers.

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- The team leader on shift also went through the Child Information form and answered any

questions the children had about the study.

- All children with Assent and Consent then participated in two Group Theraplay sessions on the

Tuesday and Thursday. The children were all aware that they did not have to do these sessions

if they changed their mind. Originally the plan was to have one Group Theraplay session per

week, but due to the intake of children changing on a weekly basis, we were unable to get a

group together that were attending Stand for two consecutive weeks. This was largely due to

this study taking place a few weeks after a Covid-19 alert level 4 lockdown.

- On the Friday, children were then taken one by one for an interview.

- Children are asked to give their Assent again before the start of the interview if they still want

to be a part of it. If they gave Assent, the interview was then commenced.

- Children are told that they can stop the interview without any penalty if they wish to do so or

skip any questions they do not want to answer. At the end they are then thanked for their

participating and for completing the interview.

Materials

Group Theraplay: bubbles, lotion, powder, black paper, bean puppies, feathers, newspaper,

flavored chips and juice, toilet paper, bean bags, crepe paper, duck-tape, cups, potato sticks and

cushions.

Interviews: colouring-in pages and pens, pop-its, foam slime, uno cards, monopoly deal cards
 34

Chapter 4: Results

PART 1: Superordinate themes and Sub-themes

The analysis of participant responses identified two superordinate themes, and a number of sub-

themes, that are summarized in table C.

Table C. Superordinate themes and sub themes

1. Perceptions About Group Theraplay

a. Recognition of what Group Theraplay is

b. Enjoyment of Group Theraplay

c. Likes and Dislikes

d. Purpose of Group Theraplay

2. Positive Social-Emotional Skills

a. Peer Relations

b. Self-Confidence

c. Emotional Regulation

Theme 1: Perceptions About Group Theraplay

The first theme identified is one of the most important themes for this interview as it explores

each child’s perceptions toward their experience of doing Group Theraplay. This was the most in

depth theme discussed in the interviews.

1a. Recognition of what Group Theraplay is. All but one child was able to identify what

Group Theraplay was. Some children also made the connection that GT is similar to Sunshine Circles

which is run every morning in the village.

Child: “We did the sunshine circles … but different.”

Child: “So we basically do [a] Sunshine Circle”

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1b. Enjoyment of Group Theraplay. When the children were asked how they feel about Group

Theraplay, each child was able to verbalize a feeling. Most children expressed positive feelings

toward GT. The most common response from children was “Happy”, with 6 children using this word

to describe how they felt doing GT. Some children expressed some hesitation toward their initial

experience of doing GT. Three children also described participating in Group Theraplay as “weird” or

“funny”.

Child: “feels kind of funny”

Child “Makes me happy … and makes me a little weird”

Child: “Happy … because it’s so much fun”

Child: “It feels a bit weird since I’m, like, picked out of a special group. Some kids got to do it

and then the other kids go into the classroom and have to do other stuff”

The last quotation was referring to the children who had consent to do GT speaking about the

children who did not participate in GT and continued with the regular classroom schedule.

One child also described their initial experience as “Nervous” to begin with before they started to

get more comfortable with the intensity of the environment.

Child: “It feels nervous when you start, but then it starts to feel better”

Children described how they felt after GT in many different ways, all of which were positive. Four

children said they felt “Good” and two said they felt “happy”. Another child used the word “proud” to

describe how they felt after GT. They said that this was due to their growth in participation and

engagement over the course of the two sessions.

Child: “I felt proud of myself. Because I was like, normally, at the first time I was really

nervous and didn’t talk as much. The second time I felt really proud of myself, because I

actually was, like, talking and doing the games”

 36

One child said they felt “Sad” after GT. This was because the child wanted to continue doing

GT. This statement expressed the enjoyment the child felt while participating in GT, due to not

wanting to leave the group.

Child: “I just feel sad because I want to keep playing and doing it”

Another child when asked how they felt after completing GT expressed dissatisfaction after doing

GT.

Child: “Not happy, because yesterday I just got dropped off like 2 seconds after it”

Throughout the interview, this child had expressed that they “loved everything” when

clarifying/rephrasing and asked how they felt after GT before they knew they had to leave to go home,

the child then answered with “Happy”.

1c. Likes and Dislikes. When asked what the children liked about Group Theraplay, all children

were able to answer with at least one activity which they enjoyed about GT. Six children said that they

liked “everything”. The food share component of GT was the activity most mentioned when children

were asked what they liked about GT, with every child mentioning the chips and/or juice box at some

stage in the interview. Another activity highlighted was the back massage/making pizza activity. Both

of these activities were Nurture activities. Another part of GT highlighted by a child with what they

liked was the staff member that they were paired up with. Another activity mentioned as something

they liked was the karate chop activity.

Child: “I loved everything”

Child: “The food and the back massage … I liked all of it”

Child: “We do snack time which was my favorite thing to do”

Child: “karate chopping the paper … and just being funny”

 37

One other child highlighted what they like about GT was to get the opportunity to speak and to

be heard.

Child: “That we all got, like, a chance to like, do something. And to like speak in it.”

When each child was asked if there was anything they did not like about Group Theraplay,

most children responded with “no’ or that they liked/loved everything. One child responded that they

did not like when it was time to leave.

Child: “No … Oh yeah, when it was time to leave”

1d. Purpose of Group Theraplay. Children were asked if they knew why they were doing

GT. All but one child responded with “I don’t know” or “no”. The one child who responded

differently said that the purpose of GT was to have fun, but also followed this up by saying they did

not know any other reason as to why.

Child: “I don’t know. You just got some food and juice”

Child: “Because we can have fun, and I don’t know what else”

Four children were able to identify someone in their life that should be doing GT. One child

mentioned their sibling should do GT because they are “naughty” and just got suspended from school.

They identified that GT would help with their sibling’s behaviour. Another child identified another

child in the village who should do GT. They said that they thought this child would “appreciate it” or

make a new friend. They recognized that this other child in the village would enjoy doing GT and get

something beneficial out of it. The third child identified their mother as someone who should do GT,

because she went to a health camp too when she was younger. The fourth child identified a friend who

should do GT.

Child: “My mum has the potential [to be] doing it, but I don’t think she will. She used to go to

a health camp too”

 38

Child: “[Named sibling] because he’s real naughty … to help him because he got suspended

… for his behaviour”

Child: “[named another child in the village] because he looks like he wants to go to

Theraplay. He looks like he should go in it … he will definitely appreciate it, he’d like it, he’d

really like it a lot. Or actually create a new friend, everybody is my friend there now”

Child: “One of my friends because it’s a boy … because I really want him to work with me.”

Theme 2: Positive Social-Emotional Skills

Children identified three positive social-emotional skills gained from attending GT sessions.

2a. Peer Relations. When asked if Group Theraplay helps, three children reported that they felt it

helped with their social skills. Most children made mention to positive peer interaction while doing

GT. When asked if they feel like GT helps them, two children said it helps them talk to people and

another said it helped them meet new people. Children also spoke about making friends in GT.

Child: “Everybody there is my friend now”

Child: “It helps me meet new people”

2b. Self-Confidence. One child was able to identify that participating in GT improved their

confidence. During the interview, this child said that in the beginning of the GT session they felt

nervous and would not speak in front of the group or participate, but by the end of the second session

they felt more confident and were able to speak in front of the group.

