Two Case Studies of Child-Centered Play Therapy for Children Referred With Highly Disruptive Behavior Jeff L. Cochran and Nancy H. Cochran University of Tennessee
William J. Nordling Institute for the Psychological Sciences
Anne McAdam Greece School District, Rochester, NY
Deborah T. Miller Rochester City School District, Rochester, NY
This article presents two cases with strong evidence measures in which child-centered play therapy (CCPT) was provided for children referred for highly disruptive behavior, including attention problems and aggression. Apparent progress was evidenced on the Teacher Report Form (TRF) of the Child Behavior Checklist (Achenbach & Rescorla, 2001). One client had a waiting period equal to his treatment period in which ratings were stable before change across his treatment period. The cases provide opportunities to consider how CCPT may work differently for similar behavioral difficulties in individual children. Researchers conceptualized each client’s areas of difficulty and apparent treatment effects as an expert panel, aided by indications from the TRF. Individual discussions are provided regarding rationales for apparent progress and why CCPT seemed to have been effective. Keywords: child-centered play therapy, highly disruptive behavior, attention problems, aggression,
classroom behavior
Children with highly disruptive behavior present a heavy burden to the schools, counselors, and others who care for them, and they present difficulties for their peers. Without effective intervention, such children face lives of high risk, emotional pain, and ever-increasing difficulty. The most common reason for referrals from teachers is behavioral problems (Abidin & Robinson, 2002), and children’s aggressive behavior is the most common presenting problem area for psychotherapists, including play therapists (Kazdin, Siegal, & Bass, 1990). DuPaul and Stoner
Jeff L. Cochran and Nancy H. Cochran, Department of Educational Psychology and Counseling, University of Tennessee; William J. Nordling, Department of Psychology, Institute for the Psychological Sciences; Anne McAdam, Greece School District, Rochester, NY; Deborah T. Miller, Rochester City School District, Rochester, NY. Correspondence concerning this article should be addressed to Jeff L. Cochran, Department of Educational Psychology and Counseling, University of Tennessee, Knoxville, TN 37996-3452. E-mail:
[email protected] 130 International Journal of Play Therapy 2010, Vol. 19, No. 3, 130 –143
© 2010 Association for Play Therapy 1555-6824/10/$12.00 DOI: 10.1037/a0019119
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(2003) reported that behavioral control is among the top reasons for referral to school and clinical psychologists. Cornett-Ruiz and Hendricks (1993) found that the behaviors commonly associated with attention deficit hyperactivity disorder negatively influenced the perceptions of peers and teachers, and Greene, Beszterczey, Katzenstein, Park, and Goring (2002) found that students with behaviors such as inattention, hyperactivity, and impulsivity caused significantly more stress in teachers than did students without these behaviors. Aggressive behaviors have consistently been found to be stable across time without effective intervention, and longitudinal studies have shown that children with high levels of externalizing behaviors are at high risk for future social and emotional problems, including psychiatric diagnoses, criminal offenses, and failure to graduate from high school (Cummings, Ianotti, & Zahn-Waxler, 1989; Dandreaux & Frick, 2009; Olson, Bates, Sandy, & Lantheir, 2000; Olweus, 1979; Patterson, DeBaryshe, & Ramsey, 1989; Veronneau, Vitaro, Pedersen, & Tremblay, 2008; von Domburgh, Vermeiren, Blokland, & Doreleijers, 2009). Patterson et al. (1989) found evidence that childhood conduct-disordered behaviors lead to academic failure and peer rejection, which in turn lead to increased risk for depressed mood and involvement in deviant peer groups and, we can assume, high risk for delinquent behavior. Early aggressive behavior problems are highly predictive of later antisocial behaviors of ever-increasing severity that are emotionally and materially costly to society in numerous ways (e.g., Caspi, Elder, & Bem, 1987; Coie & Dodge, 1998; Patterson, Reid, & Dishion, 1992). Play therapy, especially child-centered play therapy (CCPT), has been found to be effective across a wide range of mental health and behavioral problems, including recovering from great trauma and highly clinical concerns (Bratton, Ray, Rhine, & Jones, 2005; Demanchick, Cochran, & Cochran, 2003; Guerney, 1983, 2001; Landreth, 2002; Ray, Bratton, Rhine, & Jones, 2001). In recent studies of particular relevance to this research, Garza and Bratton (2005) found CCPT to be effective with Hispanic children, which is part of the ethnic background of both children in this study; Shen (2002) found play therapy to be effective in helping children with anxiety and depression, which are important parts of the case conceptualizations in this study; and Ray, Schottelkorb, and Tsai (2007) found play therapy to be effective with children exhibiting symptoms of attention deficit hyperactivity disorder, symptoms that were prominent among the reasons for referral of children in this study. We reasoned that CCPT would be a particularly effective approach for children with highly disruptive behavior. Difficulty relating to others seems to be a foundation of the difficulties faced by these clients, and therapeutic relationships are the strong foundation of CCPT (see Cochran & Cochran, 2006, for the development of the term and concepts of therapeutic relationships). CCPT emphasizes genuine, deep empathy and unconditional positive regard from therapist to child clients, child self-expression within necessary limits, and opportunities for the child to “think through” inter- and intrapersonal conflicts in play and to use play to communicate to self and counselor in therapeutic sessions (see Axline, 1969; Guerney, 1983, 2001; Landreth, 2002; Nordling, 2009). Cochran and Cochran (1999) illustrated that conduct-disordered behaviors in children can be based in core mistaken beliefs regarding expected negative outcomes in relationships with others.
