Therapist Perceptions of Relationship Conditions

in Child-Centered Play Therapy

April A. Schottelkorb
Boise State University
Karrie L. Swan
Kansas State University
Rhyan Garcia
Family Counseling Services, Meridian, Idaho
Brooke Gale and Brooke M. Bradley
Boise State University
Child-centered play therapy (CCPT) has over 70 years of research documenting its
effectiveness for children with a variety of presenting problems and diagnoses. Less
is known about the therapeutic relationship and its inuence in the process of CCPT.
In this study, a single case design was employed to examine the therapists perspective
of relationship conditions across CCPT. Two childtherapist dyads participated in
this study. Two preschool children qualied for participation because of their clinical
level of behavioral problems as identied by parents on the Behavior Assessment
System for Children-2: Parent Rating Scales Preschool (BASC-2:PRS-P). Thera-
pist perceptions of the therapeutic relationship were assessed with the Barrett-Len-
nard Relationship Inventory: Form MO-40 (BLRI: MO-40) after each session. The
effectiveness of CCPT was assessed with pre-, mid-, and post-parent ratings on the
BASC-2:PRS-P. In this investigation, we found that both children showed progress
in reducing their presenting problems, and that therapist-perceived congruence, level
of regard, and empathy increased while unconditionality decreased. Possible impli-
cations and future research is discussed.
Keywords: play therapy, therapist perceptions, therapeutic relationship, therapy process
A substantial body of theoretical and empirical research evinces curative
components of the therapeutic relationship (Goldfried & Davilla, 2005; Lambert &
Barley, 2001; Norcross, 2002). Strength of the therapeutic relationship between
client and therapist has been associated with treatment progress and improvements
April A. Schottelkorb, Department of Counselor Education, Idaho Initiative for Play Therapy
Studies, Boise State University; Karrie L. Swan, Department of Special Education, Counseling, and
Student Affairs, Kansas State University; Rhyan Garcia, Family Counseling Services, Meridian, Idaho;
Brooke Gale and Brooke M. Bradley, Department of Counselor Education, Boise State University.
The Idaho Initiative for Play Therapy Studies at Boise State University supported this research.
Correspondence concerning this article should be addressed to April A. Schottelkorb, Department
of Counselor Education, Boise State University, 1910 University Drive, Boise, ID 83725. E-mail:
[email protected]
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1
International Journal of Play Therapy 2014 Association for Play Therapy
2014, Vol. 23, No. 1, 117 1555-6824/14/$12.00 DOI: 10.1037/a0035477
in treatment goals and functioning (Arnow et al., 2013; Lo Coco, Gullo, Prestano,
& Gelso, 2011; Norcross, 2010; Shirk & Karver, 2003). Even the Task Force on
Empirically Supported Therapy Relationships held that therapist genuineness (also
referred to as congruence) and positive regard are promising and probably effec-
tive components in counseling relationships, whereas empathy is a demonstrably
effective element (Steering Committee of the APA Division 29 Task Force, 2001).
Although the therapeutic relationship is well established as a fundamental element
to successful therapy, surprisingly little is known about the particular conditions
effectuating a curative alliance, particularly in regard to child therapy.
The therapeutic relationship is particularly important in child-centered play
therapy (CCPT); a therapeutic approach for children ages 312 that is based on the
person-centered philosophy of Carl Rogers. Similar to adult person-centered ther-
apy, in CCPT, the therapeutic relationship is believed to promote childrens social,
cognitive, and affective development (Axline, 1969; Landreth, 2012; Ryan & Court-
ney, 2009). Child-centered play therapists utilize unconditional positive regard,
empathy, and congruence to affect change in CCPT. Rogers (1951) considered
these core conditions to be at the heart of change in therapy, and research strongly
supports CCPT as effective with a variety of presenting problems (Bratton, Ray,
Rhine, & Jones, 2005).