Child “I feel like it makes me more confident and speaking in front of people”

Child: When I first went up there, I wanted to speak, but I would just say no. And then the second

time … I kept getting confident”

2c. Emotional Regulation. Three children said that GT helped them learn. However, when asked

how they felt it helped them learn, they could not identify specifically what they learnt in GT. One
 39

child said that GT helped them calm down, and another child said it made them feel “relaxed”.

Another child identified that GT helped with their anger.

Child: “Helps me learn.”

Child: “Yeah … because I get free food … my anger a bit and talking to people.”

Child “It does help me a little bit … because it’s fun”

Child: “It helps me calm down … and meet new people”

One child when asked what they learnt in GT was able to elaborate on one of the challenge

activities in GT where the group passed a toy puppy around the circle.

Child: “I learn more … like lots of fun stuff … so much fun stuff. Like passing the puppies,

that was so hard. That was hard, it was really hard”

Part 2: Participants Ability to Accurately Recall Theraplay Activities

Children spoke frequently about the activities they did in the GT sessions during the

interviews. Activities from each dimension of Theraplay were mentioned in the interviews.

Nurture activities

The food share component was the most mentioned in all the interviews with the children,

every child mentioned either the chips, juice box or both. This activity is one of the most nurture

intensive activities, where the adult will feed the child an item of food, in this case, a chip. The

children were asked to guess the flavour of the chip to take the emphasis and discomfort away from

being fed.

Child: “We got some chips and we had to figure out which one was which. They were ready

salted and chicken flavoured chips. We had to look at which one was which and guess them

and stuff. I didn’t get them fed, I just put them in my hand.”
 40

Child: “We had some chippies and guess the chippies … the people with you they feed you. I

guess potato and it was potato”.

Child: “We had juice and we had food. We had to guess what type of food … and I got it

right”

The other nurture intensive activity is “Check-ins”. In the GT groups an option of lotion,

powder or cotton balls were given to the children. The adult will purposefully use one of these three

items on the child’s hands while soothing the child, using skin-to-skin touch. The adult will also ask

the child about themselves making the activity solely about the child’s needs. This activity also uses

challenge while maximizing nurture to prolong engagement This activity was mentioned in two of the

interviews.

Child: “The first time we had black paper and we had lotion on our hand, and then we put it

on the paper and put the powder over it. I mean fingerprints”

Child: “Like we started off, we do like the lotion or cotton balls”

Another nurture activity ran in one of the groups was the “making pizza” activity

where the adults massaged the child’s back using different sensations on their back for the different

ingredients of the pizza. This activity used co-regulation to achieve optimal arousal. The massaging

used proprioceptive pressure to regulate, soothe and calm the child.

Child: “We done this pizza making thing. We lie down and then the person makes pizza, so say

cheese and you go like that [Child demonstrates massage type movement]”

Children accurately recalled all nurture-based activities mentioned in the interviews. The food

share activity was the most mentioned activity, with every child mentioning it in their interview.
 41

Challenge activities

A few challenge activities mentioned in the interviews included Zoom/erk and Karate Chop.

Zoom/erk is a circle activity where you pass the “zoom” to the person on your left or “erk” to your

right. To add more challenge to the activity, the children can go “splash” passing over to anyone in the

circle. This game builds mastery through safe and predictable structure.

Child: “I don’t remember the name of it, but it was when you can do… so you’re in a circle

and then sort of like brushing goes zoom that way and you just go around the circle, but if you

want to make it go the other way, it’s erk, and then even that could be in the way. And say you

want to like; oh, I’m here, but I wanted to give it the person over me you go splash”

Karate chop used crepe paper where the child would punch, or karate chop this paper in half.

This activity builds on a child’s mastery and experience of success.

Child: “we ripped paper …we karate chop them or punch them … it was fun”

Feather drop is a challenge game designed to increase confidence and experience mastery.

This is where the adult drops a feather for the child to catch.

Child: “We would like catch feathers. [the staff] would chuck them up and then we catch

them”

Cushion jump was another challenge activity where the child relies on the adult, they are

paired with to achieve the increasingly difficult levels of challenge. This activity also aids to increase

the ability to self-regulate and wait while participating in this upregulating activity.

Child: “And we done pillow stacking and see if you can jump from one foot … so like, you

know the big pillows … the record for jumping onto a couch with one foot, so like hopping

kind of, is four. And we got fourteen”

Many different challenge activities were mentioned in the interviews, all but one child spoke

about a challenge activity in their interview. Children all recalled the challenge activities accurately.
 42

Three children spoke about these activities in an accomplished manner, appearing proud of the

achievement. This was seen through their open body language and smiling facial expression.

Engagement activities

The line walk was an introductory activity at the beginning of the second group, this

engagement activity was mentioned by a couple of different children in their interviews. This was the

only engagement-based activity mentioned in the interviews.

Child: “There was tape on the ground, and we followed it”

Child: “The second time there was tape on the ground and with one, like two feet on the line

and then we went backwards toward the door”

Structure activities

A structure activity mentioned in the interviews was the pass the puppy activity where a

stuffed toy puppy was passed around the circle from the child head to the next person’s hands until the

puppy goes around the whole circle. This also creates an element of challenge for the child. The

purpose of this is to achieve cohesion in the group and increase group connection.

Child: “So much fun stuff like passing the puppies, that was so hard”

Another structure game was Simon Says. This was mentioned in two interviews. The purpose

of this game provides an opportunity to experience successful engagement.

Child: “We did Simon Says … I didn’t even fall for it”

Children did not speak in much detail about structure-based activities.

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Chapter 5: Discussion

The aim of this study was to determine the treatment acceptability of Group Theraplay in

socially disadvantaged children as reported in semi-structured interviews. The research question

sought to answer how socially disadvantaged children perceive their experience of Group Theraplay.

This was carried out through the use of a semi structured interviews with children who participated in

Group Theraplay at the Stand Tū Māia Christchurch village. Through the use of IPA, two

superordinate themes were found. These superordinate themes and subthemes were specified in the

results section. Notable Theraplay activities mentioned in the interviews are also outlined in the

results section.

The interviews identified many perceptions, attitudes, and feelings that children have toward

Group Theraplay. Though only two themes were identified, within these two themes were many

subthemes. This study will compare the results found to some past literature in the field. This will

highlight any consistencies or deviations found within the literature as well as any new findings. The

data from the current study was all taken from within the village at Stand Tū Māia Christchurch. As

mentioned in the introduction, Stand Tū Māia is a service for children who have experienced trauma.

This service works to protect children from future trauma as well as supporting their recovery and

enhancing their wellbeing ("Stand Tu Maia," 2018).

Summary of findings

Theme 1: Perceptions about Group Theraplay

Theme 1 is the main theme of this study regarding the research question and aim. This

addresses the key perceptions feelings and attitudes that children have about Group Theraplay which

directly links to children’s acceptability of the treatment. This theme included identifying what Group

Theraplay is, how children felt before, during and after the experience, and what they liked and

disliked about the sessions. It also included what children perceive the purpose of Group Theraplay

was.
 44

All of the children’s responses about their perceptions of Group Theraplay were overall

positive. There was one negative comment given which was not directly related to the Group

Theraplay sessions, but rather the ending of the session The sub-themes are discussed further below.