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The purpose of this study is an in-depth look at cases in which CCPT appears to have been very helpful to children whose behavior was highly disruptive to see how CCPT may be helpful to children with similar difficulties. The processes and play behaviors of the children in this study are reviewed through the typical stages of CCPT (Nordling & Guerney, 1999) in Cochran, Cochran, Nordling, McAdam, and Miller (2009).
METHOD Clients The clients were referred by teachers and school administrators for severe attention and aggression difficulties that had persisted in increasing intensity from one school year to the next. Normal interventions for behavior change had been ineffective. Both were 6 years old and in first grade. Both are Hispanic, but ethnicity is not seen as an important factor in treatment or effects. They were selected for this report because of their high degree of similarity in problem severity, type, and age.
Treatment The treatment is CCPT in the model taught through the National Institute for Relationship Enhancement (NIRE; Guerney, 1983, 2001; Nordling, 2009). All other normally available interventions, such as crisis management, classroom guidance lessons, and parent and teacher consultation, remained available throughout the treatment and data collection periods. Whenever we were able to discern that something other than the treatment may have effected change, we report the possibility with results. Treatment was provided in the school in 30-min twice-weekly sessions. Authors Anne McAdam and Deborah T. Miller were based in the schools the children attended throughout the study. Anne McAdam is a licensed school counselor with extensive training in CCPT (at least one full, in-depth graduate course and additional workshops) and more than 10 years experience counseling children in a school setting. Deborah T. Miller is a licensed master’s-level social worker and licensed school social worker who has extensive training in CCPT (at least one full, in-depth graduate course, supervision, and additional workshops) and certification as a child-centered play therapist by NIRE and more than 15 years experience serving children in a school setting.
Design and Procedures For the purpose of reporting, we assigned pseudonyms to personalize the boys’ descriptions for readers and protect their identities. Anton had a waiting period before treatment of equal length to his treatment period. His scores across his waiting period remained quite consistent, suggesting a baseline. The only variable
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known to change for him after his waiting period is the treatment. Data collection and treatment procedures for Berto were the same, except that he did not have a waiting period. Raters were the boys’ primary teachers, who completed ratings during their planning periods at 9-school-week intervals. The rating scale was selected in part for properties of reliability. Teacher rating conditions were held consistent with no known factors (such as time of day or year) likely to affect teacher ratings of behavior. The presenting problem descriptions or case conceptualizations and rationales for apparent treatment applicability were developed after treatment. Jeff L. Cochran conducted semistandardized interviews with each play therapist regarding how she understood her client (e.g., Why was he referred? What do you think was going on with him? Why did he act out?) and how CCPT may have helped him (e.g., Do you think CCPT was effective for him? Why do you think so or think not? How do you see CCPT as having worked for him or not?). Each therapist responded with her thoughts on presenting problems and explanations of how and why the treatment seemed to work, providing as many behavioral anecdotes as possible. Jeff L. Cochran then responded with Teacher Report Form (TRF) of the Child Behavior Checklist (Achenbach & Rescorla, 2001) scores in relation to these same questions, and the he and the play therapist reached consensus understandings based on therapist’s direct observations, TRF ratings, and discussion. Jeff L. Cochran drafted descriptions and rationales that were reviewed by the therapists and the co-researchers, Nancy H. Cochran and William J. Nordling. Author consensus was reached. Then a final refinement of descriptions and rationales was completed by Jeff L. Cochran and Nancy H. Cochran. The therapists’ credentials were described earlier in the Treatment section. Nancy H. Cochran’s and William J. Nordling’s qualifications to serve as expert panel members include certifications as CCPT supervisors by NIRE with more than 10 and 15 years experience, respectively, teaching and supervising CCPT, licenses that cover the responsibilities of diagnosis and client conceptualization and treatment planning in the fields of mental health counseling and psychology, and extensive clinical supervision experience.
