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Whole Family Theraplay: IntegratingFamily Systems Theory and Theraplay toTreat Adoptive FamiliesKyle N. Weir a , Song Lee a , Pablo Canosa a , Nayantara Rodrigues a ,Michelle McWilliams a & Lisa Parker aa California State University–Fresno , Fresno , California , USAPublished online: 18 Nov 2013.

To cite this article: Kyle N. Weir , Song Lee , Pablo Canosa , Nayantara Rodrigues , MichelleMcWilliams & Lisa Parker (2013) Whole Family Theraplay: Integrating Family SystemsTheory and Theraplay to Treat Adoptive Families, Adoption Quarterly, 16:3-4, 175-200, DOI:10.1080/10926755.2013.844216

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Adoption Quarterly, 16:175–200, 2013Copyright © Taylor & Francis Group, LLCISSN: 1092-6755 print / 1544-452X onlineDOI: 10.1080/10926755.2013.844216

Whole Family Theraplay: Integrating FamilySystems Theory and Theraplay to Treat

Adoptive Families

KYLE N. WEIR, SONG LEE, PABLO CANOSA,NAYANTARA RODRIGUES, MICHELLE McWILLIAMS,

and LISA PARKERCalifornia State University–Fresno, Fresno, California, USA

This article regarding the effectiveness of Theraplay for the clinicaltreatment of adoptive families both outlines a model for integrat-ing family systems theory with Theraplay to create a new approachentitled Whole Family Theraplay (WFT), as well as provides a pre-liminary report of a pilot study demonstrating the efficacy of thatmodel. WFT integrates Theraplay with family systems approaches(Structural and Experiential Family Therapies) to treat parents andall the siblings within adoptive families. The findings indicate thatWFT treatment may lead to statistically significant benefits in re-gard to family communication, adults’ interpersonal relationships,and children’s overall behavioral functioning.

KEYWORDS adoption, play therapy, family systems, Theraplay,integration, clinical efficacy

Family therapy and play therapy are two treatment modalities that both havehistories of demonstrated efficacy (Bratton, Ray, Rhine, & Jones, 2005; Carr,2000a, 2000b; Charles, 2001; Cottrell & Boston, 2002; Crane & Hafen, 2002;Holder, 2008; Larner, 2004; Murphy Jones & Landreth, 2002; Pinsoff & Wynne,

Received 9 April 2012; revised 4 April 2013; accepted 1 May 2013.The authors gratefully acknowledge the support of the Theraplay Institute for the training

grant, support, supervision, and assistance with this project. We also express appreciation toFresno Family Counseling Center, who provided the facilities to conduct the Whole FamilyTheraplay Project sessions.

Address correspondence to Kyle N. Weir, Associate Professor of Marriage & Family Ther-apy, Counselor Education Program, Department of Counselor Education and Rehabilitation,California State University–Fresno, 5005 N. Maple Avenue, M/S ED3, Fresno, CA 93740–8025.E-mail: kweir@csufresno.edu

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1995; Sprenkle, 2002; Wettig, Coleman, & Geider, 2011). Each approach con-tains numerous models of treatment that have a record of usefulness for avariety of clinical issues with which adoptive families present in clinical set-tings. For example, Structural Family Therapy (SFT), Bowenian Family Sys-tems Therapy, Narrative Family Therapy, multiple Behavioral Family Therapyapproaches including Parent-Child Interaction Therapy (PCIT), and Solution-Oriented Family Therapy have all had studies indicating that these modelsare effective in the systemic treatment of adoptive families (Barth, Crea,John, Thoburn, & Quinton, 2005; Becker, Carson, Seto, & Becker, 2002; Cat-tanach, 2008; Doherty & McDaniel, 2010; Nims & Duba, 2011; Timmer et al.2006; Weir, 2003, 2007, 2011a, 2011b). Additionally, multiple models of playtherapy such as Filial Family Play Therapy (FFPT), Dyadic DevelopmentalPsychotherapy (DDP), and Theraplay have been shown to be effective withadoptive families (Becker-Weidman, 2006; Booth & Jernberg, 2010; Hughes,1997; Hughes, 2007; Ryan & Madsen, 2007; Van Fleet, 1994; Van Fleet, Ryan,& Smith, 2005; Weir, 2007, 2011a, 2011b).

Lebow (1997) has called the integration of theories of therapy treat-ments the “zeitgeist of our time.” Mostly, such focus on integration has hadto do with family therapy theories in general (e.g., integrating Solution-Oriented or Brief Family Therapy integrated with Strategic Family Therapyto form “Brief Strategic Family Therapy,” Santisteban, Suarez-Morales, Rob-bins, & Szapocznik, 2006) and couples therapies in particular (e.g., Integra-tive Behavioral Couple Therapy, Christensen, Jacobson, & Babcock, 1995;Emotionally Focused Couple Therapy [EFT], Johnson et al., 2005; and Col-laborative Attachment Systems Therapy, Weir, 2012). Only recently havewe seen a significant interest in integrating family therapy with play ther-apy models to develop more effective treatment approaches for familiesof all types regardless of their adoption status, in general (Dermer, Olund,& Sori, 2006; Early, 1994; Gil, 1994, 2006; Gil & Sobol, 2000; Poole, 2006;Sori, 2006; Weir, 2011a; Wittenborn, Faber, Harvey, & Thomas, 2006) andfor adoptive families, in particular (Cattanach, 2008; Gil, 2006; Weir, 2007,2011a) in the contemporary literature. The integration of family therapy andplay therapy has wide practical applications for clinicians in the counsel-ing, marriage and family therapy (MFT), psychology, and social work fieldswho specialize in working with adoptive families. One study (Weir, Fife,Whiting, & Blazewick, 2008) found that master’s-level, accredited trainingprograms in counseling, MFT, and social work provided very little specificcoursework in adoption or foster care services to their students (despitethat a range of nearly 14% to 26% of the graduates of these programs areestimated to work in child welfare careers after graduation). The counsel-ing and MFT accredited programs did have statistically significant greateramounts of coursework in child development and practicum experiencesin child welfare (leading one to consider the possibility that in some wayscounselors and MFT professionals may be better trained for these positions

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Whole Family Theraplay 177

than social workers), but none of the programs indicated specific training inintegrating family systems approaches with play therapy approaches for thetreatment of adoptive or foster families.