Recognition of what Group Theraplay is. Toward the beginning of the interview, children

were asked if they remembered going upstairs with the Theraplay practitioner and some of the other

leaders to do some activities to which all children recalled this. Children were then asked what it was

called that they participated in. All but one child was able to identify that it was Group Theraplay. A

couple of children took some prompting/rephrasing of the question. This involved repeating the

question and repeating where they went to do the sessions and who was there. The one child who did

not know what it was called said they had forgotten the name of it but remembered once the name was

said. The importance of this question was to ensure children had an understanding of what Group

Theraplay was and to ensure they knew the questions they were answering were about these sessions.

The fact that majority of the children were able to identify Group Theraplay was a positive result.

A number of the children interviewed were also able to make the connection between Group

Theraplay and Sunshine Circles. Some children made a comment after identifying what Group

Theraplay was, that it was like Sunshine Circles. All children who participated were also doing daily

Sunshine Circles as part of their regular intervention programme with Stand Tū Māia. This meant that

they were all very familiar with the process and running of a Group Theraplay session as there is

overlap in the activities and the setup of the session. This connection demonstrated that the children

had a deeper understanding of what Group Theraplay is.

Enjoyment of Group Theraplay. A standout finding in the interviews was the positive words

that children all had toward their experience of Group Theraplay. Every child perceived their

experience as positive overall. All children used the words happy or good to describe how they felt

when participating and after participating in Group Theraplay. Several children also used the word fun

to describe their experience and the activities. These findings are in line with the findings of Siu
 45

(2009), with majority of children rating their experience as happy, and rating the experience as fun,

which is what has been seen in the current study. The current study’s findings around the enjoyment

of Group Theraplay also align with the findings from Francis et al. (2017), which found that children

enjoyed their sessions of Group Theraplay. Children did not use any overtly negative words to

describe their experience of Group Theraplay.

A few children described their initial feelings as nervous and weird. This is likely due to the

intensity of the sessions. This might also be due to Theraplay’s focus on the “baby brain” by soothing

and nurturing the children (Bundy-Myrow, 2000). This experience is often perceived as strange and

maybe even a little uncomfortable for the child in the beginning. Children tend to use a lot of social

referencing particularly at the beginning of a new situation to see what their peers around them are

doing. Social referencing is where one observes another individual to comprehend an obscure

situation in order to guide their own actions (Feinman, 1982). All three of these children later in their

interview described their experience as happy or good.

Likes/dislikes. When asked if there was anything the children did not like about GT, all but

one child responded saying there was nothing they did not like. The one who stated otherwise said

they did not like when the session was over. There is potential that children were giving me the

answer that they perceived that I would want to hear due to the power imbalance of an adult-child

interview. Children will often try to produce the ‘right’ answers in order to please the adult

(Einarsdóttir, 2007). This is something that needed to be taken into consideration when evaluating

what children disliked about the experience.

When asked if there was anything they liked about Group Theraplay, children identified

various activities they enjoyed about it. A common answer was the food and drink they received in

GT, with some children saying the food share was their favourite thing about GT. This may be due to

the children perceiving the food share as a treat. The food that was given in the food share was potato

chips and the drinks was juice. Several children when asked if there was anything they liked about GT
 46

responded saying they liked everything. It is important to also consider the concept of children

potentially perceiving this answer as the ‘right’ answer as outlined above (Einarsdóttir, 2007).

Children may not have wanted to pin-point what they really enjoyed in the sessions without making

the rest of the session seem as though it was not as good. This is likewise with pointing out any

dislikes they had.

Purpose of Group Theraplay. When children were asked if they knew why they were doing

Group Theraplay, all but one child responded with either “no” or “I don’t know”. The one child who

responded differently said that the purpose was to have fun. This result was not surprising as children

were not told why they are doing Theraplay at the beginning of their first session. It may be beneficial

to tell children at the beginning of their first session how Theraplay is designed to help them. When

asked directly if children new why they did Group Theraplay, all children said they did not know,

however, asking the children an indirect question around the purpose of Theraplay found more of a

response.

A handful of children were able to indirectly demonstrate their understanding of the meaning

and purpose of Theraplay by identifying someone in their life that they felt should be doing Group

Theraplay. Four children identified a person in their life and were able to give a reason why they

should do Group Theraplay. Each child also expressed a different reason as to why that person in their

life should do Group Theraplay. The reasons identified for why the person in their life should do

Group Theraplay were based around behaviour difficulties, building peer relationships and enjoyment.

This shows that some of the children have identified why they do Group Theraplay and what it can

help with. This also demonstrates the versatility of Group Theraplay as an intervention (The

Theraplay Institute, 2021). It also indirectly showed that children somewhat understand the purpose of

GT and how it may help the person that they identified who should participate.
 47

Theme 2 Positive Social Emotional Skills

The second theme identified three social emotional skills that children learned or built on

during their experience of participating in Group Theraplay. These social emotional skills were

identified in the children’s interviews These skills were labelled as subthemes peer relations, self-

confidence, and self-regulation. These responses largely were identified through asking children if

they felt Group Theraplay helped them and how they think it helps them. All children responded with

yes when asked if they felt Group Theraplay helps them.

Peer Relations. A common response was that Group Theraplay helped the children to talk and

meet new people. A few children expressed that they felt they knew everyone at the end of their

second session. Some children even said they had made a friend while in the groups. Peer relations is

an important skill for children to have. Its importance is especially high in socially disadvantaged

children as this is an area many of these children struggle with. Maltreated children have been

reported to have less satisfactory peer relationships and more negative self-concepts when compared

to children who have not been maltreated (Cicchetti, Lynch, Shonk, & Manly, 2016). It has been

found that positive peer relations in those that have experienced childhood trauma is a protective

factor during adolescent development. It is also a useful preventative approach for helping youth to

cope with trauma experiences (Sokol et al., 2020). Teaching children these positive peer relation skills

can promote positive development in future and act as a protective factor toward future traumatic

experience.

Self-Confidence. One child in the interviews spoke frequently about their gain in confidence

during the GT sessions. The confidence gained was in relation to speaking in front of the group and

participation in the Theraplay activities. This subtheme relates closely to the previous subtheme in

positive peer relations around gaining the confidence to speak to peers. A lot of activities in Group

Theraplay are based around experiences of mastery and experiences of success to build confidence.

Theraplay also has an emphasis on ‘no hurts’ creating a safe space for children and providing a
 48

supportive environment for children to build on their self-confidence around participation (The

Theraplay Institute, 2021). Self-confidence is an attribute that is linked to resilience. Resiliency is a

protective factor against maladaptive outcomes (Troy & Mauss, 2011). Building on skills in self-

confidence can then be a protective factor for children. Although this skill was only directly

mentioned by one child in the interviews, it is possible that some of the other children built skills in

this area. This is due to many of the children expressing that they learnt new skills in peer relations,

which they may have used new skills learnt in self-confidence to do so.

Self-Regulation. The third positive social-emotional skills subtheme is self-regulation. In the

interviews, when children were asked if they felt Group Theraplay helps them, many said that it helps

them learn. Although some could not articulate what specifically they learnt, some children were able

to identify that it helps with anger, or it helps them to feel calm and relaxed. As mentioned in the first

chapter, self-regulation is an essential component for a child’s development. A traumatized child can

have extreme difficulty self-regulating or may be unable to self-regulate (Saxe et al., 2005).