Instrument The TRF (Achenbach & Rescorla, 2001) was developed to measure problematic child behaviors as indicated in specific teacher ratings. Included are 118 items that ask teachers to mark, on a 3-point scale of frequency, the presence of behavioral symptoms and emotional descriptors. The TRF reports clinical behaviors in Total Score, Internalizing and Externalizing Composites, and eight syndrome scales including Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Aggression, and Rule-Breaking. Standard errors of measurement are provided by gender, age group, and referred versus nonreferred norm groups for total scores, composite areas, and syndrome scales. The standard errors of measurement provided allow clinicians or researchers to determine confidence intervals of 68% or 90%, which allow statements of significance of score changes to those confidence levels. Anxious/Depressed, With-
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drawn/Depressed, and Somatic Complaints make up the Internalizing Composite. The Aggression and Rule-Breaking syndrome scales make up the Externalizing Composite. Test–retest reliability for the TRF was established at correlations of .90 for Total Score and .91 and .92 for the Internalizing and Externalizing Composites, respectively. The internal consistency of problem area scales was supported by alpha coefficients of .78 –.97. Strong validity evidence for TRF scores has been established through multiple studies conducted over the past 20 years (Achenbach & Rescorla, 2001).
INDIVIDUALIZED CASE RESULTS AND DISCUSSION FOR ANTON Background: Hypervigilance, Attention, Aggression, Thought, and Social Problems Anton had exhibited disruptive behavior that was markedly different from his peers’ behavior during kindergarten and the early months of first grade (he was referred and began his waiting period in the 3rd month of the school year). Behavior areas of particular concern for him included failing to concentrate, follow directions, and finish schoolwork; an apathetic attitude toward schoolwork; seeming to lack guilt in breaking rules or hurting others; frequent arguing with his teacher and peers; defiance; destruction of property and disobedience; low frustration tolerance and being very quick to get angry and tantrum; and seeming to enjoy little in life. A referral for off-campus therapeutic services was made during his kindergarten year, but his parents did not follow through. His Total Score and Internal and External Composite scores were well into the clinical range. His syndrome ratings in the clinical range included, ordered with highest areas of concern first, Attention Problems, Aggressive Behavior, Thought Problems, and Social Problems. His ratings were nearly identical at the end of his waiting period, with his Total Score, composites, and syndrome scales in the clinical range. His therapist observed that he seemed to have a very poor relationship with his teacher, who seemed quite impatient with him and generally maintained a negative tone toward him. See Tables 1 and 2.
Table 1. Anton’s Teacher Report Form (TRF) Total and Composites Teacher ratings on standardized measures Scale or composite
Pre–wait period
Post–wait period
Posttreatment
TRF total score Internalizing Externalizing
107, clinical, T ⫽ 77 11, clinical, T ⫽ 64 34, clinical, T ⫽ 74
109, clinical, T ⫽ 77 11, clinical, T ⫽ 64 34, clinical, T ⫽ 74
83, clinical, T ⫽ 70 7,b normal, T ⫽ 58 29,a clinical, T ⫽ 71 a
Note. Rows include total or composite scores (lower scores suggest improvement), range (clinical, borderline, or normal), T score, and note regarding change (e.g., positive trend, significant, or highly significant). a Score change more than twice the standard error of measurement for referred children at the 90% confidence interval. b Score change greater than the standard error of measurement for referred children at the 68% confidence interval.