The concept of congruence in the child-therapist relationship encompasses a
therapeutic stance that is authentic, spontaneous, creative, and living (Lietaer, 1993;
Schmid, 2001). Rogers (1951) explained that congruence is displayed when the
feelings the therapist is experiencing are available to him (sic), available to his
awareness, and is able to live these feelings, be them, and able to communicate
them if appropriate (p. 61). Thus, in the realm of play therapy, therapists congru-
ently attune to their clients in a manner that increases connection and contact. For
child therapists using CCPT, congruence is exhibited by matching internal dialogue
and feelings with verbal communications with child clients (Ryan & Courtney,
2009). As a result of this relational process, Ryan and Courtney argued that
childrens attachment relationships strengthen, self-awareness and emotional re-
sponsiveness increases, and self-worth, connectivity, and vitality rises. To assess the
impact of therapist congruence in treatment outcome, Kolden, Klein, Wang, and
Austin (2011) reviewed results from 16 studies published from 1971 to 2009. In their
meta-analysis, Kolden et al. found that congruence accounts for 6% of variance in
treatment outcome, representing a small to medium effect size (.24).
In a qualitative study, Schnellbacher and Leijssen (2009) examined the signif-
icance of therapist congruence for adult clients (N 6). Through content analyses,
the authors found that for adult clients, therapist congruence played a signicant
role in therapeutic progress. Schnellbacher and Leijssen also noted that therapist
use of genuine self-disclosures helped clients improve self-concepts and mental
schemas. For some clients, therapist congruence was the most important factor in
therapeutic treatment, but for others, empathy and acceptance were more impor-
tant. Furthermore, results of the study seem to highlight the need to better
understand the importance of therapist congruence in child therapy and how the
expression of congruency promotes positive outcomes for children.
An additional attitudinal quality and facilitative condition is therapists use of
empathy. Empathy has been dened as a two way process which occurs when two
people relate to one another in a context of interest in the other, emotional
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2 Schottelkorb, Swan, Garcia, Gale, and Bradley
availability, responsiveness, and the intent to understand (Jordan, 1987; p. 7).
Miller (1986) further highlighted the importance of responsive understanding for
developing childrens self-worth, connectivity, and vitality. Research consistently
shows that empathic adultchild relationships play a vital role in childrens healthy
development and functioning (Brazelton & Greenspan, 2006; Jensen, Weersing,
Hoagwood, & Goldman, 2005). Spencer, Jordan, and Sazama (2004) proposed that
the expression of compassionate understanding by which mutual empathy is based
fosters childrens relational competence and psychological growth. Specically,
positive outcomes for children that have empathic connections with adults include
increased emotional regulation, social expression, and resiliency (Brazelton &
Greenspan, 2006; Masten, 1994).
A third essential component affecting the therapeutic relationship in CCPT is
unconditional positive regard. Mearns and Thorne (1988) dened unconditional
positive regard as the fundamental attitude of the person-centered counselor
toward her client. The counselor who holds this attitude deeply values the humanity
of her client and is not deected in that valuing by any particular client behaviors.
The attitude manifests itself in the counselors consistent acceptance of and endur-
ing warmth toward her client (p. 59). For the child-centered play therapist,
unconditional positive regard involves unconditionally accepting and prizing the
child as well as believing deeply in the childs potential for inner growth. According
to Wilkins (2000), the experiencing and imparting of unconditional positive regard
is the most challenging quality to develop and subsequently most arduous to
examine.
PURPOSE OF THE STUDY
Although conceptually and theoretically therapist congruence, empathy, and
unconditional positive regard have received much attention, little empirical re-
search exists regarding the impact and outcome of Rogers facilitative conditions.
It is clear from a review of the research studies that more rigorous testing of
Rogers relationship conditions is required in order for it to remain focal as the
most important aspect of treatment . . . (Cooper, Watson, & Holldampf, 2010, p.
245). Whereas the core relationship conditions have been somewhat explored in
adult therapy, they have yet to be the focus of attention in child therapy. In
particular, to date, researchers have not investigated how congruence, empathy,
and unconditional positive regard relate to treatment outcome in CCPT.
This study provides a preliminary investigation of therapists perceptions of
their levels of the core relationship conditions (congruence, empathy, unconditional
positive regard) through three phases of CCPT in a single-case exploratory design.