Theraplay uses co-regulation to aid with building on the child’s self-regulation (Tucker et al.,

2021). The GT sessions used a mixture of up regulated and down regulated activities to increase the

child’s window of tolerance ("The Theraplay Institute," 2021). Children who have learnt to self-

regulate are able to regulate themselves to the activity. Children that reported that GT helped them feel

calm and relaxed suggests that they may have learnt how to regulate themselves more effectively. This

is a significant finding due to children’s perceptions around their learnings of self-regulation being in

line with that of the purpose of Theraplay.

Participants Ability to Accurately Recall Theraplay Activities

In the interviews, children spoke a lot about the activities they did during their sessions. All

activities that were spoken about were accurately recalled. I felt that this section was important to add

in not just to see how well children were able to recall the activities, but to see which activities made

the biggest impression for the children who participated in the GT sessions. The purpose of this is to
 49

give each child free reign to talk about the activities and to speak about anything they may have liked

or disliked about them. This information could then potentially help to aid future Group Theraplay

sessions to try and keep them as fun and enjoyable for the children as possible.

The two most spoken about dimension activities of Theraplay was the nurture and challenge

activities, with children speaking to most of the activities they did within these dimensions in the GT

sessions. Engagement and structure activities were less talked about. However, these two dimensions

are often utilised throughout each activity and in interim activities of the sessions.

Nurture activities. The food share component of the GT sessions was among one of the most

widely mentioned activities in the interviews with every child mentioning this at least once in their

interview. Many children also reported that this was their favourite part of the session. It is possible

that children perceived the food share as a treat as they were given chips and juice. This activity is a

very nurture intensive activity, this is due to its nature where the adult will feed the child. Its purpose

is to increase the child’s capacity of receiving nurture. It is also possible that the children in the

sessions were quite nurture-seeking children, which is why they may have expressed this as their

favourite part. This activity may have proven popular with children due to the perception that the

children were receiving a ‘treat’.

The other nurture intensive activity in the GT sessions that was widely mentioned in the

interviews was “check-ups” using lotion, powder, or cotton balls. A few children described in their

interviews what the check-ups entailed. The purpose of this activity is to use skin-to-skin touch to

soothe the child. This activity may have been significant to children due to the level of nurture used in

this activity as it utilises skin-to-skin touch.

Challenge activities. Children spoke about a range of different challenge activities in the

interviews, with the most mentioned activities being karate chop and zoom/erk. Many of the children

were observed to talk about these challenge activities with a sense of achievement. They appeared to
 50

have proud and open body language when explaining the activity. Some children also spoke about

their experience of achievement of the activity after explaining how it worked. The purpose of most

challenge activities is to give each child an experience of mastery and success. It appears that

achieving these activities might have been empowering to the child judging by the manner in which

they spoke about the activities and speaking about their achievement.

Engagement activities. One stand-out engagement activity was the line walk. This was

mentioned in a couple of the interviews. This activity started off the second session of week 1 and

week 2 groups. This activity incorporated an element of challenge which may have meant children felt

a sense of achievement upon completion. This may be why this activity was mentioned in the

interviews. Engagement is a dimension often used a lot at the beginning of a GT session in order to

gain children’s attention and participation in the group. It is then utilised throughout the session in

other dimension activities to focus on the adult presence with the child ("The Theraplay Institute,"

2021).

Structure activities. Like engagement, structure is a dimension that is often utilised

throughout the session and is used within other activities. The only two structure activities that were

mentioned in the interview was a structure/challenge-based activity called puppy pass and Simon says.

Simon says is a classic children’s game which most children are already familiar with. Puppy pass

was mentioned by one child in the interviews. This child expressed how difficult they found this game

and how they managed to achieve it. The challenge element of this activity was what appeared to

really stand-out through this child’s experience of mastery. This dimension was the least spoken about

of the four dimensions, likely due to its nature of being scattered throughout the sessions in order to

keep an organised, predictable environment that communicates safety ("The Theraplay Institute,"

2021).
 51

Implications

The results of this study suggest a high treatment acceptability of Group Theraplay in socially

disadvantaged children. This can be seen through the positive perceptions, feelings and attitudes

children shared toward GT in their interviews as outlined in theme 1, and the positive social-emotional

skills children expressed that they learned in the groups as outlined in theme 2. Findings around child

perceptions of Group Theraplay appear to align with The Theraplay Institutes claims of this

intervention, with children finding this experience enjoyable and fun. The social-emotional skills

subthemes also aligned with The Theraplay Institutes claims around expanding arousal regulation,

social engagement and developing positive self-esteem ("The Theraplay Institute," 2021).

Theme 1: Perceptions about Group Theraplay

Results of theme 1 suggest that children perceive GT as fun and enjoyable, making them feel

happy and good. These findings are in line with both the satisfaction questionnaire by Siu (2009) and

the semi-structured interviews by Francis et. al, (2017). These studies incorporated the child’s voice

and aided the research of this current study around the child’s perceptions of GT. This theme answers

the research question of this study, finding that children perceive GT as positive and enjoyable. These

findings also support The Theraplay Institute’s claims of Theraplay being an enjoyable and fun

intervention for children. The element of fun and enjoyment is the main aim for Theraplay as an

intervention ("The Theraplay Institute," 2021). This implication suggests GT has a high treatment

acceptability among this population of children. This will in turn have an impact on Theraplay’s

treatment effectiveness and success (Kazdin, 2000).

Another implication in this superordinate theme was children’s lack of knowledge around the

purpose of Theraplay. All children expressed that they did not know why they were doing GT when

they were asked directly. However, some children showed an understanding as to why they were

doing GT indirectly by suggesting someone in their life that they think should be doing GT. A

possible solution to increasing children’s knowledge around why they do Theraplay would be to give
 52

children some education in the purpose of Theraplay either on their first day of their stay at Stand or

before their first Theraplay session. This solution could also be used for education around the purpose

of Sunshine Circles as well as in Group Theraplay.

Theme 2: Positive Social-Emotional Skills

The implication of the second theme identified social-emotional skills that children were able

to build on in the Group Theraplay sessions. These skills were peer relations, self-confidence, and

self-regulation. This finding confirms some of the skills that the intervention Theraplay aims to

develop. The Theraplay Institute (2021), claims that Theraplay aids children to learn to establish

social engagement, felt safety, expanded arousal regulation and positive self-esteem. The current study

supports The Theraplay Institutes claims of some of the skills Theraplay teaches children. The current

study has added to the literature around the social engagement, expanded arousal regulation and the

positive self-esteem aspects of Theraplay. All three of these skills are important in the growth and

development of children, particularly those who have been socially disadvantaged and therefore might

be lacking in the development of these skills (Saxe et al., 2005).

Strengths

Some strengths exhibited in this study was the high level of experience that the Theraplay

practitioner and co-facilitators exhibited in GT both around planning the sessions and facilitating

them. This meant that the sessions were well planned and catered for the children participating in

them and running of the sessions was led confidently and in accordance with the rules of Theraplay.

Another strength of this study was the flexibility and ability to reassess the running of the GT sessions

in order to work around the changes in Stand Tū Māia as a result of Covid-19 and a recent Covid-19

lockdown. Both of these strengths ensured the smooth running of the study. A third strength was the

two strong superordinate themes that the results identified, along with the subthemes identified.
 53

Limitations

A significant limitation for this study was the presence of Covid-19 during data collection. Due to

a lockdown, the data collection phase was postponed. The lockdown also meant that there was a

smaller number of children coming into the village. This meant that there was a backlog of children

who had planned stays when the lockdown commenced. Children were then having shorter stays in

the village resulting in a change in the running of GT sessions, with the plan changing to two sessions

and interview over one week rather than two weeks due to groups of children were changing weekly.