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Table 2. Anton’s Teacher Report Form (TRF) Syndrome Scale Scores Teacher rating TRF subscale
Pre–wait period
Post–wait period
Posttreatment
Anxious/depressed Withdrawn/depressed Somatic complaints Rule-breaking Aggressive Social problems Thought problems Attention problems
3, normal 8, borderline 0 7, borderline 27, clinical 8, clinical 7, clinical 45, clinical
3, normal 8, borderline 0 8, borderline 26, clinical 8, clinical 8, clinical 46, clinical
1,a normal 6,a borderline 0 9, clinical b 20, borderline 4,c normal 5,c borderline 37,c borderline
Note. Rows include score (lower scores suggest improvement), range (clinical, borderline, or normal), and a note regarding change (e.g., positive trend, significant, or highly significant). a Change greater than the standard error of measurement for referred children at the 68% confidence interval. b Considered significant if score change is greater than the standard error of measurement for referred children at the 90% confidence interval. c Score change more than twice the standard error of measurement for referred children at the 90% confidence interval.
In a pretherapy interview in which his therapist asked him to respond to a series of true–not true statements, it became clear to her that he was quite sad, anxious, worried for his mother, and unsettled. His home life was believed by school adults to be chaotic, and his mother may have been at risk for, or experiencing, domestic violence. In early sessions, he would often seem suddenly worried and want to contact his mother. We conceptualize many of his difficulties as possibly resulting from hypervigilance related to living with high levels of worry and stress. This hypervigilant way of being seemed to have left him inattentive (or preoccupied), appearing apathetic, easily irritated and emotionally upset to the point of tantrums, and easily drawn into conflict partly as a way to escape the high stress level that he seemed to live with.
Measures of Progress Although his scores remained nearly exactly the same from his initial ratings to post–waiting period, they improved significantly or with strong trends from pre- to posttreatment. His Total Score improved at more than twice the 90% confidence interval. His scores on the Internalizing and Externalizing Composites demonstrated strong positive trends (improving beyond the 68% confidence interval), with his Internalizing Composite shifting from clinical to normal ranges. His Social Problems score improved from pre- to posttreatment at more than twice the 90% confidence interval and shifted from the clinical to the normal range; his Aggressive Behavior score improved beyond the 90% confidence interval, shifting from the clinical to the borderline range, as did his Thought Problems score. He had strong positive trends in Attention Problems, Anxious/Depressed, and Withdrawn/Depressed. His Attention Problems score shifted from the clinical to the borderline range. See Tables 1 and 2.
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Nontreatment Factors Potentially Influencing Changes in Ratings Anton’s school began a mentoring program midway through his treatment. He participated in the program and commented to his therapist that he liked his mentor. Although his therapist attempted to implement regular parent and teacher consultation on his behalf, neither his teacher nor his parent welcomed this assistance. Both seemed distressed regarding other matters to a level that made consultation regarding new adult actions toward him ineffective. Near the end of treatment, Anton’s home life seemed to be newly disrupted. He was said to be living with another relative for the last few weeks, then was suddenly moved out of the district.
Conceptualization and Discussion of Results for Anton We see the changes in TRF scores as indicating significant change for Anton. Our consensus is that CCPT was an effective intervention for him for the following reasons.
Choice, Self-Expression, and Self-Direction The focus within CCPT on Anton’s self-expression, as well as his choices and decisions, seemed to help him make new decisions about who and how he wanted to be. As his therapist picked him up for one session, his teacher was scolding him for not completing a piece of work. He was obstinately refusing. After his CCPT session, he appeared to have made a new choice, and he immediately asked to work on and complete the task. Over the course of therapy, he seemed to shift from a focus on others’ reactions to him to self-directed choices. His play shifted from being self-restricted in ways that avoided risk of criticism or rejection (e.g., playing with action figures or doll house very carefully, with his back to therapist, his body hiding the action and his eyes furtively checking to see whether she was watching, but that she could not see too much) to testing the therapist’s reactions (e.g., limit testing and personally abrasive behaviors, such as having action figures in his play suddenly jump out to bite at her and later vehemently arguing over ending sessions), to expansive and free play that seemed to hold little regard for her or anyone’s reactions (e.g., sprawling battles that encompassed the playroom and self-made games in which he reveled in the defeat of his therapist), to equally expansive play that was also easily cooperative and considerate of his therapist (e.g., cooperative role-plays in which he engineered the giving and receiving of nurturing and self-made games in which his therapist was “helped” to win a portion along with him). The balance of empathy, unconditional positive regard, and limits seemed to give him an opportunity to express enough of his emotion to calm down, think, and choose more clearly. The experience seemed to allow him the opportunity to develop self-control and responsible freedom of expression (e.g., expressing his aggressive feelings to the fullest within limits helped him experience expression
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along with self-control of those feelings and impulses). Because he was warming up well to his therapist and the opportunities provided in CCPT to self-express, his behavior seemed to be saying, “I have a lot of anger and hurt to express. And you seem to care to hear it. So, here I go.” After that, he argued heatedly over limits, screaming at times about unfairness, to a level well beyond his actual interest in the limited behavior. He seemed, rather, to take this as an opportunity to get really mad, to feel that anger and be heard, and to be met with empathy and unconditional positive regard for all thoughts and feelings experienced.