Because single case research typically includes collection of data prior to interven-
tion (baseline phase), we determined that the rst three sessions of the play therapy
relationship would serve as the baseline phase (phase A). In most theoretical
models of child therapy, the rst three sessions account for the development of the
therapy relationship wherein play behaviors of child clients are typically explor-
atory (Landreth, 2012; Withee, 1975). Thus, the rst three sessions were deemed
the baseline phase in this study. Sessions 4 through 11 were identied as the middle,
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3 Therapist Perceptions of Relationship Conditions
working phase (Phase B), and Sessions 1214 were distinguished as the termination
phase. Therefore, in this study a single subject research design was used to inves-
tigate therapists perceptions of relationship conditions across CCPT.
METHOD
Participants
Participants were recruited from a preschool in the Northwest United States.
After institutional review board approval was received, all parents and guardians
received a letter inviting their children to participate in play therapy. The rst
author met with interested parents/guardians and reviewed consents and criteria to
participate. The following were noted as qualifying criteria: (a) aged between 2 and
5, and (b) clinical score on one behavioral subscale of the Behavior Assessment
System for Children2: Parent Rating ScalePreschool (BASC: PRS-P). Of seven
initial subjects, four qualied to take part in this study. After play therapy was
discontinued, parents/guardians of two participating children indicated they had
concurrently attended parenting classes during the course of this investigation.
Consequently, their data was removed from further analyses; thereby data from
two children and two cooperating therapists will be reviewed. All client and
therapist names were changed to protect their condentiality.
ClientTherapist Dyads
Jordan (name altered), a 2.5-year-old Caucasian male, was referred for partic-
ipation in this study because of his mothers concerns about his aggressive behav-
iors and difculties in transitioning to new tasks. Jordans mother rated his behavior
in the clinical range on the Hyperactivity subscale (n 77) of the BASC-2: PRS-P.
His mother also rated his behavior in the at-risk range (n 67) for Aggression and
Somatization (n 61). Jordans mother completed the BASC-2: PRS-P prior to
beginning play therapy, after 7 sessions of play therapy, and after the nal, 14th play
therapy session. Jordans therapist, Shannon (name altered), was a graduate stu-
dent, working toward completion of her masters degree in counseling. She had
completed 3 courses in play therapy, two semesters of practicum, one semester of
internship, and was completing her nal semester of internship during the course of
this study.
Anna (name altered) was a 4-year-old, Caucasian female, who was referred for
participation in this study because of her mothers concern that she had difculty in
relationships with peers and family members. Annas mother rated her behavior in
the clinical range on the Anxiety subscale (n 70) and Withdrawal subscale (n
89) of the BASC-2: PRS-P. Annas mother completed the BASC-2: PRS-P prior to
beginning play therapy, after 7 sessions of play therapy, and after the nal, 14th play
therapy session. Annas therapist, Jamie (name altered), was working toward
completion of her masters degree in counseling. She had participated in two play
therapy courses and completed two semesters of practicum.
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4 Schottelkorb, Swan, Garcia, Gale, and Bradley
Design
An exploratory single subject quantitative-qualitative design was used to ex-
amine therapist relational variables and their associations with changes in childrens
behavior in CCPT (Hilliard, 1993; Jordans, Komproe, Tol, Nsereko, & De Jong,
2013). Specically, we examined changes in levels of therapist process variables and
their corresponding relationships with changes in childrens behaviors within and
between cases to better understand therapeutic processes that impact child behav-
ior, as well as the therapeutic relationship. We assessed changes in therapist process
variables across the following phases in CCPT: relationship building phase (A;
Sessions 13), working phase (B; Sessions 411), and termination phase (C; Ses-
sions 1214). Then, we used qualitative data from therapists case notes to examine
patterns between changes in child behaviors and trends in therapist processes.
Procedures
After parent consents were received, the parents/guardians completed the
BASC-2: PRS-P for determining eligibility in the study. Data from parents ratings
of their childrens behaviors was also collected at mid- and postintervention. In
addition, graduate students in a counseling program in the Northwest United States
were invited to participate in this study. Informed consent procedures were fol-
lowed with cooperating therapists. To investigate therapist perceptions, therapists
completed the Barrett-Lennard Relationship Inventory: Form MO-40 (BLRI: MO-
40) after each session.