Because adoptive families may disproportionately experience issues re-lating to attachment (Levy & Orlans, 2000), non-coercive attachment-basedtreatments logically offer promise for clinical efficacy. Barth et al. (2005) ar-gue against using attachment therapies for attachment-disordered childrenin preference of behavioral and other evidenced-based models. Their study,however, narrowly defines attachment therapies as the coercive disreputabletreatments that can be harmful to a child (such as holding or rebirthing thera-pies): treatments that all ethical clinicians should avoid. In their article, Barthet al. (2005) do not address the value of non-coercive attachment-basedmodels (such as Theraplay and Dyadic Developmental Psychotherapy) thatare appropriate, effective treatments for children with attachment issues.Despite this omission, Barth et al. (2005) highlight some of the positive,beneficial behavioral models (and other similar evidence-based approaches)that can be effective in children with attachment concerns. These includethe Incredible Years (Webster-Stratton & Hammond, 1997), Parent Manage-ment Training (Reid & Kavanagh, 1985), Multisystemic Therapy (Henggeler,Schoenwald, Borduin, Rowland, & Cunningham, 1998), Parent Child Interac-tion Therapy (Eyberg et al., 2001; Chaffin et al., 2004), and Functional FamilyTherapy (Alexander & Parsons, 1997) as effective intervention strategies. Be-havioral approaches and other similar treatment models utilize systems ofrewards and punishments, praise and (re-)direction, clear expectations, andseveral other effective training mechanisms, inducements, incentives, andconsequences to modify the child’s behavior and effect desired changes.For the most part, these approaches work well with children without at-tachment disorders and even can be successful with some who do struggleto form healthy attachments. But for some attachment-disordered children(particularly the ones who have been traumatized by significant abuse andneglect of various types), behavioral approaches may have the effect of ex-acerbating the problem and the children might not respond to the rewardsand punishments of behavior modification systems as desired. Some of thechildren do not fully grasp the reward portions of behavioral approachesand disproportionately focus on the punishment aspects of behaviorism. Itis almost analogous to a “cognitive distortion” in which the child personal-izes the consequences or punishment aspects of the behavior modificationsystem in an exclusively relational way. They see the behavioral systemthrough the “lens” or perspective of hurtful relationships and faulty attach-ments and therefore focus on the behaviorally imposed consequences andmisattribute the punishment portions to relationship deficits rather than theneed for changes in their behavior (Weir, 2011a, 2011b). For example, anadopted or foster child with reactive attachment disorder who receives a con-sequence for misbehavior is more likely to think, “I hate my (foster) mom”

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instead of thinking “I shouldn’t have done that” in response to their conse-quence. Because children with reactive attachment disorder have difficultieswith relationships, problem solving, and responses to discipline (Hughes,1997, 2007; Weir, 2011b), these children misjudge the motives of the care-giver and assume the discipline is a sign of a bad relationship rather thanan instructive gesture or opportunity to correct their behavior. Therefore, itis critical that treatments of adopted or foster children with significant at-tachment issues include an appropriate, non-coercive attachment treatmentbasis.

It is important to distinguish among the various attachment-based treat-ment approaches the disreputable ones (which are coercive) and the rep-utable non-coercive models and to select from among the non-coercive mod-els an approach that can be integrated with family therapy. Coercive attach-ment therapy models may be termed Holding Therapy, Rebirthing Therapy,or simply Attachment Therapy; they have been controversial models of treat-ment, in some cases have led to the harm or death of children, and havebeen warned against in the ethical guidelines of many major mental healthprofessional associations (American Psychiatric Association, 2002; ATTACh,2007; Weir, 2006). Speltz (2002), Mercer (2002), and Mercer (2005) providean excellent history and critique of coercive attachment theories.

Among the non-coercive attachment-based play therapies, Filial Fam-ily Play Therapy (FFPT), Dyadic Developmental Psychotherapy (DDP), andTheraplay have been the most studied (Becker-Weidman, 2006; Booth &Jernberg, 2010; Hughes, 1997, 2007; Rubin, Lender, & Mroz, 2009; Ryan &Madsen, 2007; Van Fleet, 1994; Van Fleet et al., 2005; Weir 2007, 2011a,2011b; Wetting, Franke, & Fjordbak, 2006). Each of these three models war-rants consideration in the treatment of adoptive and foster families. Briefdescriptions of each ensue.

According to Ryan and Madsen (2007), FFPT is a non-directive form ofplay therapy developed by Bernard and Louise Guerney in which parentsare taught to conduct child-centered play therapy with their children:

With the goal of increasing parent-child relationship satisfaction, filialfamily play therapy (FFPT) was created in the early 1960s to train birthparents to conduct child-centered play therapy sessions with their chil-dren. The purpose of FFPT was to allow the parent and child to expe-rience each other differently through this unique relationship workingthrough issues in a nondirective, empathic methodology. (pp. 112–113)

DDP was developed by Daniel Hughes in the 1990s out of his workwith foster and adopted children on the East Coast of the United States.DDP involves a keenly attuned relationship among the therapist, caregiver,and child. Hughes (2007) identifies the posture that therapists take towardchildren with the acronym “PACE.” PACE stands for playfulness, acceptance,

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curiosity, and empathy. For parents or caregivers, Hughes (2007) adds thedimension of love to form the acronym “PLACE.” One article describes thecentral component of DDP as:

Dyadic Developmental Psychotherapy has as its core, or central therapeu-tic mechanism and as essential for treatment success, the maintenance ofa contingent collaborative and affectively attuned relationship betweentherapist and child, between caregiver and child, and between therapistand caregiver. (Becker-Weidman, 2006, p. 148)

Theraplay was developed by Ann Jernberg in 1971. “Theraplay is anactive, playful, short-term (about 12-week period of therapy sessions) treat-ment method that uses attachment-based play to create better relationshipsbetween parents and their children” (Booth & Koller, 1998, p. 308). Ther-aplay integrates interpersonal theories of human development, object rela-tions theory, and the attachment theories of Bowlby and Ainsworth (Booth& Lindaman, 2000).

Theraplay helps to improve attachment by engaging a parent and childin playful activities. In adopted children, Theraplay helps to reduce some ofthe internal attachment models they gained in their previous abusive environ-ments and helps them to produce new healthy internal attachment modelswith their adoptive families. Additionally, Theraplay builds attachment byreplicating healthy parenting patterns that foster secure attachment, such asunderstanding the importance of the parent-child relationship, recognizingpatterns of attachment, and including parents in treatment (Jernberg & Booth,1999, p. 12). Theraplay follows the premise that children excel and thrivein the context of secure attachments to their caregivers. When parents andchildren interact in playful ways that balance four key dimensions of attach-ment, children and parents will develop more secure attachments leading toseveral beneficial outcomes (including better affect regulation and behavior).The four key dimensions to building such healthy attachments through playare structure, engagement, nurturing, and challenge (SENC). Brief descrip-tions of each dimension are given here:

Structure: The goal of structure is to assure the child that the parent is incharge and the child is safe with them being in charge. Structure helpschildren listen to and follow directions, providing them with a sense ofsecurity because they know they are being protected and guided. Aschildren are regulated in a caring but structured manner, their ability toco-regulate their emotions will increase.