Self-Perception and Expectations Because CCPT and other person-centered approaches often help people gain self-awareness and thus establish realistic self-expectations, we see that CCPT helped Anton see himself in new ways. He seemed to expect rejection from others (we saw this as implied in his early restricted, semihidden, seemingly highly selfconscious play), but once he was able to express the perceived “worst parts” of himself in the structured empathic relationship of CCPT (e.g., aggressive acts met with empathy and limits within empathy), he seemed to see that his expressions of his worst emotions could be accepted and responded to with empathy and unconditional positive regard from his therapist. Then through expressing these worst parts, he came to see that he could master and manage these feelings that had previously seemed so monstrous and unmanageable. Once past this phase, he appeared to see himself in a more confident, positive light. He carried himself with a confident posture and gait and began to spontaneously acknowledge the things that he was good at and to express his dreams of his future and things that he would like to do and be.
Nontreatment Factors We see few reasons to suspect nontreatment factors in his apparent change. His repeated-measures pretreatment ratings before and after his waiting period seem to form a baseline rating. The relationship with his mentor may have contributed to his progress, or his openness to a mentor may have been influenced by his work in CCPT. It is difficult to know whether his move near the end of treatment was a long- or short-term positive or negative. We take it to have been at least an additional short-term high-level stressor in a normally high-stress life. Yet, his progress was maintained in spite of this through the end of his time at the school.
INDIVIDUALIZED CASE RESULTS AND DISCUSSION FOR BERTO Background: Depression Underlying Attention Problems and Acting-Out Behavior Berto was referred for attention and aggression difficulties that were markedly different from his peers’ behavior during kindergarten and the early months of first
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grade (he was referred and began treatment in the 2nd month of the school year). His therapist saw him as manipulative but starved for caring attention and seeking it in all the wrong ways (i.e., frequently refusing work and having a crying tantrum if pressed). His teacher and therapist suspected excessive punishment at home. His parents had explained that his behavior was out of control because they were no longer able to hit him, implying some sort of criticism or restriction associated with physical abuse. His parents were seen by school personnel as highly controlling and restrictive and as loving, but not liking, Berto. In contrast to his reasons for referral, his pretreatment ratings suggested his greatest problem area to be anxiety and depression, and we concur on the basis of our clinical consensus. Behavior areas of particular concern for Berto included perfectionism, being highly self-conscious, being easily hurt when criticized, fearing mistakes, being overcome with worries, failing to concentrate, hyperactivity and impulsivity, demanding attention, becoming easily frustrated, and breaking rules (including stealing). He was seen as both highly dependent and defiant and easily jealous of others (especially if they were seen as gaining advantage in relation to the teacher). His Total Score and Internal and External Composite scores were well into the clinical range. Syndrome scores in the clinical range, ordered with highest first, were Anxious/Depressed and Attention Problems. Syndrome scores in the borderline range were Aggression, Rule-Breaking, Social Problems, Thought Problems, and Withdrawn/Depressed. We conceptualize his attention and aggression difficulties as resulting from a low sense of self-worth, which drove him to demand caring attention as confirmation from others. This excessive need for confirmation drove him to attempt to force favorable opinions of himself, often in ways that annoyed and aggressed toward others. Additionally, his excessive need to force affirmation drove him to an inability to accept conflict, challenge or criticism.