Relationship Phase (A)
In this phase, and throughout all phases, child participants received twice-weekly
30-min individual child-centered play therapy sessions. After each play session, thera-
pists used the BLRI: MO-40 to rate their perceptions of relational conditions. This
relationship-building phase, Phase A, consisted of the rst three sessions because a
minimum of 3 data points is considered adequate for a baseline (Kennedy, 2005) and
because play therapists frequently consider the rst three sessions as the exploratory,
relationship-building phase (Landreth, 2012; Withee, 1975).
Working Phase (B)
Participants continued to receive two 30-min individual CCPT sessions per
week. Therapists continued to rate their perceptions of relationship variables using
the BLRI: MO-40 after each play session.
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5 Therapist Perceptions of Relationship Conditions
Termination Phase (C)
During this phase, Sessions 1214, therapists began the process of termination.
Clients continued to receive play therapy for 30 min twice per week. Therapists
continued to use the BLRI to rate their perceptions of relationship conditions.
Instruments
BLRI
The BLRI (Barrett-Lennard, 1962) was developed in the 1960s by Barrett-
Lennard to measure therapeutic relationship conditions put forth by Rogers as the
essential conditions for client change. The BLRI is considered one of the best
instruments for measuring Rogers facilitative conditions, has been utilized in many
clinical studies aimed at examining the therapeutic relationship, and has been
translated into many languages (Friere & Grafanaki, 2010). For this study, because
the 64-item BLRI is not appropriate for use with children under the age of 10 years,
(G. Barrett-Lennard, personal communication, February 21, 2013) the therapist
client relationship was assessed from the therapist perspective with the Barrett-
Lennard Relationship Inventory: Form Myself-to-the Other40 (BLRI: MO-40). In
this 40-item questionnaire, therapists rate their relationship with an identied
client. The mean internal consistence reliability of the BLRI is high, with Gurman
(1977) reporting a range of .74 to .91 across 14 studies using the BLRI. Caution is
warranted because the 64-item version of the BLRI has been most commonly used
in studies where validity and reliability were examined; the 40-item version has not
received the same scrutiny.
The BLRI: MO-40 has four subscales, each related to the three core relation-
ship conditions in person-centered therapy: Level of Regard, Empathy, Uncondi-
tionality, and Congruence. In the BLRI, the core condition of unconditional
positive regard is split into two subscales: Level of Regard and Unconditionality.
There are 10 questions for each subscale and therapists are required to answer each
item based on how they view the relationship with their client. A 6-point scale is
used that ranges from 3 to 3, with 3 dened as No, I strongly feel that it is
not true and 3 dened as Yes, I strongly feel that it is true. The higher the
scores in each area, the more likely positive change in therapy will occur (Barrett-
Lennard, 1962). The Level of Regard subscale measures the level of respect one has
for the client (Barrett-Lennard, 1962). One item within the Level of Regard
subscale, for example, states, I feel friendly and warm toward (clients name).
The Empathy subscale assesses the therapists ability to understand the clients
feelings. A corresponding example is, I usually sense or realize how (clients
name) is feeling. The Unconditionality subscale appraises variability of regard one
experiences for the client and is based on how the client behaves (Barrett-Len-
nard). For example, item 19 states I would like (clients name) to be a particular
kind of person. The nal subscale, Congruence, is used to evaluate the therapists
perception and ability to demonstrate genuineness or realness in the therapeutic
relationship. For example, item 24 assesses therapist congruence with I am able to
be openly myself in our relationship.
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6 Schottelkorb, Swan, Garcia, Gale, and Bradley
Behavior Assessment System for Children2: Parent Rating ScalePreschool
The BASC-2: PRS-P is a 134-item assessment designed to assess parents
perceptions of problematic and adaptive behaviors in preschool children ages 25
(Reynolds & Kamphaus, 2004). The BASC-2: PRS-P requires parents to rate their
childrens behaviors on a four-point frequency scale of Never, Sometimes, Often,
and Almost Always. The BASC-2: PRS-P provides externalizing, internalizing, and
adaptive skills composite scores, as well as problem and adaptive subscales. The
problem subscales include Hyperactivity, Aggression, Anxiety, Depression, Soma-
tization, Atypicality, Withdrawal, and Attention Problems. Adaptive subscales of
the BASC-2: PRS-P includes Adaptability, Social Skills, Activities of Daily Living,
and Functional Communication. The BASC-2: PRS-P was utilized in this study
because it assesses a range of problematic and adaptive behaviors with young
children, is based on diverse, large, normative samples and has high internal
consistency and testretest reliability (Reynolds & Kamphaus, 2004).