Engagement: The goal of engagement is to connect with the child ina very intense and personal way, allowing the child to know that sur-prises can be fun and safe. Engagement involves paying attention tothe child, making good eye contact, being upbeat, being playful, and

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communicating that the child is of worth through the adult’s attunementwith the child. Often attunement begets affect regulation.

Nurture: The goal of nurture is to produce an environment for the childthat is caring, calming, and predictable; this gives the child a feelingof comfort and stability. This dimension (along with the other three di-mensions) assists a child with affect regulation by meeting the child’semotional needs where they are developmentally. Nurturance providesopportunities for tenderness, parent-child affection, and healing.

Challenge: The goal of challenge is to give a child a challenge, but notto make that challenge undoable; this promotes a child’s self-esteemand promotes feelings of competence. As adults and children face andovercome challenges together, such cooperation enhances attachment.Also, as children experience some minimal frustration in facing and over-coming challenges, their frustration tolerance will grow and their affectregulation will increase.

Affect regulation and attachment enhancement are consistently im-proved through Theraplay (Lindaman & Lender, 2009). Nida and Pierce(2000) indicate that emotional regulation within a child’s socioemotional de-velopmental growth stems, in part, from healthy parent-child attachment pat-terns and that a child’s increased capacity to respond well to co-regulation ofaffect leads to improved behavioral regulation. It is, therefore, by improvingthe parents’ capacity to parent in attachment-savvy and affect–co-regulatingways (Laakso, 2009) that the child’s behavioral regulation may be best served.This “backdoor” approach to behavioral regulation, through strengtheningattachment relationships and then enhancing co-regulation of affect, repre-sents a potential equifinal path to improving a child’s behavior. Booth andKoller (1998) best describe the goal of Theraplay by saying:

The goal is to empower parents to continue on their own the health-promoting interactions of the treatments sessions. Training parents to betherapists for their children was a natural development of the Theraplaymethod. It is the parent, not the child’s therapist, who must live withthe child 24 hours a day; thus, the parent has the greatest opportunity toinfluence the child for good or ill. (Booth & Koller, 1998, p. 308)

While FFPT, DDP, and Theraplay all have efficacy for working withadopted and foster children (Becker-Weidman, 2006; Booth & Jernberg,2010; Hughes, 2007; Ryan & Madsen, 2007; Van Fleet, 1994; Van Fleet et al.,2005; Weir, 2007, 2011a, 2011b), Theraplay was chosen as the best modelto integrate with family therapy models for three primary reasons: First, thedirective nature of Theraplay is more conducive to the directive posture ofclassical family systems models (compared to FFPT). Due to the directivenature of many of the family systems models (particularly Structural Family

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Therapy and Experiential Family Therapy), the directive style of Theraplayseemed the best theoretical fit to integrate family counseling and play therapyapproaches. Particularly, the use of the “self-of-the-therapist” as the direct in-strument for family change in both Theraplay and Structural and ExperientialFamily Therapy appeared to have a theoretical and practical affinity. Second,Theraplay has a longer history of treatment and slightly longer history ofempirical testing for efficacy than DDP. Finally, the primary investigator ofthis study had prior training in Theraplay and had formed a collaborativerelationship with the Theraplay Institute and was designated by them as a“university-based Theraplay researcher.”

In developing an integrative model of family systems and Theraplay, itwas necessary to be clear about the different kinds of uses of play so asto be prepared for the larger family systemic contexts. In traditional Ther-aplay, one or two parents interact with just one child. In developing WFT,we anticipated working with parents, the adopted child, their siblings, andanyone else residing in the home (foster children, grandparents, etc.) whois part of the family system. This caused us to think about how to play in alarger family system. We drew upon traditional Theraplay (Booth & Jernberg,2010), group Theraplay (Rubin & Tregay, 1989), Parten’s (1932) descriptionsof preschool children’s play, and several models of family systems theory(particularly, Structural Family Therapy, Experiential Family Therapy, andObject Relations/Attachment Theory; Minuchin, 1974; Napier & Whitaker,1988; Nichols, 2009), noting the different types of playful interaction (andthe exponentially increasing number of interactions in the room) amongwhole families.

In a landmark study, Parten (1932) identified six types of play amongpreschool children: unoccupied, onlooker, solitary independent play, paral-lel play, associative group play, and cooperative group play. As we beganexamining how families could play the Theraplay games and activities, itbecame apparent that some activities and games would lend themselves toa whole-group interactive process akin to Parten’s (1932) associative groupplay or cooperative group play. These types of activities1 included thingslike: zoom-erk, weather report, pass a touch, hand-stacking, and keep-the-balloon-in-the-air. Other activities required parents and co-therapists to pairoff with a child so that the parent-child interaction could be more one onone. This was more akin to the parallel play Parten (1932) described. A childand therapist might be engaged in the same activity as a sibling and parentmight be doing (e.g., imaginary face-painting, feeding M&Ms, or mirroring),which descriptively is more like parallel play.

We also needed to clinically address family systems issues due to havinglarger families in session. Some of the ways WFT addressed those systemicissues drew from Structural Family Therapy and Experiential Family Therapymodels by focusing on unhooking the identified patient, observing the im-pact of marital conflicts on children, balancing or resolving sibling rivalries,

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increasing family openness and authenticity, and supporting the hierarchicalstructure of the executive subsystem (parents) over the sibling subsystem(children) (Weir, 2011a).