Measures of Progress Berto’s TRF Total Score improved at more than twice the standard error of measurement for the 90% confidence interval for referred children. His Internalizing Composite score improved beyond the 90% confidence interval, led by his Anxiety/Depression subscale score improving at more than twice that interval. His Attention Problems score improved at more than twice the standard error of measurement for the 90% confidence interval, shifting from the clinical to the normal range. His Thought Problems syndrome score improved beyond the 90% confidence interval, shifting from borderline to normal range. His Externalizing Composite score did not change, nor did his scores on the syndrome scales RuleBreaking and Aggression. See Table 3. Anecdotally, his therapist saw that he changed quite a bit. She noted that he still tended to manipulate in the classroom, but that he had come a long way in his behavior and relationships with adults. The intensity and frequency of his acting out were reduced. His time on task appeared to have improved. Because his therapist was the counselor based in his school, she also provided classroom guidance lessons. She noted that before treatment, he undermined lessons, insisting on being the center of attention and responding with tantrum behavior, when not granted the
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Table 3. Berto’s Teacher Report Form (TRF) Teacher Ratings Teacher ratings on standardized scale
Scale or composite and subscale
Pretreatment
Posttreatment
TRF total score Anxious/depressed Withdrawn/depressed Somatic complaints Internalizing composite Rule-breaking Aggressive behavior Externalizing composite Social problems Thought problems Attention problems
107, clinical, T ⫽ 77 20, clinical 6, borderline 0, normal 26, clinical, T ⫽ 75 7, borderline 20, borderline 27, clinical, T ⫽ 69 7, borderline 5, borderline 40, clinical
83,a clinical, T ⫽ 70 13,a clinical 4, normal 0, normal 17,a clinical, T ⫽ 69 6, borderline 21, borderline 27, clinical, T ⫽ 69 6, borderline 2,b normal 30,a normal
Note. Rows include score (lower scores suggest improvement), range (clinical, borderline, or normal), T score when available, and a note regarding change (e.g., positive trend, significant, or highly significant). a Score change more than twice the standard error of measurement for referred children at the 90% confidence interval. b Considered significant if score change is greater than the standard error of measurement for referred children at the 90% confidence interval.
center of attention. By the end of the treatment period, he was comfortable with not being the center of attention through lessons. She noted that he progressed to the point at which he would typically voice complaints, but then be able to let it go and move on. He developed a close, trusting relationship with his therapist and also developed a close relationship with a vice principal. He developed only a marginally better relationship with his teacher in the year of treatment, but she seemed only marginally open to a relationship with him. At one point, he asked his therapist to take him to see his kindergarten teacher on the way back to class, which she did. Although he had previously said he hated this teacher, he explained to his therapist that he wanted her to see him now and to know how well he was doing.
Nontreatment Factors Potentially Influencing Changes We are aware of no nontreatment factors that would have had important effects on Berto’s areas of change. Although his therapist attempted to implement regular parent and teacher consultation aimed at enhanced relationships and behavior management, neither his teacher nor his parents participated consistently. Both seemed intransigent, seeing their patterns of managing behavior and relationships as adequate and Berto as being inadequate. He developed an informal mentor relationship with a vice principal during the treatment period that he had not seemed open to before treatment. His therapist taught social skills in his classroom once per week, but because she observed very low levels of interest in the lessons from Berto, we do not attribute his progress to these lessons. She explained that his classmates were often seen trying new skills and would report their use of skills to her, but Berto did not participate in similar ways.
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Conceptualization and Discussion of Results for Berto Changes in Self-Perception or Self-Talk We believe that CCPT provided Berto with a reformative experience, based on a very different set of interactions from what he had come to expect. We conceptualize him as feeling starved for caring attention but acting out to get it in mistaken ways (e.g., annoying his teacher into attending to him over others, becoming angry, scolding his teacher or hurting peers when she did not attend to him, refusing activities in an apparent attempt to engage his teacher). We see him as having developed a mistaken self-perception that can be paraphrased as “I am not being loved/liked. I may be unlovable and unlikable. I am about to be rejected and I can’t stand that!” We see the fear produced by this belief system as creating nearly panicked mistaken attempts to seek nurturing, which encompassed much of his misbehavior. See Cochran and Cochran (1999) for illustrations of how this can happen in similar children. So, first and foremost, CCPT provided some much-needed caring attention for Berto, like giving a refreshing drink of water to one who is thirsting in the desert— one who is severely parched— but has no awareness of how to look for or even accept water when it is offered. Equally important to this caring attention and similar to Anton, CCPT provided an experience that appeared to change Berto’s self-perception. It is as though his experience of deep empathy and unconditional positive regard changed his belief self-perception to a new, experience-based, more complex self-perception, something like “My play therapist who really knows me [deep empathy with his aggressive and annoying impulses amounts to really knowing], likes and loves me [note the nonpossessive affection of unconditional positive regard or prizing (Rogers, 1961; Wilkins, 2000) inherent in CCPT]. This really knowing and unconditional positive regard is for who I am, not for what I do or don’t do.” Because this relationship with his play therapist was close, genuine, and deeply felt, it may have served to initiate a reevaluation and change process in his self-perception and resulting behaviors. It appeared that once Berto experienced this therapeutic relationship, he also began to reach out for other positive relationships, opening up to a relationship with the vice principal who had attempted a closer relationship with Berto before and had been rebuffed and seeking to have his teacher from the year before see him in a new light and know how he had changed.
Anxious/Depressed Feelings Leading to Disruptive Behavior Because we conceptualized Berto’s presenting difficulties as depression, driven by an unreasonably low sense of self-worth, we see his overall progress in TRF scores as led by his progress in the Anxious/Depressed problem area, which was one of his top two progress areas, equal to Attention Problems. We conceptualize that his reduced feelings of anxiety and depression and changed self-perception enabled him to better calm himself and attend, thus earning improved ratings in the Attention Problems subscale and also reflected in his significant progress on the Thought Problems subscale.
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It is important to note that CCPT is a self-expressive, affect-based, wholeperson approach rather than a behavior- or thought-focused approach. We see that it was more important that Berto deeply experience his therapist’s empathy and unconditional positive regard than to have his therapist attempt to direct or teach new behavior. Landreth (2002) described learning in CCPT as “developing experiential, intuitive learning about self that occurs over the course of the therapeutic experience” (p. 90), as opposed to a more intellectual mode of learning. Had his therapist attempted to teach him new cognitive– behavioral skills, no matter how subtle the teaching, Berto would probably have perceived such teaching and the evaluation it requires as further rejection. He would likely have resisted the intervention or, worse, internalized it as reinforcing his errant belief system. We see the deep empathy inherent in CCPT as the fastest and most efficient way to connect with Berto at his core and to provide a powerfully corrective relationship.
CONCLUSIONS The results for these clients suggest strong possibilities for CCPT for children with highly disruptive behavior. Both clients made significant progress, against reasonable expectations based on their levels of difficulty in behavior. However, one must be careful not to generalize from single cases. Additionally, although Anton had a waiting period with stable scores suggesting a baseline, Berto did not, which makes it more difficult to conclude with certainty that the treatment caused the changes. But more important than outcome assertions from this research, we get a glimpse into why such progress seems possible. First, these boys’ cases present comparative views of what can underlie highly disruptive behavior, with hypervigilance seeming to prompt attention problems and aggression for one and depression seeming to underlie attention problems and aggression for the other. Additionally, in spite of this variation, CCPT seems to have helped in similar ways. For Anton, self-expression within the therapeutic relationship seemed to lead to new awareness of choice and greater self-direction, and his experience in the therapeutic relationship seemed to have changed core self-perceptions. Berto appears to have similarly changed his self-image, and resulting reductions in depressed feelings and thoughts appear to have prompted change in disruptive behavior. The stories of these boys’ progress through CCPT suggests the potential for the progress of others and sheds light on some of the mechanisms of progress in therapeutic relationships. We see their stories as illustrating how self-actualization can be reactivated through the self-expression, self-awareness, and choice making facilitated in the therapeutic relationship inherent in CCPT. Useful additional research may include large-scale studies of the effectiveness of CCPT with highly disruptive children, as well as a greater variety of case studies illuminating the mechanisms of progress provided in CCPT. We hope that the results help play therapists see the potential for reaching out and helping children who may initially seem hard to reach and that our conceptualizations will help them consider new ways of articulating how CCPT can work. We additionally hope that counselor–therapist
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educators will gain new tools from these boys’ stories to inspire and encourage up-and-coming counselors and therapists through improved understandings of how counseling and therapy can work and thus to reach more children in need.
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