Another potential limitation could have been an observant expectation bias. This is due to children

wanting to give the ‘right’ answer (Einarsdóttir, 2007). As I am employed with Stand Tū Māia,

children have seen me participate in Sunshine Circles in the village. Although I was not involved in

the Group Theraplay sessions of this study, it is possible that children could have perceived that I am

in support of Theraplay and therefore gave answers in response to how they perceived I felt about

Group Theraplay.

It is also important to consider a possible unconscious confirmation bias also due to my

employment with Stand Tū Māia. As part of my job, I participate in Sunshine Circles with the

children in the village. I have also completed basic training in Sunshine Circles. Although I have been

mindful to remain impartial to Theraplay, I feel it is important to consider this possible confirmation

bias as I am surrounded by this intervention in my workplace.

Another limitation would be the small sample size in this study and that this study. This study only

interviewed children in the Canterbury region of New Zealand. Both of these may have an impact on

generalizability of this study. The study design of this study is another limitation. This is due to the

fact a qualitative case-study design often lacks scientific rigour and difficult generalizability (Hyett,

Kenny, & Dickson-Swift, 2014). Another limitation to the study design is as mentioned above around

confirmation bias.
 54

Due to time constraints and frequently changing groups of children in the village as Stand, only

two Group Theraplay sessions were administered. Results may have been more accurate if there were

more GT sessions. Wettig et al. (2011) reported that to reach a therapeutic outcome, an average of 17-

18 sessions of Group Theraplay was required. The difference between the study by Wettig et al.

(2011) and my study is that my study was focused around child perceptions around treatment

acceptability of GT, whereas Wettig et al. (2011) was researching the effectiveness of Group

Theraplay around treating socially withdrawn children. In comparison, the study by Siu (2009) only

implemented eight GT sessions. The study by Siu (2014) implemented 20 sessions and the study by

Francis et. al, (2017) implemented 12-18 sessions. It is possible that a child’s perceptions may have

changed if the child reached their therapeutic outcome. More GT sessions may have identified more

superordinate themes in the interviews.

Recommendations for future research

Recommendations for future research would be to replicate this study with a larger and

broader sample size to achieve more generalizable results. This will confirm as to whether treatment

acceptability of Group Theraplay is high in socially disadvantaged children across New Zealand.

More research around Theraplay’s implementation specifically in New Zealand would also be

beneficial, particularly the cultural considerations around implementing Theraplay with Māori

children.

Another recommendation would be to implement more Group Theraplay sessions in the study

before doing the follow up interview. Implementing just two GT sessions per group may have proved

to be a limitation. Taking into consideration the number of GT sessions implemented in the studies

that were reviewed in Chapter 2, a more appropriate number of GT sessions may be 10-12 GT

sessions. This number reflects the amount of GT sessions that were implemented by the studies that

researched around the child’s voice (Francis et al., 2017; Siu, 2009).
 55

Another recommendation is to continue to do more research into the child’s voice around

Theraplay as a treatment intervention. Asking children for their perceptions of the treatment is

empowering to the child. One thing this study identified was the lack of research in this area when

considering the child’s voice.

Conclusion

This study sought to find child perceptions about Group Theraplay. Findings were all in line

with what has been claimed for Theraplay as a treatment. This study found two superordinate themes:

enjoyment of Theraplay and positive social emotional skills. Both themes suggest Group Theraplay

was positively received by participants, showing it to have high treatment acceptability. This study has

made a valuable addition to the limited literature there is on the treatment acceptability of Group

Theraplay. This is an important contribution to Theraplay literature because to my knowledge, there

has been no research done examining the treatment acceptability of Group Theraplay. Although this

study has opened a starting point for further research in this area, the academic integrity of this study

was affected due to the limitations present. Further research into the child perceptions of Group

Theraplay is needed to confirm these findings using the recommendations mentioned above.

Nevertheless, this research added new information to the field of Theraplay research through using

Group Theraplay as an accepted treatment in socially disadvantaged children.

 56

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Appendix A: Parent/Caregiver Information Sheet

School of Health Sciences

Telephone: +64 3 3693524
Email: [email protected]
01/11/21
HEC Ref: 2021-83

Treatment Acceptability of Group Theraplay: A survey on feelings

Information Sheet for Parent or Caregiver

Kia Ora, my name is Emma Marrison. You may have seen me around the village as I work
casually as a Therapeutic Care Worker. I also study Psychology at the University of Canterbury
with a goal of becoming a Child Psychologist. Part of my study means completing a master’s
research thesis which involves coming up with a small research project and writing a research
paper. I am doing this project at Stand. While working at Stand I have seen and learnt about
Theraplay and the difference it makes in our tamariki. I am interested to learn more about what the
children think about Theraplay and how they feel about doing the Theraplay groups. You have
been approached for your child to take part in this research because your child will be participating
in small Theraplay groups in their time at Stand. I have located your contact details through Stand.

If you choose for your child to be involved in this study, your child will be asked to participate in a
30-minute interview at Stand. I would try make the interview as fun and interesting as possible for
your child. I will have a small list of questions to ask your child during the interview. I will explain
to them that their answers about Theraplay will be written up in my study. I will audio record the
interview to allow me to focus on the interview rather than needing to scribble down notes. The
only information that will be included in the study is the children’s verbal answers about what they
think about Theraplay. You will be provided with a summary of the results of this study.

Participation in the study is voluntary and you also have the right to withdraw your child at any
stage without penalty. You may ask for your child’s answers to be returned to you or destroyed at
 60

any point. If you withdraw your child, I will remove all information relating to them. You may
choose to withdraw your child from the study at any time prior to the interview, and up to eight
weeks following your child being interviewed. Withdrawing will have no effect on your child’s
stay at Stand.

Why is the project being done?

I am doing this project because there is currently no research on what children think about
Theraplay. I am hoping to find out a little bit more about what children like and do not like about
Theraplay, and their overall feelings about it. Knowing this information can help Stand and many
other organisations improve their Theraplay programmes.

What would your children’s participation involve?

Participation will involve a single 30-minute interview with your child by myself (Emma
Marrison). The child may bring along another staff member for support if they wish.

What choice do you and your child have?

Participation in the study is completely voluntary. You can withdraw your child from the study at
anytime without giving a reason and without any consequences. If you withdraw, any information your
child gives will be deleted and paper records destroyed. Your child will also have to agree (assent) to
the interview themselves. I will ask them if they agree before and at the beginning of the interview.
Children can also decide to withdraw from the study.

What if my Child gets upset?

The interview will aim to be fun. The interview will consist of some set questions which will
allow your child to answer however they want. Your child will be able to answer the questions however
they feel, there are no right or wrong answers. I will be a familiar face to many of the children as they
may have seen me around at Stand working as a Therapeutic Care Worker. Your child can choose to skip
a question or stop the interview at anytime they wish. If your child looks visibly unhappy or upset, then I
will immediately stop the interview and involve your child in a fun activity.

How will your child’s privacy be protected?

All information about your family will be kept confidential and anything your child says in the
interview will be kept private, even from other staff members. The only exception is in the case of your
child disclosing harm or the risk of harm to themselves or others and in this case the Team Leader on
 61

shift will be notified. All the information about the study will be kept on a secure password protected
computer and in a locked filing cabinet and will be deleted or destroyed once the study is finished. No
names will be used in the research report, there will be no way for anyone to read the report and identify
who participated. This study is independent from Stand.