Such inclusion of family systems concepts included a variety of familysystems theories and methods. The directive style of WFT and the dimensionsof attachment (especially the Structure and Engagement dimensions) fits wellwith the Structural Family Therapy (Minuchin, 1974) goals of directive use ofthe “self-of-the-therapist” to facilitate change. The student-trainees reportedthat using Theraplay helped them better understand such Structural FamilyTherapy concepts as hierarchy, boundaries, coalitions, scapegoating, and en-meshment/disengagement. Likewise, using WFT helped the students-traineessee theoretical and methodological affinity with the Experiential Family Ther-apy goals of the “here-and-now” temporal focus (Nichols & Schwartz, 2006),being attuned to the family’s emotional needs (Napier & Whitaker, 1978),and understanding the roles individuals play in families (Satir, 1988). Addi-tionally, because Theraplay seeks to identify dimensions where the familymay be weak in its attachments (i.e., too much or not enough structure, en-gagement, nurture, or challenge), WFT integrates the concept of “correctiveemotional experience” from Experiential Family Therapy. We strive to createfor the parent-child relationship right there in the room the emotional expe-rience of attaching to one another that they seem weak or incapable of doingon their own. As they experience activities that facilitate their emotional at-tachment, they realize they are capable of loving and connecting with oneanother. It is the experiencing of such attachment bonds that leads to furtherattachment. Furthermore, Experiential Family Therapy (more so than Struc-tural Family Therapy or Object Relations) has at its core the flexibility to beplayful (sometimes even silly or zany) and spontaneous when that is whatis most needed by a family in treatment. In this way, the playfulness of theTheraplay therapist and the Experiential therapist are integrated into one.

Integrating all of the literature, clinical considerations, theories, andmodalities, we developed the following central research questions for thisstudy:

• Can Theraplay be modified to accommodate whole families either withone child or more than one child in treatment?

• What are the principles involved with such modifications for larger families?• How does family systems theory (specifically Structural Family Therapy and

Experiential Therapy), including the role of sibling relationships, inform thepractice of Theraplay with whole families?

• Would a modified Theraplay model demonstrate empirical support (or atleast the potential promise of empirically supported clinical efficacy)?

• Further, is such a modified Theraplay model effective with a particularpopulation, namely adoptive families?

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METHOD

Sample

The sample consisted of 12 adoptive families from the local community. Ofthe 12 families, 23 parents participated and 30 children participated in theWFT sessions (n = 53). The parents of the 12 families participated in theWFT sessions with their spouses or partners with one exception (in one fam-ily the father worked out of town during the week and was not available toparticipate in sessions, but the mother attended with her children). We had8 married couples, 1 lesbian couple, 2 cohabitating heterosexual couples,and 1 married woman (whose husband was unavailable due to work) par-ticipate in the study. Notably, all 12 families completed at least 12 sessionsof WFT treatment. None dropped out of the treatment, lending support tothe assertion that they found value in the therapy modality and regarded thetreatment approach as helpful for their family’s needs.

There were 5 biological children (meaning biologically related to theirparents in therapy with them) and 25 adopted children in the sample. Thenumber of children in these adoptive families ranged from 1 to 6. Theaverage number of children in a family in this sample was 2.5 and themodal number of children in the family was 1 (4 families with 1 child, 3families with 2 children, 3 families with 3 children, 1 family with 5 children,and 1 family with 6 children). The average age for the children in this samplewas 8.64 years. The average age of the biological children was 13.3 yearsand the average age for the adopted children was 7.52 years in this sample.In every instance (except one) in this sample the biological children wereolder than the adopted children. In the one exceptional case, the youngestof three biological children was 12 and was supplanted in birth order by a14-year-old adopted child and a 12-year-old adopted child the same age (buta couple of months older than the biological 12-year-old in the family).

The gender of the children included in this sample was 16 female and14 male. Among the biological children there were 2 girls and 3 boys. In theadoptive subset there were 14 girls and 11 boys. Thus, the female genderpercentage of adopted children in this sample (56%) is slightly elevated fromthe number of females adopted from the public child welfare systems ofthe United States (49% as reported by the most recent Adoption and FosterCare Analysis and Reporting System report; see U.S. Department of Health& Human Services, 2011). Unfortunately, the researcher did not gather infor-mation about the length of placement in the home or the age at placement ofthe adopted children in the home. This oversight will be corrected in futurestudies.

The ethnic make-up of the children in the sample included 7 Latinochildren, 8 mixed Latino/Caucasian children, 9 Caucasian children, and 6African American children. The ethnicities of the parents were 3 Latino, 1mixed Latino/Caucasian, 15 Caucasian, 3 African American, and 1 Southeast

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Asian (India). Of the 12 families, 8 were families in which multiple ethnicitieswere present (i.e., cross-ethnic or transracial adoptions), and 4 families wereall of the same race or ethnic heritage (1 Latino, 2 Caucasian, and 1 AfricanAmerican).

Of the 25 adopted children in this sample, 23 were adopted from publicchild welfare services agencies in the local community (a small urban city sur-rounded by several rural and agricultural communities in the region). Two ofthe adopted children were adopted through private adoption agencies. Thehigh number of public adoptions was likely due to recruitment procedures.

Recruitment of Participants

Adoptive families from the community were invited to participate in thisstudy primarily through advertising through local public child welfare agen-cies (e.g., the county’s Child Protective Services department) and privatefoster and adoption agencies (e.g., religious adoption agencies, foster fam-ily agencies with foster/adopt programs, and nonsectarian private adoptionagencies). The university’s student training clinic, Fresno Family Counsel-ing Center, operated by the students and faculty of our Council for theAccreditation of Counseling and Related Educational Programs–accreditedcounselor education program (MFT option) generously agreed to allow fam-ilies to receive WFT for free to facilitate the project. This seemed to helpin the recruitment of families from the public child welfare agencies in thecommunities nearby.

Training and Supervision

Students from the MFT program enrolled in a course taught by the leadauthor. The students would participate in the study for one semester andthen new students would be recruited and trained each new semester. Twograduate assistants and co-authors of this study also attended the trainingsand provided continuity throughout each semester by assisting in the trainingand modeling of Theraplay to the other students. Prior to each semester,the Theraplay Institute provided a certified Theraplay trainer/supervisor toconduct a 3-day training in Theraplay with the lead author and his students.Students were paired into partnerships that they would work with throughoutthe semester as co-therapists. As part of the training, co-therapist teams wouldpractice providing Theraplay through role plays.

Once the semester commenced, students would conduct WFT sessionsunder the local supervision of the lead author, who is a licensed marriageand family therapist and a university-based Theraplay researcher. Sessionswere recorded, burned onto compact discs, and provided to the TheraplayInstitute for supervision to ensure reliability and validity verification that thesessions met the Theraplay Institute standards.