Treatment
CCPT
CCPT was originally developed by Virginia Axline (1969) as a developmentally
appropriate method to counsel children based on Carl Rogers person-centered
theoretical approach. Using Rogers relationship conditions deemed essential for
client change, Axline developed eight propositions for play therapists to live out in
their relationship with child clients: (1) Build rapport with children, (2) Accept
children unconditionally, (3) Establish a permissive relationship, (4) Reect chil-
drens feelings, (5) Respect children, (6) Allow children to lead the session, (7)
Children cannot be rushed in growth, and (8) Establish limits when necessary (pp.
7374). Garry Landreth (2012) further developed and delineated the conditions and
skills needed to be an effective child-centered play therapist and conducted much
research on the effectiveness of CCPT with a variety of populations. Dee Ray
(2011) has continued to further dene the skills and conditions needed in CCPT
with the development of the CCPT treatment manual.
Signicant research in CCPT exists (Ray & Bratton, 2010), including a meta-
analysis of 93 studies (Bratton et al., 2005), which found a large treatment effect for
play therapy. In addition, many researchers have determined CCPT is effective in
improving academic achievement (Blanco & Ray, 2011; Blanco, Ray, & Holliman,
2012), decreasing attention-decit/hyperactivity disorder (ADHD) symptoms (Ray,
Schottelkorb, & Tsai, 2007; Schottelkorb & Ray, 2009), decreasing trauma symp-
toms (Kot, Landreth, & Giordano, 1998; Schottelkorb, Doumas, & Garcia, 2012;
Shen, 2002), improving externalizing behaviors, decreasing aggression and conduct
problems (Bratton et al., 2013; Garza & Bratton, 2005; Ray, Blanco, Sullivan, &
Holliman, 2009; Schumann, 2010), and decreasing teacher stress (Ray, 2007).
In this study, the play therapy room was set up using toys and materials as
recommended by Landreth (2012). Both therapists in the study received training
and supervision in CCPT from the rst author, a doctoral-level licensed profes-
T
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.
7 Therapist Perceptions of Relationship Conditions
sional counselor, counselor educator, and Registered Play Therapist-Supervisor.
This supervisor provided face-to-face supervision to the therapists for a minimum
of 1 hr for every 10 hr of clinical work. The CCPT treatment manual (Ray, 2011)
was followed for play therapy sessions, and the Play Therapy Skills Checklist (Ray,
2011) was applied in supervision to ensure that CCPT basic skills were utilized. A
minimum of three parent consultation sessions took place with each clients parent,
during which themes and progress in play therapy was shared with the parent(s).
Analyses
Using visual analysis, we independently examined changes in trend, level, and
variability for each process variable on the BLRI: MO-40 per subject within and
across the relationship phase, working phase, and termination phase. In following
single-case analysis recommendations from Kennedy (2005), the relationship phase
(Phase A) was compared with the middle phase, Sessions 411 (Phase B), and the
termination phase (Phase C; Sessions 1214). In addition to performing visual
analyses, linear regression analysis was used to validate discernable changes in each
process variable. Because statistical analysis tends to strengthen results from visual
analysis, signicant beta coefcients were analyzed for assessing trend stability and
direction (Jordans et al., 2013). Regression analysis was also used to assess patterns
among process variables within cases. Accompanying this analysis, we performed a
content analysis of therapists treatment notes to assess relationships between
therapeutic processes and child client processes.