How will the information collected be used?

The results of my research project will be written as a University thesis and may possibly be
published as an article in an academic research journal. Quotes from participants may also be included in
the written Thesis and any other publications and presentations.

Who has approved this study?

This study is independent from Stand Children’s Services; however, approval has been given by
Stand’s regional manager. This project has been looked at and approved by the University of Canterbury
Human Ethics Committee, and if you have any complaints, you can send an email to The Chair, Human
Ethics Committee, University of Canterbury ([email protected]). If you have any questions
about this study, you can ask me, Emma Marrison ([email protected]), my supervisor Professor
Michael Tarren-Sweeney ([email protected] ) or you can contact Dr Petria
Thoresen ([email protected]).

Thank you for reading.

Emma Marrison
Master’s student
University of Canterbury
Email: [email protected]

Supervisor: Professor Michael Tarren-Sweeney

School of Health Sciences
University of Canterbury
Ph: +64 3 3693524
Email: [email protected]
 62

Appendix B: Parent/Caregiver Consent Form

Consent Form

School of Health Sciences

Telephone: +64 3 3693524
Email: [email protected]

Treatment Acceptability of Group Theraplay: a study on feelings

Consent Form for Parents or Caregivers

• I have been given a full explanation of this project and have had the opportunity to ask
questions.
• I understand what is required of me and my child if I agree for my child to take part in the
research.
• I understand that participation is voluntary, and I may withdraw my child at any time
without penalty. Withdrawal of participation will also include the withdrawal of any
information you and your child has provided should this remain practically achievable.
Withdrawal must be within 8 weeks of your child’s interview.
• I understand that any information or opinions my child provides will be kept confidential to
the researcher and that any published or reported results will not identify the participants. I
understand that a thesis is a public document and will be available through the UC Library.
• I understand that all data collected for the study will be kept in locked and secure facilities
and/or in password protected electronic form and will be destroyed after five years.
• I understand the risks associated with taking part and how they will be managed.
• I understand that I can contact the researcher Emma Marrison ([email protected]) or
supervisor Michael Tarren-Sweeney ([email protected]) for
further information. If I have any complaints, I can contact the Chair of the University of
Canterbury Human Ethics Committee, Private Bag 4800, Christchurch (human-
[email protected])
• I would like a summary of the results of the project.
• By signing below, I agree to participate in this research project.

Name: Signed: Date:

 63

Email address (for report of findings, if applicable):

[return forms back to the Team Leader on shift to make a copy of the forms. Please keep a copy of
the information sheet and consent form.]
 64

Appendix C: Child aged 5-9 Information Sheet

School of Health Sciences

Ph: +64 3 3693524
Email: [email protected]
Date: 01/11/21
Ref: 2021-83
A Study of Children’s Feelings of Theraplay

Child Information Letter

Dear ____________

My name is Emma, and I look after kids like yourself at Stand. You may have seen me round if you
have been here before! When I am not working at Stand, I go to a school for grownups called
University and I have to do a big homework assignment called a study. You probably know that kids
go to Theraplay at Stand. My study is asking kids what they think about Theraplay. I was hoping that
you could help me with my study by telling me what you think about Theraplay.

You do not have to be in this study. If you do not want to be in it, nothing about your stay at Stand
will change. If after you have started to take part, you decide you want to stop then we will stop
straight away.

About The Study

If you decide you want to be in the study, I will ask you some questions about how you feel and think
about Theraplay. You do not have to answer any questions that you do not want to. If I ask you a
question that you do not want to answer you can say skip and if you do not want to do the interview
anymore you can say stop. I will record your answers on a voice recorder so that afterwards I can
listen carefully to what you said. If you want to have another staff member to sit with you during the
interview, then let me know and I can arrange it.

I will keep all the things you say to me in the interview safely locked away where no one can see
them except for me. When I write about what you said to me, I will not use your name. Your parents
will not be able to hear anything you tell me. However, if during our conversation I hear anything
which makes me worried that you might be in danger of harm, I might have to tell other people who
need to know about this. If you want a staff member there to support, then they also promise not to
tell anyone what you say.
 65

Where The Interviews Go

When I have talked to all the children in my study about Theraplay, I will write about what I have
learned in a big written assignment called a thesis for my school. I will tell you and the other children
who have taken part what I have found out about Theraplay if you would like. I will delete the voice
recording I took with you after I have written down what you said during our talk. I will then get rid
of the notes when my big assignment is finished.

The Human Ethics Committee at the University of Canterbury and Stand Children’s Services have said
yes to me doing this study and have made sure it is safe. The Ethics Committee a group of people that
makes sure studies are safe. They are not part of the study.

Before we start the interview, I will ask if you have any questions or concerns about the interview or
my study, and then I will check again at the end of the interview. If you have any questions or
concerns after you have left the interview, then you can send me an email ([email protected])
and I will make a time to chat with you at Stand or on the phone.
If you have any other concerns, you can contact Dr Petria Thoresen
([email protected]) or you can contact my supervisor at University Professor
Michael Tarren-Sweeney ([email protected]).

This project has been looked at and approved by the University of Canterbury Human Ethics
Committee, and if you have any complaints, you can send an email to The Chair, Human Ethics
Committee, University of Canterbury ([email protected]).

Thank you for reading.

 66

Appendix D: Child aged 10-13 Information Sheet

School of Health Sciences

Ph: +64 3 3693524
Email: [email protected]
Date: 01/11/21
Ref: 2021-83
A Study of Children’s Feelings of Theraplay

Child Information Letter

Dear ____________

My name is Emma, I work at Stand as a Therapeutic Care Worker, you may have seen me round if
you have been here before! When I am not working at Stand, I go to University where I have to do a
big assignment called a study.

What is the purpose of the study?

The purpose is to find out what children think and feel about Theraplay.

Why have I been chosen?

You are being asked to take part because you are staying here at Stand, and you will be taking part in
Theraplay as part of your village stay.

Do I have to take part?

You do not have to take part in this study. If you decide not to take part, nothing will change with
your stay here at Stand. If you agree to be in the study but then change your mind, just let me know
and you can stop at any stage. If you decide not to be in the study after you have told me what you
think about Theraplay, then I won’t include your answers in my study.

What does taking part look like?

If you decide to take part, you will be asked to do a half an hour interview with me (Emma) after a
Theraplay session. In the interview, I will ask you some questions about how you feel and think
about Theraplay. You do not have to answer any questions that you do not want to. During the
interview, if there is a question you do not want to answer you can say skip and if you do not want
to do the interview anymore you can say stop. I will record your answers on a voice recorder so that
afterwards I can listen carefully to what you said. If you want to have another staff member to sit
with you during the interview, then let me know and I can arrange it.

Will the information that I give you in this study be kept confidential?
 67

I will keep the information in a locked cabinet or in a password protected file on my computer.
When I write about what I have found, your name will not be mentioned. Your parents will not be
able to hear anything you tell me. However, if during our conversation I hear anything which makes
me worried that you might be in danger of harm, I might have to tell other people who need to
know about this. If you want a staff member there to support, then they also promise not to tell
anyone what you say.

What will happen to the results of this study?