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Instruments and Study Design

The design of this study was a pre-test/post-test quasi-experimental designusing four key instruments: the McMaster Family Assessment Device (FAD),the Outcome Questionnaire-45 (OQ), the Youth Outcome Questionnaire2.01 (Y-OQ), and the age-appropriate (depending on the age of the child)Achenbach Child Behavior Checklist (CBCL). The FAD was used as an over-all measure of the family’s systemic functioning. It has seven subscales:Problem Solving, Communication, Roles, Affective Responsiveness, Affec-tive Involvement, Behavior Control, and General Functioning. The OQ wasused to measure the parents’ outcomes through treatment on three aspects:Symptom Distress, Interpersonal Relations, and Social Role. The Y-OQ andthe CBCL were used to measure the outcomes for the children. In partic-ular, the Y-OQ has six subscales: Intrapersonal Distress, Somatic, Interper-sonal Relations, Critical Items, Social Problem, and Behavior Dysfunction.The CBCL has eight scales: Anxious/Depressed, Withdrawn/Depressed, So-matic Complaints, Social Problems, Thought Problems, Attention Problems,Rule-Breaking Behavior, and Aggressive Behavior.

Reliability and validity scores for the FAD, OQ, Y-OQ, and CBCL areall acceptable or high. The FAD subscales’ reliability scores (as measuredby Cronbach’s alpha) ranges from 0.72 to 0.90 (Epstein, Baldwin, & Bishop,1983; Miller, Bishop, Epstein, & Keitner, 1985). According to Ellsworth,Lambert, and Johnson (2006); Wells, Burlingame, Lambert, Hoag, and Hope(1996); and Lambert and Finch (1999), the reliability score for the OQ is0.93, with the subscales ranging from 0.70 to 0.93. Similarly, the internalconsistency reliability scores from the Y-OQ range from 0.74 to 0.93 forthe subscales (Wells et al., 1996), with a very high total scale estimate of0.97 (Wells, Burlingame, & Lambert, 1999). The Achenbach CBCL reliabilityis 0.88 (Achenbach, 1999). Similarly, various forms of validity testing havebeen thoroughly conducted on each of these four instruments all werefound to be valid at acceptable or high levels (Achenbach, 1999; Ellsworthet al., 2006; Epstein et al., 1983; Miller et al., 1985; Lambert & Finch, 1999;Wells et al., 1999; Wells et al., 1996).

Families completed the assessment instruments prior to commencing theWFT treatment sessions and again at the conclusion of the treatment. Parentswere to complete 1 FAD for their family, 1 OQ for each spouse or partner,1 Y-OQ for each child in their family, and 1 age-appropriate CBCL for eachchild in their family. In all cases, the mothers completed the FAD and Y-OQ questionnaires for the families, although sometimes a father may haveexpressed an opinion or gave input. Each adult completed their own OQassessment. The CBCL was completed by a few mothers in the beginning,but its length became a deterrent in getting the completed assessments at theend of the study. Student-trainees were available to assist the families if theyhad questions, but most families chose to take the instruments home and

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return them the next week. This created problems for getting the post-testdata. Of the 12 families, only 2 families completed all four instruments forall their family members, and 7 families had complete pre-test and post-testassessment data sets for the FAD, OQ, and Y-OQ (but not the CBCL). Theother 5 families had pre-test assessment data sets but had gaps or missingdata in some of their post-test assessment data sets to the point that wecould not report accurately with integrity despite the fact that no familiesdropped out of treatment in this study. It became obvious that the length (anddifferent age-appropriate versions for differing children) of the AchenbachCBCL was a significant barrier to families completing the assessments upontermination. As this was a pilot study, this identification of an assessmentbarrier was useful information to make modifications for the WFT Project’sfuture studies. We determined to discard the data on the CBCL and focus onthe 7 complete data sets of the FAD, OQ, and Y-OQ.

After completing the pre-test assessment data sets, families engaged ina modified version of the Marshak Interaction Method (MIM) simplified andadapted to just five tasks to accommodate larger families. The modified MIMassessment was only utilized in the first session of treatment as sort of a sub-jective clinical diagnostic tool to determine the attachment themes, strengths,weaknesses, and patterns in the adoptive families. Afterward, the family re-ceived 12 to 15 weekly sessions of WFT with a wide variety of treatmentgames and activities based on what was learned from the WFT’s modifiedMIM throughout a 16-week semester and then completed the assessmentinstruments upon termination.

Clinical Procedures

Families contacted the lead author via phone or e-mail to be screened forappropriateness of the study. Screening factors included the following: atleast one child in the family had to be adopted or in adoption placement,the adopted child had to be between the ages of 3 and 12, and the par-ents had to be willing to attend and bring the other children living in theirhome (whole family) during the available hours allocated by the clinic forthese sessions. Once the family passed the screening process, appointmentswere scheduled at the beginning of the semester to complete the assessmentforms, conduct the WFT MIM (on the first session only), and begin treatmentsessions with the student-trainees for the remainder of the semester. In ad-dition, families signed both a research informed consent form and a clinicalinformed consent form. The research was approved by the Human SubjectsCommittee/Institutional Review Board at California State University–Fresno.Families were also given the policy regarding the privacy practices of medicalinformation as required by the Health Insurance Portability and Accountabil-ity Act.

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The WFT MIM used in this study during the first session with the familydiffers from the original MIM assessment in that it is simplified to accom-modate large numbers of children playing and interacting in their family.During the first session, families were given cards with specific directions ontasks to play with their child along with a bag of materials needed to ac-complish the tasks. Families performed the tasks in the treatment room whilethe student-trainees observed the WFT MIM session from a monitoring room.The student-trainees looked for strengths and weaknesses in the four dimen-sions of attachment outlined by Theraplay: structure, engagement, nurture,and challenge (SENC). There were just five tasks families were asked to doduring this initial, subjective assessment:

1. Play with hats with your child or children.2. Play a familiar game with your family.3. Play a game of stacking hands. Be sure to lead the family in going up and

down, fast and slow.4. Lotion your child or children.5. Feed your child or children a snack.

Hats, lotion, and a snack such as M&Ms, fish crackers, or raisins wereprovided to the parents (after checking with the parents for allergies anddietary restrictions).

The WFT MIM generally took families between 20 and 30 minutes tocomplete. The remaining part of the first session, the student-trainees re-turned to the treatment room with the family. One student-trainee spentsome time with the parents to explore their interests in therapy and informedthem about Theraplay and its purpose. Meanwhile the other student-traineeengaged in play with the children.

After the WFT MIM initial session, the assigned two student-trainees,acting as co-therapists, would begin using WFT based on what they learnedabout the family’s attachment strengths and weaknesses from the WFT MIMand emphasizing different activities from the four dimensions of Theraplay(SENC) in subsequent weekly sessions. Subsequent WFT sessions lasted for30 to 35 minutes of family play and 15 to 20 minutes of debriefing (totaling50 minutes of treatment sessions). During the 30 to 35 minutes, both co-therapists would engage in a wide range of attachment-based Theraplayactivities with the entire family. During the remaining 15 to 20 minutes ofthe session, one co-therapist would sit in a corner of the room and debriefor talk with the parents about the games and activities, answering theirquestions about the activities, emphasizing their purpose, and instructingthe parents how they can be successful in playing those games and activitiesat home. They would also use the time to briefly talk about progress theirchildren were making regarding any emotional and/or behavioral issues theparents saw at home. During this same 15 to 20 minute time period, the

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other co-therapist would continue to play with the child or children. Thisplay was not specifically aimed at any particular treatment issues (and noparticular play therapy model was implemented), but it did allow for thechildren to be cared for in a fun way with someone they trusted while theparents and other co-therapist talked.

Student-trainees also contacted the families at a prearranged timethroughout the week either by phone or e-mail. This “midweek communica-tion” was essential to allow parents to discuss items with the student-traineeout of the hearing of the children because we were concerned children mightoverhear some of the discussion during the debriefing period at the end ofeach session. This confidential midweek communication also allowed formore coaching on the WFT games and activities and gave parents the op-portunity to ask detailed questions about their child’s or children’s behaviorsand attachment needs.

The family received 12 to 15 WFT weekly sessions throughout thesemester. The reason for the variation of 12 sessions to 15 sessions wasdue to attendance and occasional holidays disrupting the schedule. Post-testassessments were handed out to the families on the penultimate scheduledsession, allowing them to take them home and return them on the lastsession. In the event families did not return with the assessments, we en-couraged them to return them in person or by mail by a certain date. Wealso engaged in follow-up phone calls to obtain the post-test assessments.Due to the missing data, we intend to change that structure in future studiesand have scheduled time for the families to complete the assessments at theclinic to ensure we obtain the needed data.

Termination sessions were celebratory in nature. Children chose andplayed their favorite games and activities that they most enjoyed throughoutthe treatment. Families often brought food such as a cake or pizza to createa festive party atmosphere for the children. Silly party hats were typicallyworn, and the upbeat power of play was emphasized. Parents, children, andco-therapists also discussed the progress they have seen in the family.

Analysis

Utilizing t-tests comparing pre-test and post-test responses on the assessmentinstruments, we looked for statistically significant improvement from Time 1(pre-test) to Time 2 (post-test). In our analysis of the FAD we looked at theseven subscales (Problem Solving, Communication, Roles, Affective Respon-siveness, Affective Involvement, Behavior Control, and General Functioning)as well as overall total scores on the FAD. The FAD served as a systemicmeasure of the family system. One FAD was filled out by the mother (oftenwith some input by the father) for the whole family. Essentially, this tells usher perspective of the family’s systemic functioning.

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We also did t-test comparisons on the OQ for each parent from Time1 to Time 2. We examined the change over time at both the subscale level(Symptom Distress, Interpersonal Relations, and Social Role) and the overalltotal OQ score. The OQ was used to measure the impact WFT sessions hadon the parents. Each parent filled out their own OQ.

Finally, we examined t-test comparisons of Time 1 and Time 2 for eachchild on the Y-OQ. The Y-OQ has six subscales (Intrapersonal Distress, So-matic, Interpersonal Relations, Critical Items, Social Problem, and BehaviorDysfunction). We ran t-tests for each subscale and the overall total score onthe Y-OQ from the data from Time 1 to Time 2. Children, regardless of theiradoptive or biological status, were included in the analysis. Given that 25 outof the 30 children were adopted and that only 3 of the 12 families had biolog-ical children, we determined to review the analysis from a family systemicperspective. Rather then targeting a specific identified patient, we soughtto determine how all children in the family system fared. Thus the Y-OQscores for all children were examined rather than distinguishing any subsetsof biological versus adopted children. We did not conduct any analysis ofthe Achenbach CBCL because so few of these assessments were returned.Because multiple t-tests were utilized, we also conducted Bonferroni tests toadd statistical rigor to our analysis.

RESULTS

Despite several measures showing the possibility that WFT was helpful toadoptive families, very few items from these measures were statistically sig-nificant. Although it is possible that many measures in this study were notstatistically significant for a wide variety of reasons (i.e., the treatment isnot effective in those areas, the assessments were not filled out correctly,the sample size is too small, sampling error is present, or the protocol didnot measure what the researchers intended it to measure, among an assort-ment of available reasons), the researchers still felt that a future study with amuch larger sample size may provide better information. Despite the smallsample size, lack of a control group, and the failure to use mixed meth-ods that would have strengthened this study (thus the inability to draw firmconclusions in a inferential manner from these findings due to these andother limitations discussed later), three items showed statistically significantfavorable improvement at the p ≤ .05 level: the FAD Communication sub-scale, the OQ Interpersonal Relations subscale, and the overall total score ofthe children on the Y-OQ. This leads our research team to believe that WFTdid show promising results and is worth further study with an improvedresearch design. The statistical results are presented in Table 1.

These findings suggest that family systemic functioning did not showa statistically significant change after WFT treatment in terms of the total

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TABLE 1 Paired t-Test Findings From the Whole Family Theraplay Project Pilot Study: FamilyAssessment Device—Total Score and Subscale Scores Results

SigM SD SE t df (2 Tailed)

FADTotal −2.143 16.263 6.147 0.349 6 0.739FADProblem Solving 2.143 3.078 1.164 1.842 6 0.115FADCommunication −2.00 1.83 0.69 −2.90 6 0.027∗FADRoles 1.43 3.237 1.223 0.117 6 0.911FADAffective Involvement 0.857 5.080 1.920 0.446 6 0.671FADGeneral Functioning 0.143 4.670 1.765 0.081 6 0.938

∗p ≤ .05.

score or in the subscale measures, except for the family communicationsubscale. FADCommunication did improve and is statistically significant at thep < .027 level. This subscale measures family communication with statementsto which the respondent agrees or disagrees on a four point Likert scale. Suchstatements include: “When someone is upset the others know why,” “Youcan’t tell how a person is feeling from what they are saying,” “People comeright out and say things instead of hinting at them,” “We are frank with eachother,” “We don’t talk to each other when we are angry,” and “When wedon’t like what someone has done, we tell them.” The findings indicate thatWFT treatment improved family communication patterns.

The adult parents were also assessed using the Outcome Question-naire. The results are presented in Table 2. The results from the OutcomeQuestionnaire (OQ) indicate that adult parents did not show any statisti-cally significant improvement in their overall functioning (OQ Total) or in thesubscales pertaining to symptom distress (e.g., statements measuring feel-ings of worthlessness, feeling tired, unhappiness, feeling anxious, havingsore muscles, having headaches, having disturbing thoughts they cannot getrid of, troubling sleeping, and other indicators of mental or emotional dis-tress) or their social role (e.g., feeling stressed at work/school, not enjoyingtheir spare time, not feeling satisfied with relationships, and other similarindicators). The results from the study do indicate that adults/parents report

TABLE 2 Paired t-Test Findings From the Whole Family Theraplay Project Pilot Study: Out-come Questionnaire (Adults/Parents)—Total Score and Subscale Scores Results

SigM SD SE t df (2 Tailed)

OQTotal (Mothers) 1.429 9.914 3.747 0.381 6 0.716OQTotal (Fathers) 7.143 8.745 3.305 2.161 6 0.074OQSymptom Distress 3.286 5.880 2.222 1.478 6 0.190OQInterpersonal Relations 3.14 3.19 1.20 2.61 6 0.040∗

OQSocial Role −1.571 3.867 1.462 −1.075 6 0.324∗p ≤ .05.

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TABLE 3 Paired t-Test Findings From the Whole Family Theraplay Project Pilot Study:Youth–Outcome Questionnaire (Children)—Total Score and Subscale Scores Results

SigM SD SE t df (2 Tailed)

Y-OQTotal Score 14.00 12.65 4.78 2.93 6 0.026∗

Y-OQIntrapersonal Distress 3.286 7.432 2.809 1.170 6 0.286Y-OQSomatic 2.857 4.298 1.625 1.759 6 0.129Y-OQInterpersonal Relations 2.571 6.188 2.339 1.100 6 0.314Y-OQCritical Items 1.571 3.457 1.307 1.203 6 0.274Y-OQSocial Problem 0.429 1.512 0.571 0.750 6 0.482Y-OQBehavior Dysfunction 3.286 5.794 2.180 1.500 6 0.184

∗p ≤ .05.

that their interpersonal relations improved. The OQInterpersonal Relations scoreswere statistically significant at the p < .04 level. This subscale measures anadult’s interpersonal relations with statements on a 5-point Likert scale witha range of never, rarely, sometimes, frequently, and almost always. Examplesof such statements include “I get along well with others,” “I feel unhappyin my marriage/significant relationship,” “I am concerned about family trou-bles,” “I have an unfulfilling sex life,” “I feel loved and wanted,” “I havefrequent arguments,” and “I am satisfied with my relationships with others.”This finding of statistically significant, enhanced interpersonal relations onthe part of the parents is remarkable given that marital issues (such as theirsex life and other relational aspects with their spouse or partner) and otherinterpersonal aspects pertaining to their adult life were not directly addressedin WFT treatment (although one couple did receive marital counseling sep-arate from WFT sessions).

The results presented in Table 3 from the Y-OQ indicate that WFTtreatments made a statistically significant difference in the “overall condition,”“behavioral functioning,” and positive “subjective experiences” in the livesof the children who participated in this study (Burlingame & Lambert, 2007,pp. 5–8). The Y-OQ Total score has a p value of 0.026, the most statisticallysignificant finding in the study.

After discovering the three statistically significant findings, we then ex-amined the p values using a Bonferroni test. Although three of the p values(FADCommunication, OQInterpersonal Relations, and Y-OQTotal) were significant at the.05 alpha level in our initial analysis, none of the 18 p values reported in thisstudy met the more rigorous standard of .00278 (α/n or .05/18) required byBonferroni corrections. Despite these disappointing Bonferroni test results,we cite Perneger (1998), who argues against using Bonferroni adjustmentsin certain circumstances due to their propensity to perpetuate Type II errorsand thereby unnecessarily nullify practical and useful approaches that maybe of value when the alternative of accepting the null hypothesis and doingnothing may be harmful to the patient/client in need.2 Given the exploratory

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nature of this study, the practical needs of adoptive families to receive someuseful therapeutic assistance, and the arguments Perneger (1998) makes, wesurmise that Bonferroni corrections may not be the best measure to ulti-mately evaluate these findings, at least not yet. Future studies with largersamples and better controls will be necessary to determine whether such astandard can be met by this treatment approach.

DISCUSSION

These initial findings indicate that WFT is a practice model that shows promis-ing potential, and tentatively, we can say that it might have some level ofclinical efficacy in at least three key areas: improving family communicationwithin adoptive family systems, enhancing adult parents’ interpersonal rela-tional skills, and assisting children in adoptive families to have better overallclinical outcomes.

As both researchers and clinicians, our team found it interesting thatalthough Theraplay does not explicitly focus on verbalization in its formof play, the study found that WFT did significantly improve family com-munication. Perhaps families found that coming together and playing (bothin session and at home) facilitated more emotional openings and therebyled to more opportunities to communicate authentically as attachment im-proved and secure relationships were enhanced. It is possible that as wholefamilies more frequently engaged in playful postures, they grew more com-fortable being together as a whole system. This new comfort level mighthave allowed more open dialogue at home in the presence of others in-stead of seeking to communicate more privately (wherein such private meth-ods of communication may naturally lead to more structural coalitions andalliances).

The finding that the parents’ interpersonal relations (as measured bythe OQIR subscale) improved leads us to consider that WFT may effectivelyassist adults in enhancing their interpersonal skills. We find it curious thatWFT had a significant beneficial role on the adults’ interpersonal relationshipswith others. Future waves of research with this study will include assessmentinstruments concerning couples and marital relationships to learn whetherwe can determine whether WFT has any positive effect on the parents’couple/marital relationship.

The most important finding of this study is that the Y-OQ total scoresfor children in adoptive homes improved with treatment. The implemen-tation guidelines that accompany the OQ and Y-OQ state: “the most re-liable and valid quantitative measure of the child/adolescent’s conditionis the total score” (Burlingame & Lambert, 2007, p. 8). The finding thatadopted children’s overall “behavioral functioning and subjective experi-ence” (Burlingame & Lambert, 2007, p. 5) were improved as indicated by

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a statistically significant amount as a result of participating in a short-termcourse of WFT treatment is promising. In terms of clinical efficacy WFTdemonstrates signs of merit, or at least the promise of merit, and furtherstudies are warranted.

Descriptively, it is clear that Theraplay can effectively be modified toaccommodate whole families with either one child or multiple children intreatment together. This article is valuable because it describes the modifica-tion of Theraplay into WFT. WFT involves the integration of family systemsmodels (most notably Structural and Experiential Family Therapy), carefulattention to Parten’s (1932) types of play, and traditional Theraplay. By in-cluding the siblings and other family members of the adopted child’s familysystem, parents are able to learn how to play in attachment-savvy ways withtheir children that are more natural to their family context and thereforemore conducive to successful implementation at home.

From a theoretical perspective, integrating Theraplay with family sys-tems approaches is exciting. Lebow’s (1997) description of integrative frame-works helped the researchers to conceptualize integrating Structural FamilyTherapy, Experiential Family Therapy, and Theraplay. All three models haveas strategies a “here-and-now focus,” use the “self-of-the-therapist” as an in-strument of change, use a directive posture to facilitate change in the familysystem, correct emotional/attachment weaknesses, and maintain a relationalcontext. By expanding traditional Theraplay (where the focus is on onechild) to include the entire family system, we were able to help the adoptivefamily integrate therapeutic play into the natural context of the entirety ofthe family. At the theory level, boundaries, systems and subsystems, siblingdynamics, parental-child coalitions, family roles, non-summativity, and cir-cular causality all become added dimensions to the therapeutic power ofTheraplay when the whole family participates. Techniques or interventionsthat draw from Theraplay and Group Theraplay are modified according toParten’s (1932) model to draw in the many children and family members ofthe system. Specifically, we had to be clear about which games, activities,and interventions need to be done in a group process with the whole familyor in parallel play with the adults in the treatment room (both parents andtherapists) pairing up with a child. Counselor and MFT educators wouldbenefit from examining this model of integration in their theory instruction(particularly for courses relating to theories of play therapy). For practition-ers, WFT proffers the benefits of an integrated form of treatment for familiesthat combines the benefits of both family systems approaches with traditionalTheraplay. Moreover, it has begun to demonstrate clinical efficacy with onepopulation: adoptive families.

We also note, with deep appreciation to the families who participatedin the study, that families remained in therapy throughout the entire courseof treatment. The fact that none of the families dropped out and all thefamilies utilized the services offered through at least 12 sessions says much,

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anecdotally, about the usefulness and benefit that they ascribed to WFT intheir lives.

There are some important limitations to note about this study. The studylacks a control group. Every adoptive family who participated in the studyreceived treatment from the WFT approach. In future studies, we intendto include a control group who receive FFPT or DDP. The study wouldhave been enhanced if we had used mixed methods and included analysisof qualitative data. Unfortunately, we did not consider that prior to thecommencement of the study and our informed consent (which the familiessigned) did not include the use of the videos to be analyzed in that manner(they only agreed to allow videos to be used for supervision purposes). Tobe ethical, we could not go back and revisit such qualitative data for thatpurpose. Second, the sample size is small. Future renditions of this studywill expand to include a larger sample size. One of the main limitations ofthis study was our inability to extrapolate these findings to other adoptivefamilies (or other populations of families) due to our small sample size. Ourintent is to explore the usefulness of WFT with both adoptive and fosterfamilies, hoping to acquire a much larger sample size in the process. Third,our data gathering for Time 2 assessments was less than ideal. We trustedthe subjects to fill out assessments at home (because of the number andlength of the assessments) and return forms. We did not get back the criticalTime 2 data we needed on 5 of the families. In comparing completers tonon-completers (e.g., on the FAD we looked at the Total Scores and thesubscales: Problem Solving, Behavioral Control, or General Functioning), noclear picture emerged that would indicate why some families completedthe tests and returned them where others failed to. Non-completers werenot any more likely to score poorly in these areas that would measuresome level of disorganization or lack of follow-through on their part. Norwas the average number of children in each family much different betweenthe groups. Non-completers averaged 2.4 children and completer familiesaveraged 2.57 children per family, so on average each group had to fill outassessments on roughly the same number of children (and the two largestfamilies with the most children completed both sets of assessments). We areonly left to believe that some families simply chose to make returning theassessments a priority and others (due to the busy nature of their lives, theirforgetfulness, or some other reason not known) did not. In future versionsof this study, we will be certain to have the families fill out the Time 2assessments on site. We will also seek to get post-treatment data at 3- and6-month follow-up intervals to determine sustainability of improvement andrelapse prevention.

In addition to continuing the use of the FAD, OQ, and Y-OQ, futurerenditions of this study will also include the Revised Dyadic AdjustmentScale (Busby, Crane, Larson, & Christensen, 1995) and the Disturbancesof Attachment Interview (Smyke & Zeanah, 1999; Smyke, Dumitrescu, &

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Zeanah, 2002). We hope to determine what types of couples/marital impacta family systems based Theraplay approach, such as WFT, might have onmarriages and hope the Revised Dyadic Adjustment Scale will give us usefulinformation on that subject. We also desire to have an assessment that moreprecisely measures attachment issues in children, and the Disturbances ofAttachment Interview appears to offer the promise of that result.

CONCLUSION

In summary, WFT is an integrative model developed to work with adoptivefamilies by including siblings and other members of the family system in aholistic, systemic context. By integrating family systems theory with Ther-aplay, WFT enhances quality parent-child attachment and sibling relationsand improves overall behavioral functioning and subjective emotional expe-riences of the children within the adoptive family system. It also appears toimprove family communication and the interpersonal role of the adults. Byintegrating family systems theory with Theraplay, WFT also provides coun-selors and marriage and family therapists with a powerful model for assistingadoptive families. Such a model shows great promise for clinical efficacy andwarrants further research.

NOTES

1. See the appendix of Booth and Jernberg (2010) for full descriptions of Theraplay activities andgames.

2. Note that this argument is not the extreme position of permitting any unexamined gimmickor therapy method with zero evidence basis to be utilized because “anything is better than nothing.”Rather this is a moderate position that when one finds statistically significant findings that a treatmentworks, the added cautionary posture of Bonferroni might be too rigorous when the alternative to thetreatment is to do nothing for a patient, client, or family in need. There is a “window” between statisticallysignificant findings of effective treatments and the increased desirable position that Bonferroni affordsof near certainty. Apparently, these findings fall within that window and can be useful information untilsuch time as a better-designed study with enhanced controls can be attempted and reported.

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