RESULTS
Visual analyses for both therapists across all phases of the study are presented
in Figures 1 and 2. As indicated across all phases, the data for Shannon and Jamie
showed similar patterning across the three phases of CCPT. As noted, visual
analysis illustrates increased mean levels and increased trends for Regard and
Empathy from baseline (Phase A) to termination (Phase C). Analysis further
demonstrated moderate levels of variability across both conditions for each ther-
apist. For both therapists, examination of Congruence shows low variability, in-
creased levels and increasing trends. In the Unconditionality domain, both thera-
pists demonstrated decreased levels and decreasing trends from baseline to
termination. Regression analyses were employed to examine each therapists con-
tinuous rating of the relational conditions in CCPT (Table 1). Beta coefcients can
be used to clarify the presence and direction of trends across conditions. Speci-
cally, signicant s suggest the existence of a trend, whereas nonsignicant s
implicate the absence of a trend (Jordans et al., 2013). Table 1 substantiates visual
analysis, illustrating that empathy, regard, and congruence increased through the
process of play therapy, whereas unconditionality decreased.
T
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.
8 Schottelkorb, Swan, Garcia, Gale, and Bradley
Identication of Child Behavioral Changes
To further identify patterns between therapists ratings on the BLRI:
MO-40 and child behavioral changes, we examined session treatment notes.
Therapists used Rays (2011) treatment form to record theme identication,
toys used in session, use of limit setting, and progress in session. Table 2
presents a detailed combination of this qualitative and quantitative data. From
this combined qualitative and quantitative analysis, two primary themes in child
behaviors and therapist processes emerged. First, we found that therapists
ratings of unconditionality decreased when their respective child clients were
noncompliant or aggressive. Review of treatment notes also indicated that
unconditionality decreased when therapists set limits on childrens behaviors in
the playroom. Our second major theme revealed that therapists ratings of
congruence continually increased through each phase of the study. Congruence
as a process appeared to be the most stable therapeutic process, with the least
amount of variability. Notably, visual analysis revealed that when child behav-
iors worsened, congruence increased.
Parent Results on BASC-2: PRS-P
Jordan
Jordans mother completed the BASC-2: PRS-P at pre, mid-, and postinter-
vention. At preassessment, participant one scored in the clinical range on the
Figure 1. Rates of Shannons use of therapeutic qualities across conditions.
T
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9 Therapist Perceptions of Relationship Conditions
Hyperactivity subscale (n 77), at midassessment (after 7 sessions), he continued
to score in the clinical range (n 75), and at the postassessment, Jordans mother
rated his behavior in the at-risk range (n 69). For the Aggression (n 67) and
Somatization (n 61) subscales, Jordans mother rated his behaviors in the at-risk
range at preassessment. During the midassessment, Jordans behaviors for Aggres-
sion fell in the at-risk range (n 64) and at postassessment; his behaviors fell in the
normal range (n 54). On Somatization, Jordans scores fell in the normal range
at mid- and postassessments (n 51 and n 48). Thus, play therapy helped
decrease Jordans clinical and at-risk behaviors of Hyperactivity, Aggression, and
Somatization.
Figure 2. Rates of Jamies use of therapeutic qualities across conditions.
Table 1. Results of Regression Analyses
(SE); p
RGARD EMPTY UCOND CNGCE
1 .595 (.73); .02
*
.734 (.30); .00
*
.638 (.28); .01
*
.909 (.17); .00
*
2 .789 (.29); .00
*
.877 (.08); .00
*
.219 (.56); .45 .92 (.12); .00
*
Note. RGARD level of regard; EMPTY empathy; UNCOND unconditionality; CNGCE
congruence.
*
Statistical signicance.
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10 Schottelkorb, Swan, Garcia, Gale, and Bradley
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11 Therapist Perceptions of Relationship Conditions
Anna
Annas mother completed the BASC-2: PRS-P at pre-, mid-, and postinterven-
tion. At preassessment, Anna scored in the clinical range on the Anxiety subscale
(n 70), and in the at-risk range (n 66) at mid- and postassessment periods.
Anna also scored in the clinical range on the Withdrawal subscale at the preassess-
ment period (n 89), midassessment period (n 83), and at the postassessment
(n 79). With the play therapy intervention, Annas anxiety and withdrawal
behaviors decreased.