When I have gathered all the information from everyone who is taking part, I will write about what I
have learned in a big written assignment called a thesis. This will be read and marked by my teachers
at University. I will tell you and the other children who have taken part what I have found out about
Theraplay if you would like. I will destroy my recordings after I have written down in my notes what
you said, and I will destroy the notes when the project is finished.

Who has made sure this study is safe?

This study has also been approved by the Human Ethics Committee at the University of Canterbury and
Stand Children’s Services have given their approval for the study. The Ethics Committee a group of
people that makes sure studies are safe. They are not part of the study.

Who can I contact for further Information?

Before we start the interview, I will ask if you have any questions or concerns about the interview or
my study, and then I will check again at the end of the interview. If you have any questions or
concerns after you have left the interview, then you can send me an email ([email protected])
and I will make a time to chat with you at Stand or on the phone.

If you have any other concerns, you can contact Dr Petria Thoresen
([email protected]) or you can contact my supervisor at University Professor
Michael Tarren-Sweeney ([email protected]).

This project has been looked at and approved by the University of Canterbury Human Ethics
Committee, and if you have any complaints, you can send an email to The Chair, Human Ethics
Committee, University of Canterbury ([email protected]).

Thank you for reading.

 68

Appendix E: Child Assent From

School of Health Sciences

Ph: +64 3 3693524

Email: [email protected]

A Study of Children’s Feelings of Theraplay

CHILD ASSENT FORM

(Tick the green box if you understand and agree)
I agree to talking with Emma Marrison after doing the small group Theraplay at Stand.
I understand that I can stop anytime I want to and that I do not have to say why.
I understand that before I meet up with Emma, she will check again that I am happy to talk
with her.
I understand that the staff at Stand think that it is okay for me to talk with Emma.
I understand the information I give will not be shared with Stand.
I understand that I can have another staff member there to support me if I want.
I understand that if I am not happy with something that happened in the interview then I can
tell Emma or her teacher Michael (+64 3 3693524) or talk to Petria Thoresen
([email protected]) at Stand. I could also get help to message the Chair
of the University of Canterbury Human Ethics Committee, ([email protected]).
I agree (consent) to:
Talking with Emma while I am at Stand Children Services.
A microphone being used to record the talk that Emma and I have. When Emma finishes
writing the conversation into words, she will destroy the recording.

Child’s Name: (please write)

Signature:
Date:
AT TIME OF INTERVIEW
Child’s Name: (please write)

Signature:
Date:
 69

If you have any questions, please contact Emma Marrison via email. If you have any
concerns, you can contact Petria Thoresen ([email protected]) or you can
contact my supervisor Michael Tarren-Sweeney (+64 3 3693524 OR michael.tarren-
[email protected]). This project has been reviewed and approved by the University of
Canterbury Human Ethics Committee, and parents/caregivers or participants should address any
complaints to The Chair, Human Ethics Committee, University of Canterbury, Private Bag
4800, Christchurch ([email protected]).

Emma Marrison
Master’s Student
University of Canterbury
Email: [email protected]
 70

Appendix F: Human Ethics Committee Approval Letter

HUMAN ETHICS COMMITTEE

Secretary, Rebecca Robinson
Telephone: +64 03 369 4588, Extn 94588
Email: [email protected]

Ref: HEC 2021/83

27 July 2021

Emma Marrison
School of Health Sciences
UNIVERSITY OF CANTERBURY

Dear Emma

The Human Ethics Committee advises that your research proposal “Treatment Acceptability
of Group Theraplay for Children” has been considered and approved.

Please note that this approval is subject to the incorporation of the amendments you have
provided in your email of 20th July 2021.

Best wishes for your project.

Yours sincerely

Dr Dean Sutherland
Chair University of Canterbury Human Ethics Committee
 71

Appendix G: Stand Tū Māia Approval Letter

 72

Appendix H: Theraplay Group 1 Session 1 Plan

GROUP THERAPLAY SESSION PLAN

INTAKE: SESSION: 1 DATE: 2nd November 2021

GOAL:
• To increase competence and sense of mastery with the Theraplay activities and with
each other.
• Establish group cohesion and promote secure base with leaders.
• Increase individual’s confidence in group engagement.

Entrance Pick and animal and move in like an animal (depending on age
Engagement – to meet favourite game/movie character)
upregulated energy
(anxious about group)
Increase connection &
engagement through
shared joy

Structure – to down- Freeze/go – to increase structure – when I moo sit down

regulate and bring into
optimal arousal
Welcome to you today
Engagement – moment
in the spotlight/assess
tolerance of intensity
Structure - Safe Pass the bean bag –
predictable eye contact
via secondary
intersubjectivity

CHECK UP/HURTS
Nurture – assess Smiley face – lotion
responses to touch and Powder Palms – with or without powder
lotion/powder
Engagement Combine with check-ups and noticing

DIMENSION/ACTIVITY
Structure – Safety and Measuring (One to one)
Predictability, soothing
through distraction –
secondary
intersubjectivity

Nurture – Self-worth,
internal regulation Decorate Child
through co-regulation –
 73

increase sense of
secure base

D/ACTIVITY
Challenge – Increase
confidence and sense
of mastery Feather Blow/Feather Drop (one to one)

D/ACTIVITY
Engagement – co- Blanket Pass – fluffy balls one (add two to increase challenge)
regulation to remain in
optimal arousal

D/ACTIVITY Transition to standing - animals/colours

Structure – assess body Simon Says
organisation within
safe and predictable
structure

D/ACTIVITY Beans
Structure – experience
up-regulation through
safe, predictable co- OR sit and move into Zoom/Erk OR Karate chop
regulation.
Depending on child’s capacity for body organisation.

D/ACTIVITY Transition to sitting – animals or colours –

Structure/Challenge –
experience mastery
through safe and
predictable structure

D/ACTIVITY
Structure/Challenge – Karate Chop
experience mastery
through safe and
predictable structure

FEEDING
Nurture - Assess Guessing the flavour of the chip
comfort with receiving
food.
 74

EXIT/SONG
Nurture – down Twinkle twinkle Song x 2
regulate – self-worth,
empathy Good bye – name – good bye
Thanks for coming to play
Structure – Outer State
regulation
Favourite Colours – release to line –
Follow the Leader back to the Education Room

NOTES: Toilet paper/feathers/bean bags/crepe/flavoured chips

RESOURCES:
 75

Appendix I: Theraplay Group 1 Session 2 Plan

GROUP THERAPLAY SESSION PLAN

INTAKE: Group 1 SESSION: 2 DATE: 4th November 2021

GOAL:
• To increase all children’s confidence in engagement as well as group engagement.
• Increase capacity (of younger boys especially) to better manage their bodies and
externally regulate through experiences of proprioceptive pressure
• Increase experiences of success and mastery
• Increase capacity to remain in optimal arousal while maximising engagement and
increased intensity of noticing

Entrance
Engagement – to meet Tightrope Entrance with final jump into space
upregulated energy
(anxious about group)
Dance/dance – Freeze – (loud noise/big body movements) seated
Structure – to down-
regulate and bring into
optimal arousal Welcome to you today (name) – one clap.