DISCUSSION
In this study, we attempted to explore and compare the core relationship
conditions with therapist case notes and parent assessment results. Through qual-
itative and quantitative analyses, we detected similar patterns on therapists ratings
of relationship conditions on the BLRI: MO-40. First, both therapists rated con-
sistently high on the Level of Regard subscale throughout the beginning, middle,
and termination phases of CCPT. Thus, results seem to show both therapists had a
high level of unwavering respect for their clients through all phases of treatment. In
CCPT, positive regard is a fundamental way of being that Landreth (2012) de-
scribed as positive respect for the child as a person of worth (p. 67). Landreth
further stated that respect cannot be taught in graduate school, rather this way of
interacting and being with children is based on deep care and esteem therapists
have for children. Additionally, both therapists also reported an increased ability to
empathically understand their clients feelings over 14 sessions. This sensitive
understanding of children is viewed as one of the most difcult and also potentially
critical factors of the therapeutic relationship (Landreth, 2012, p. 70). Thus, it
appears that both therapists became more understanding of their clients, which
likely helped facilitate their clients growth and inner exploration.
Regarding the use of congruence, both therapists perceived that their level of
genuineness increased throughout the therapeutic relationship. Consistent with
Gelso et al. (2012), our ndings show as the therapeutic process unfolds, therapist
reported congruence increases. Similarly, our results converge with the work from
Gelso et al. (2012) and Safran and Muran (2000) in that as child behaviors worsen
and the alliance weakens, the use of congruence may subsequently create a repar-
ative condition. In essence, as play therapists employ the use of congruence, these
shared, emotion-laden responses in turn seem to lead to children being able to
share their own experiences more deeply, as well as enabling therapists to deepen
their own empathy and acceptance of these children (Ryan & Courtney, 2009; p.
119). Our results are also similar to ndings from studies that demonstrate a
relationship between therapists use of congruency and client outcomes (Lo Coco
et al., 2011; Omylinska-Thurston & James, 2011). A factor that may explain the
similar ndings between this study and work by Gelso et al. (2010) and Lo Coco et
al. (2011) was that therapists in each study were humanistic-oriented. Because
congruence is often emphasized as a curative factor in humanistic therapies, it is
plausible to expect that therapists in the aforementioned studies used congruency
as a means to impact client change.
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12 Schottelkorb, Swan, Garcia, Gale, and Bradley
Surprisingly, we found that both therapists had downward trends in the Un-
conditionality subscale throughout all three phases. Specically, results indicated
that the therapists acceptance of their child clients decreased as particular child
behaviors increased. Respectively, Shannon became less accepting of Jordan when
he began displaying aggressive play; and Jamie reported having a signicant de-
crease in unconditionality when Anna refused to go to the playroom. Results
indicated that Jamies rating on unconditionality remained the lowest subscale after
Anna exhibited noncompliant behavior. This particular nding may relate to the
experience level of both therapists and therefore, may substantiate Wilkins (2000)
claim regarding the difculty in developing unconditional positive regard for cli-
ents.
Overall, our ndings conicted with Barrett-Lennards (1962) examination
of therapist and adult client perceptions of the relationship. Accordingly, Bar-
rett-Lennard found that therapist ratings decreased slightly in level of regard,
congruence, and empathy across four rating periods, while unconditionality
increased slightly. Barrett-Lennard hypothesized that increases in uncondition-
ality were likely attributable to therapists observations of positive client
change. Our results converge with the aforementioned hypothesis in that de-
creases in therapists use of unconditionality appeared related to unfavorable
child behaviors.
Beyond data collected from the BLRI: MO-40, the BASC-2: PRS-P results
indicated that clinical levels of concern decreased through CCPT, but we
speculate that convincingly signicant change might have occurred with im-
proved therapist unconditionality (Wilkins, 2000). Although Rogers (2007)
stated that it is impossible to have complete unconditional positive regard for a
client, he argued that effective therapy should have more moments of uncon-
ditional positive regard. In this study, the therapists did not appear to provide
unconditional positive regard as dened by Mearns and Thorne (1988), which
requires a valuing of the client that is unchanged or impacted by any particular
client behaviors (p. 59). Wilkins (2000) stated that experiencing unconditional
positive regard is the most difcult therapist attitude to display because thera-
pists have their own beliefs, values, and past experiences. Experiencing and
imparting this condition and attitude henceforth, requires for therapists to
develop deep internal awareness, therapeutic presence and congruence (Omy-
linska-Thurston & James, 2011).
Likewise, Wilkins (2000) stated that if the proposition is accepted that
psychopathological and/or antisocial ways of being are induced by conditions
of worth, and that communicating unconditional positive regard is a way of
redressing these, then it is implicit that effective therapy is limited only by the
therapists ability to experience and convey this attitude to the client (p. 31).
Ability to convey unconditional positive regard is dependent on unconditional
self-regard (Wilkins), thus counselors with less self-regard, maturity, and clin-
ical experience may impart conditional regard to their clients. Even Barrett-
Lennard (1962) found that experienced therapists impart higher levels of core
conditions compared with inexperienced counselors. Thus, we speculate that the
therapists personal and professional backgrounds may have contributed to
lower levels of unconditionality.
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13 Therapist Perceptions of Relationship Conditions
LIMITATIONS AND IMPLICATIONS
The ndings in this study are exploratory in nature because results from two
therapistchild dyads were examined. Future research using a larger sample should
investigate differences between experienced and inexperienced play therapists on
their use of relationship conditions. We also encourage researchers to conduct
replication studies with clients that have a variety of presenting issues, as some
researchers have found decreased levels of childtherapist alliance when children
display externalizing behaviors in comparison to internalizing behaviors (Shirk &
Karver, 2003).
In addition, measuring relationship conditions in child therapy can be difcult.
Shirk and Karver (2003) recommend using multiple sources of information to assess
the strength of the therapeutic relationship, such as therapist-report, child-report,
and observational assessment. One difculty with that recommendation is the lack
of self-report instruments for children under the age of 9. Developing instruments
to assess young clients perspectives of the therapeutic relationship would be
valuable. In addition to using therapist self-report instruments, researchers are
recommended to use observational assessments of the relationship (Shirk &
Karver). One instrument specically developed to assess CCPT is Demanchicks
(2007) Observational Assessment, which assesses Axlines eight play therapy prin-
ciples through observation of therapy sessions. This instrument could provide
researchers more insight into the core conditions as displayed in play therapy
sessions.
Despite the noted limitations, results of this study indicate therapist-per-
ceived congruence, level of regard, and empathy increased while uncondition-
ality decreased. And, as three of the four relationship conditions increased in
CCPT, the problematic behaviors of the preschool children decreased in signif-
icance. Thus, it appears that therapist use of core relationship conditions
utilized in CCPT is linked to improvement in problematic child behaviors.
Because our results conrm that unconditionality is the most difcult attitude to
display in therapy (Wilkins, 2000), the authors argue that CCPT supervisors and
instructors should spend increased attention on this important component. We
recommend that when play therapy instructors teach the core conditions in
CCPT that they also address the challenge in providing unconditionality with
clients when they are noncompliant or aggressive. We encourage instructors to
share their personal difculties with this component and how they have learned
to be more accepting of clients. We also encourage supervisors to facilitate
ongoing conversations regarding awareness of therapists genuine feelings to-
ward clients when limits on aggressive and noncompliant behaviors must be set.
Both supervisors and instructors can model this attitude in their work with play
therapists-in-training and can also urge continued growth through encouraging
personal therapy and lifelong supervision and consultation to assess how ones
beliefs and values impact work with clients.
In summary, although we have research indicating that providing the core
relationship conditions is effective in contributing to client change in adult therapy,
we have little research in this area with child therapy. Thus, this study attempted to
link therapeutic outcome to therapist relationship conditions expressed in play
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14 Schottelkorb, Swan, Garcia, Gale, and Bradley
therapy. It is clear that more process research is needed in CCPT so that we might
discover what contributes to CCPT effectiveness.
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16 Schottelkorb, Swan, Garcia, Gale, and Bradley
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Received August 7, 2013
Revision received October 22, 2013
Accepted October 23, 2013
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17 Therapist Perceptions of Relationship Conditions