Engagement – moment Thumbs Away (everyone places their left thumb down onto the
in the spotlight/ open palm of their neighbour and their right thumb upwards on
increase tolerance of their neighbours palm while seated in a circle. When the cue is
intensity given each person tries to lift their downward facing thumb to
Structure & Challenge - avoid being caught whilst simultaneously trying to catch the
Safe predictable repeat neighbours’ downward facing thumb).
of successful
engagement and
laughter (shared joy)

CHECK UP/HURTS
Nurture – use touch to Lotion – hand massage & or slippery slip (individual approach per
nurture and soothe child)
whilst assisting to keep
SES activated Combine with check-ups and noticing

Challenge & Nurture Pea Knuckle with lotion

Using challenge while
maximising nurture to
prolong engagement
(specifically with the
older boys)
DIMENSION/ACTIVITY

Feather Drop (one – to one)

 76

Challenge – Increase
confidence and
experience of success Beep Honk – Pass around – one then second then third –
and mastery remember my pattern then combination of three (own pattern).
Make up a new one, adults first (if needed).

Engagement- Increase
group connection,
cohesion and
engagement

Engagement - Expand Transition to standing – Zip Zap Magnets 4 rounds add if children
duration of responding.
engagement –
especially whilst
managing their bodies
during standing
(specifically younger
boys)
Challenge Cushion/Couch Jump
Increase opportunity
for experiences of
success and mastery.

Specifically for the

younger boys – to
increase capacity to self
–regulate and wait
during an up-regulating
activity

D/ACTIVITY
Structure/Challenge – Transition to sitting – animals or colours –
experience mastery
through safe and Zoom/Erk/Splash
predictable structure

D/ACTIVITY
Nurture – co-regulation
to remain in optimal Making Pizzas
arousal
 77

Proprioceptive
Pressure – to regulate,
soothing and calm

Experience down
regulation with in the
body

FEEDING
Nurture – Increase Guessing the flavour of the potato stick – no clues along with Juice
capacity of nurture boxes

EXIT/SONG
Nurture – down Twinkle twinkle Song - one round only
regulate – self-worth,
empathy
Good bye – name – good bye
Structure – Outer State Thanks for coming to play
regulation

Favourite Colours – release to line to the tight rope walk

Follow the Leader back to the Education Room

NOTES: Feathers/lotion/Duck tape/Potato Sticks/Cushions

RESOURCES:
 78

Appendix J: Theraplay Group 2 Session 1 Plan

GROUP THERAPLAY SESSION PLAN

INTAKE: Group 2 SESSION: 1 DATE: 16th November 2021

GOAL:
• To increase competence and sense of mastery with the Theraplay activities and with
each other.
• Establish group cohesion and promote secure base with leaders.
• Increase individual’s confidence in group engagement.

Entrance
Engagement – to meet
upregulated energy
through distraction Bubble pop walk/roll
(anxious about group)
Increase connection &
engagement through
shared joy
RULES
Structure – to down- Freeze/go or pass a move – to increase structure – when I moo sit
regulate and bring into down
optimal arousal

Engagement – moment We will Rock you X3 welcome (names) we will rock you X3
in the spotlight/assess (hands bang ground on Rock you)
tolerance of intensity
Structure - Safe Thumbs Away
predictable eye contact
via secondary
intersubjectivity

CHECK UP/HURTS
Nurture – assess Smiley face – lotion
responses to touch and Powder Palms – with or without powder
lotion/powder
Engagement Combine with check-ups and noticing

DIMENSION/ACTIVITY

D/ACTIVITY
Challenge – Increase Feather Blow/Feather Drop (one to one)
confidence and sense
of mastery
 79

Nurture – Self-worth, Lotion Print

internal regulation
through co-regulation –
increase sense of
secure base

Structure/Challenge – Progressive Pass around Pass the Pup - balancing on the hands –
experience mastery building up to five pups
through safe and
predictable structure
Re-engage & re-
connect group
D/ACTIVITY Transition to standing - animals/colours/cars
Engagement – co-
regulation to remain in Beans
optimal arousal Depending on children's vestibular/proprioceptive capacities and
body organisation go into Newspaper Punch standing or sitting

D/ACTIVITY
Challenge – Sense of
mastery and Newspaper Punch/Basketball Toss
competence Depending on child’s capacity for body organisation stand or sit.

Structure – experience
up-regulation through
safe, predictable co-
regulation.

D/ACTIVITY Transition to sitting – animals or colours –

Structure/Challenge –
experience mastery Zoom/Erk/Splash
through safe and
predictable structure

D/ACTIVITY

FEEDING
Guessing the flavour of the chip for a couple then just feed chips
plus juice box
 80

Nurture - Assess
comfort with receiving
food.

EXIT/SONG
Nurture – down Twinkle twinkle Song x 2
regulate – self-worth,
empathy Good bye – name – good bye (add a high five ?)
Thanks for coming to play
Structure – Outer State
regulation Favourite Colours – release to line –
Follow the Leader back to the Education Room

NOTES: Bubble Pop/ Lotion/Powder/Black Paper/Bean

RESOURCES: Pups/Feathers/Newspaper/flavoured chips + juice
 81

Appendix K: Theraplay Group 2 Session 2 Plan

GROUP THERAPLAY SESSION PLAN

INTAKE: Group 2 SESSION: 2 DATE: 18th November 2021

GOAL:
• To increase capacity for regulation across the group through co-regulatory activities.
• To provide opportunities for the children to receive nurture to positively impact their
IWM and sense of self.
• Increase individual children’s confidence in group engagement.
• Prolong capacity for adult led structure.
• Prolong capacity for engagement by expanding their WOT through shared joy.

Entrance Meet children with weighted animals – Breanna to lead them up.
Engagement & Double Tight Rope Walk - from door at top of stairs and down the
Structure – to down- hallway back up to the room
regulate alongside co-
regulating adult and Big Jump to X in circle
bring into optimal
arousal Freeze/go or pass a move – to increase structure – when I moo sit
down
Engagement – moment RULES
in the spotlight/assess
tolerance of intensity,
use of rhythm to calm We will Rock you X3 welcome (names) we will rock you X3
Structure (with (hands bang ground on Rock you)
elements of
engagement and
challenge) - Safe Thumbs Away
predictable
engagement to
promote sense of
safety & enhance
engagement through
shared joy and enhance
confidence through
experience of mastery

CHECK UP/HURTS
Nurture – increase Juice Box and Lotion
sense of being cared
for early on in the Combine with check-ups and noticing
session
Engagement

DIMENSION/ACTIVITY

D/ACTIVITY
 82

Challenge – Increase Tap Tap Pass (Progressive Pass Around with Cup)
confidence and sense
of mastery

Structure – Down Simon Says/Zoom - Erk

regulate through
increased need for
focus – opportunities
to experience
successful engagement.

Nurture – Down-
regulating activity to Making Pizza
achieve outer state
regulation and body
relaxation through
proprioceptive
pressure – increase
sense of secure base

D/ACTIVITY
Challenge – Sense of
mastery and Newspaper Punch/Basketball Toss
competence Depending on children’s capacity for ongoing engagement.

Structure – experience
up-regulation through
safe, predictable co-
regulation.

D/ACTIVITY Transition to sitting – animals

FOOD SHARE
 83

Nurture – Provide Guessing the flavour of the potato sticks for a couple then just feed
nurture for children chips plus juice box

EXIT/SONG
Nurture – down Twinkle twinkle Song x 2
regulate – self-worth,
empathy
Good bye – name – good bye (add a high five ?)
Structure – Outer State Thanks for coming to play
regulation
Favourite Animals out – release to line –
Follow the Leader back to the Education Room

NOTES: Duck-tape/ Lotion/Cups/Newspaper/potato sticks + juice (10)

RESOURCES: