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Interviews with children: how they perceive psychotherapy

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INTERVIEWS WITH CHILDREN:
HOW THEY PERCEIVE PSYCHOTHERAPY
by
Judy Renee Mahoney
A Dissertation Presented to
THE FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Counseling Psychology)
August 1995
UMI Number: 9616986
Copyright 1996 by
Mahoney, Judy Renee
All rights reserved.
UMI Microform 9616986
Copyright 1996, by UMI Company. All rights reserved.
This microform edition is protected against unauthorized
copying under Title 17, United States Code.
UMI
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UNIVERSITY OF SOUTHERN CALIFORNIA
TH E G RAD U A TE SC H O O L
U NIVERSITY PARK
LOS ANG ELES, C A LIFO R N IA 90007
This dissertation, w ritten by
aHon^ey
under the direction of h..zx D issertation
Com m ittee, and approved by all its m em bers,
has been presented to and accepted b y The
G raduate School, in partial fulfillm ent of re
quirem ents for the degree of
D O C T O R OF PH ILO SO PH Y
C . . — ✓
D ean o f G raduate Studies
Date ....August:. 3 , ..1995..............
DISSERTATION COMMITTEE
C hairperson
ii
Table of Contents
I. Introduction .......................................... 1
A. Problem................................................1
B. Importance of the S t u d y .............................. 2
II. Review of the Literature.............................. 9
A. Adult Process Research ............................... 9
B. Process Research with Children .................... 22
III. Research Methods ................................... 33
A. Research Design......................................33
B. Procedure............................................ 37
IV. Results...............................................53
A. The Interviewees......................................54
B. The Psychotherapeutic Experience/Relationship . . 70
C. The Interview Process............................... 91
D. Additional Findings ............................... 91
V. Discussion .......................................... 95
A. Comparison with Adult Research.......................95
B. The Interview Process.............................. 102
C. Limitations......................................... 103
D. Implications..........................................106
VI. References........................................... 108
VII. Appendices........................................... 117
A. Research Introductory Letter........................117
B. Parent or Guardian Consent F o r m .....................119
C. Participant Information ........................... 120
D. Child Consent Form...................................121
iii
E. Interview Questions ............................... 122
VIII. Table
A. The Participants......................................41
IX. Figure
A. The Psychotherapeutic Experience/Relationship . . 73
iv
ABSTRACT
Children's experiences of psychotherapy were investigated.
Eleven learning disabled and/or seriously emotionally
disturbed children, between the ages of 8 and 13, were
interviewed. Using the qualitative interview method, they
were asked predetermined questions, followed by
individualized questions based upon their responses.
Strauss and Corbin's (1990) grounded theory approach was
used to interpret and analyze the data. It was discovered
that the most important feature of psychotherapy for
children is the relationship between the child and the
therapist. The child's perceived level of respect from the
therapist and the child's consequent level of trust in the
therapist determine the quality of the relationship. The
aspects of psychotherapy which influence respect and trust
are discussed.
1
CHAPTER ONE
Interviews with Children:
How They Perceive Psychotherapy
Problem
The differences between children and adults are such
that the way a child experiences psychotherapy is different
from that of an adult. Although each person's perspective
is unique, maturational differences cause distinct contrasts
between the experiences of children and adults. Children
are different from adults in that they are still in the
developmental stages cognitively and, therefore, may be
incapable of reasoning or of having insights in the same
manner as adults. They come into therapy without a vast
store of life experiences to aid them in understanding their
current situation. They lack the power to control their
environment to the extent that adults do. For the most
part, they do not enter therapy because they are seeking
help to change. Instead, they are usually referred by
parents, schools, or social service agencies.
The process of psychotherapy itself is different.
Children's psychotherapy is different from adults' in that
it is usually involved with more physical activities, such
as playing, whereas adult psychotherapy is most often
limited to conversation.
With these many differences, children's and adults'
perspectives are dissimilar from each other.
2
What, then, is the experience of psychotherapy from a
child's point of view?
Importance of the Study
In order to study these differences, it is necessary to
discuss the process of psychotherapy. I will begin by
demonstrating why this type of research is vital to the
field of psychotherapy. I will then explain what was
explored in the present study.
Psychotherapy Research
The two types of research used in studying
psychotherapy are process, "what happens in psychotherapy
sessions, specifically in terms of therapist behaviors,
client behaviors, and the interaction between therapists and
clients," and outcome, "changes that happen as a result of
the processes of psychotherapy" (Hill & Corbett, 1993, p.
3). This study's specific focus was in the area of the
process of child psychotherapy from a phenomenological point
of view.
Importance of Process Research
The study of process is important, because it is
necessary to understand what factors produced change in
order to employ the most effective treatment. Without
knowing what takes place within the session, i.e., the
process, the outcome tells little about how change occurred
(Hill, 1991). Process research is important, also, because
3
it gives an empirical basis to clinical practice (Kazdin,
Bass, Ayers, & Rodgers, 1990).
Special considerations with children. Psychotherapy
with children has unique considerations which make process
research valuable. A most important consideration comes
from an ethical standpoint. With children, the therapist
has the added responsibility of insuring that proper caution
is taken to avoid possible damaging effects on a client who
has not requested or is not knowledgeable about the
treatment (Kazdin, 1988). Another consideration is the
potential for preventative treatment. By using the findings
of process research, more effective treatment for children
may be possible, resulting in the deterrence of adult
dysfunction (Kazdin, 1988).
Need for process research with children. According to
epidemiological studies, a substantial number of children in
the United States are in need of psychological services. It
is estimated that 17% to 22% of the population under 18
years of age, or approximately 11-14 million children,
suffer from behavioral, developmental, or emotional problems
(Kazdin, 1993). Many of these children could be helped with
psychotherapy.
Despite the vast number of children in need of
psychotherapeutic treatment, a paucity of research in the
area of child psychotherapy exists. Reference to this is
made in almost any article one reads concerning the topic
4
(e.g., Casey & Berman, 1985; Hill, 1985; Kaser-Boyd,
Adelman, Taylor, & Nelson, 1986). Kazdin et al. (1990), in
a review of the child and adolescent research, lament "the
restricted quantity, quality, and focus of psychotherapy
research [with children and adolescents]" (p. 729).
The scarcity is further reflected in the latest edition
of the Handbook of Psychotherapy and Behavior Change (3rd
edition, Garfield & Bergin, 1986), one of the foremost texts
on psychotherapy research. The chapter on child
psychotherapy was eliminated from this edition, because so
little research had been conducted since the previous 1978
edition.
Another example is a review of research in child
psychotherapy since 1963 (Barrnett, Docherty & Frommelt,
1991), in which individual therapy was the focus of
investigation. Excluded from the evaluation were behavioral
or cognitive behavioral forms of treatment with children.
The review indicated that since 1973, only five studies
meeting the designated criteria have been published.
Need for knowledge of the client's perspective.
Historically, in adult process research, the
therapist's part in the session has been studied to a much
greater extent than the client's, with the majority of
research focusing on the therapists' verbal behaviors (e.g.,
Friedlander, 1982; Hill, 1986; Stiles, 1979). The adult
client's part in the process of psychotherapy has had both
5
fewer measures and lesser levels of analysis (Heppner,
Kivlighan, & Wampold, 1992). Hill and Corbett (1993)
speculate that the disproportionate interest may result from
concern about gaining information for training therapists
and/or the difficulty in measuring client behaviors.
Also, a major emphasis in process research has been on
the relationship between the therapist and client. This has
been explored, for example, in terms of Rogers' necessary
and sufficient conditions for therapy (Rogers, 1957), the
working alliance (Horvarth & Greenberg, 1986), and
interactional influence (Tracey, 1985).
The clients' perceptions of psychotherapy, however, are
also of vast importance, because it is in the domain of the
client experience that the therapist hopes to effect change
(Elliott & James, 1989). The lack of interest in
researching this area is puzzling. As Orlinsky and Howard
(1975) indicate
there has been a general neglect of the
patient's perspective as a source of
valuable data, despite the fact that the
therapist in practice tries to listen
empathically and to understand the
patient's experience from the patient's
point of view. (p. 4)
In a fairly recent review of the literature concerned
with the client's experience (Elliott & James, 1989), it is
apparent that even though the client's experience is the
topic of interest, the client often is not the person who
reports the experience. Many measures are rated by the
therapist or judges. Yet, it has been found that the peopl
involved in psychotherapy are in the best position to
provide information of what takes place (Feifel & Eells,
1963). This lack of research from the client's perspective
has been remedied somewhat with recent qualitative studies
with adult clients (e.g., Rennie, 1994; Rhodes, Hill,
Thompson, & Elliott, 1994; Watson & Rennie, 1994).
For children, however, the study of the client's
perspective has continued to be neglected to a greater
extent. In general, "research on the process of child
psychotherapy is virtually nonexistent" (Smith-Acuna,
Durlak, & Kaspar, 1991,p. 126). Because of children's
differences from adults, the previous adult research does
not provide an adequate model to follow in studying the
process of psychotherapy with children. I propose that
before one can establish measures for studying the process
of psychotherapy, one has to establish what the experience
is like for the participants. The experience of the child
client is virtually unexamined by research. Because what
aspects of psychotherapy are relevant to the child are
unexamined, it is necessary to approach the child client
directly to discover what is important in his or her
experience.
Client as Source of Information. From adult research,
it has been found that the therapist, client, and observer
have quite different views of what happens during the
7
therapeutic session (Heppner et al., 1992). The Smith-Acuna
et al. (1991) study supported the finding that the clients'
and therapists' perspectives vary also between child clients
and therapists.
When treating children, another source of information
has been their parents. However, studies (e.g., Edelbrock,
Costello, Dulcan, Conover, & Kala, 1986; Herjanic & Reich,
1982; Kazdin, Esveldt-Dawson, Unis, & Rancurello, 1983;
Weissman, Orvaschel, & Padian, 1980), comparing reports of
psychiatric symptoms of children, have found poor agreement
between parents' and children's descriptions. The
suggestion from these findings is that "children may, in
fact, be the best source of information for research
requiring the answers to very personal questions relative to
themselves" (Herjanic & Reich, 1982, p. 323).
The Present Study
Process research historically has been concerned with
the experience of the therapist, the experience of the
client, or the interaction between the two (Garfield, 1990).
The focus of the present study was on the experience of the
child client, an area of study which has been much neglected
in process research (Kazdin, Bass, Ayers, & Rodgers, 1990).
Studies of process research vary in regard to who
reports what was happening during the psychotherapy
sessions. Often third parties, such as judges, raters, or
therapists are used in an explanation of the
8
psychotherapeutic experience of the client (Hill, 1991). In
proposing that the best source of discovering the client's
experience is the client him/ or herself, I used a
phenomenological approach in which the child client was
asked directly to explain his or her experience.
Analyses used in process research differ in their focus
of what portion or portions of the therapeutic experience
are explored. Studies may vary from looking at a single
session (e.g., Elliott, 1986) to looking at the entire
process at a later date (e.g., Axline, 1950). The present
study's focus was on what I thought would give the clearest
overall perspective of the experience. The clients gave
their perceptions of the ongoing psychotherapy sessions in
which they were currently involved.
9
CHAPTER TWO
Review of the Literature
Adult Process Research
In the following paragraphs I will characterize six
major methods of studying adult process research: Carl
Rogers' theory, the Working Alliance theory, Verbal Response
Modes, Interpersonal Process Recall, the Interactional
Influence theory, and Session Impact. I will describe
various instruments that have been used within each method
and critique their applicability to child process research.
Rogers' Theory
Carl Rogers (1942) is generally considered to have
founded process research in the 1940s. It is considered
that the process of psychotherapy became open to scientific
scrutiny when he and his colleagues allowed their therapy
sessions to be taped (e.g., Porter, 1943; Seeman, 1949;
Snyder, 1945). Prior to this time, psychoanalysts had also
shown interest in discovering what transpired during their
sessions by reviewing case studies. However, their
procedure was criticized for its lack of objectivity (Hill,
1983) .
Early research, based on Rogers' theory, focused on
measuring the verbal behaviors of both clients and
therapists, the in-session behaviors of the therapist and
client, finding differences in therapist behaviors, and
finding the immediate impact of therapist interventions
10
(Bergman, 1951; Porter, 1943; Robinson, 1950; Seeman, 1949;
Snyder, 1945, 1963; Strupp, 1955, 1957).
Rogers' later focus changed from the technique of
clarification of feelings made by the therapist to the
client's phenomenological experience of therapy (Rogers,
1951). Researchers began looking at empathy, genuineness,
and warmth within the therapist and the experience of the
client (Carkhuff, 1969; Klein, Mathieu, Gendlin, & Kiesler,
1970; Truax & Carkhuff, 1967).
Instrumentation. Instruments to assess client
involvement were developed, such as the Experiencing Scale
(Klein, Mathieu, Gendlin, & Kiesler, 1970; Klein, Mathieu-
Coughlan, & Kielser, 1986) and the Client Vocal Quality
Classification Scale (Butler, Rice, & Wagstaff, 1962; Rice &
Kerr, 1986). Both assess the affective involvement of the
client during the therapy session by using trained judges.
The Barrett-Lennard Relationship Inventory (Barrett-Lennard,
1962, 1986) was developed to assess both the client's and
the therapist's perceptions of the therapist's empathy,
genuineness, and unconditional personal regard. It is a
self-report instrument that asks the participants to declare
their level of agreement with statements based on a six-step
anchored scale. The statements are reflective of the
therapist's level of regard, empathic understanding, the
unconditionality of regard, and congruence.
11
Orlinsky and Howard (1975) developed the Therapy
Session Report to discover the participants'
phenomenological experience. The experience of the client
consists of a 167-item instrument. The experience of the
client is determined by asking the client how he or she felt
during the therapy session, what was talked about during the
session, what the client hoped to get out of the session,
how the client acted toward the therapist, how the client
felt during the session, how satisfied the client was with
the session, how the therapist acted during the session, and
how the therapist felt during the session. To answer these
guestions the participant is given the choice of either a
four-, five-, or six-point Likert-type scale or an item
checklist ranging from nine to 45 items. There are no open-
ended questions.
Critique. The Experiencing Scale (Klein et al., 1970;
Klein et al., 1986) and the Client Vocal Quality
Classification Scale (Butler et al., 1962; Rice & Kerr,
1986) are limited in focusing on the client's experience in
terms of affect. The Barrett-Lennard Relationship Inventory
(Barrett-Lennard, 1962, 1986) is based on Rogers' theory of
the necessary and sufficient conditions required for change
to occur. It assesses the clients' experiences only in
terms of their perceptions of the therapist's empathy,
genuineness, and unconditional personal regard. Therefore,
these scales are too limited to address the question of this
12
dissertation. The scales have forced-choice answers and
were used with adults, not with children.
The Therapy Session Report (Orlinsky & Howard, 1975)
fully covers the client's experience. However, as was shown
in the Smith-Acuna et al. study (1991), its use with
children necessitated altering it so that just a small
portion of the instrument was used with the wording
simplified. Because this alteration was done arbitrarily,
one doesn't know for certain if the chosen measures were
those that are most salient to children. In addition, the
focus was on one session rather on the entire experience as
was of interest in this study.
Working Alliance Theory
Later in the history of process research, the concepts
of client-centered therapy combined with the influence of
psychoanalytic theory to form a major topic known as the
working alliance. This once again changed the focus from
therapist attitudes or skills to one in which both the
therapist and client were examined (Hill & Corbett, 1993).
Also, cognitive and behavioral psychotherapy and
psychopharmacology, even though not part of its discipline,
recognized the importance of the working alliance and
contributed to establishing the alliance as central to the
change process (Goldfried, Greenberg, & Marmar, 1990).
Bordin (1979) proposed that the development of a
working alliance between the person who seeks change and the
13
person who offers to be a change agent is a key aspect of
the change process. When reviewing the concept of the
working alliance, he advocated that it could be generalized
to all psychotherapies. What he defined as the features of
the alliance were that the therapist and client agreed on
the goals of therapy, that the client viewed the tasks
assigned by the therapist as being relevant to his or her
problem, and that the therapist and client have a bond
between them. He noted that it was the strength of the
alliance, not the kind of alliance, that was the major
factor in change. Also, although the three features might
differ depending on the therapist's orientation, they still
combine to form the working alliance.
Instrumentation. One instrument used in process
research to measure the three components of the working
alliance is the Working Alliance Inventory (Horvath &
Greenberg, 1986). It is a 36-item inventory, covering items
from the goal dimension, the task dimension, and the bond
dimension. Subjects indicate the degree to which a
particular statement applies to their experience in a
current therapy situation. The responses are made on a
five-point Likert scale. Two other instruments for
measuring the working alliance are the Penn Helping Alliance
Scales (Alexander & Luborsky, 1986) and the Therapeutic
Alliance Rating System (Marmar, Horowitz, Weiss, & Marziali,
1986) .
14
Critique. These instruments are not appropriate for
children, because young children are incapable of
conceptualizing the working alliance as it applies to their
psychotherapy. Although children have a bond with the
therapist, they often do not participate in reaching a goal
for their therapy. They are not in a position to judge
whether the therapeutic tasks are meaningful to their
problem resolution.
These instruments are based on the theory that the
components of what is called the working alliance are
involved in the change process. As such, it structures the
client's experience to fit its model. This is a
conceptualization from an adult viewpoint. It does not
reflect the experience of a child.
Verbal Response Modes
Another area of interest for many researchers has been
with verbal response modes (Elliott, Bill, Stiles,
Friedlander, Mahrer, & Margison, 1987). The verbal response
mode is "a category of language that implies a particular
interpersonal intention" (Stiles, 1979, p. 49). That is, a
question asks information from another; advice gives
directions to another. This interpersonal nature is
attractive to process research in that it characterizes the
therapeutic relationship without involving the content of
the interaction.
15
Instrumentation. Hill (1986) is one researcher who has
used response modes of both therapists and clients
extensively. Using verbatim transcripts of the therapy
session, data are analyzed by three trained judges, (Hill,
1992). The judges assign a response mode category to each
response unit (i.e., grammatical sentence) from a list of
predetermined categories. According to the Hill Counselor
and Client Verbal Response Category Systems (Hill, 1978,
1985, 1986; Hill, Greenwald, Reed, O'Farrell, & Carter,
1981), the therapist responses include minimal encourager,
approval-reassurance, information, direct guidance, closed
question, open question, restatement, reflection, nonverbal
referent, interpretation, confrontation, self-disclosure,
silence, and other. The client responses include simple
response, request, description, experiencing, exploration of
client-counselor relationship, insight, discussion of plans,
silence, and other (Hill, 1986).
The Client Behavior System is another measure which
uses the verbal response mode (Hill, 1992). Four trained
judges are given a verbatim transcript of the session, and,
because categories may vary depending upon nonverbal cues,
they also view a videotape of the session. The judges then
categorize clients' behaviors into one of the following
eight categories: resistance, agreement, appropriate
requests, recounting, cognitive exploration, affective
exploration, insight, and therapeutic changes.
16
Critique. As with other scales previously reviewed,
both the Client Reactions System and the Client Behavior
System are designed to measure the client's experience based
on the adult form of therapy in which the therapist and
client sit and talk to each other. Because therapy with
children involves so much more than conversing, the scales
would have to be modified and extended to cover the many
facets of play therapy. I contend that the modification
would be based on assumptions of what the child is
experiencing. I think the first step is to find out from
the child what he or she is experiencing.
Interpersonal Process Recall
Another form of gaining information about psychotherapy
process is through a specialized interview situation known
as Interpersonal Process Recall (IPR) (Elliott, 1986).
Using this procedure, the conversation during the
therapeutic session is taped and played back for the
participants shortly thereafter. Each participant is then
asked to remember and describe the experiences and
perceptions that occurred at the time of the conversation.
This procedure was originally used by Bloom (1954) and
his colleagues in studying the thought processes of college
students during discussions. Kagan (1975) gave the
procedure the name "interpersonal process recall" and was
the first to apply it to psychological helping situations.
The types of studies that use IPR have been influenced by an
17
interest in cognitive theory (Hill & Corbett, 1993). The
intentions differ from the response modes in that the
response modes may be observed behaviorally, whereas the
intentions are part of an internal process that may not be
detectable to an outsider.
The cognitive mediational paradigm (Martin, 1984) also
uses IPR in researching the process of therapy. It differs
from the other research using IPR in that it proposes that
outcome is based upon cognitive processes, that is, the
client's and therapist's cognitive processes are mediators
between the therapist and client interactions. The paradigm
is borrowed from instructional psychology and relates client
change to a continuous cycle which begins with therapist
intention and behavior and continues with client perception,
cognitive processing, and behavior (Martin, Martin, Meyer, &
Slemon, 1986).
Instrumentation. The Therapist Intentions List uses
IPR as the procedure to rate therapists' intentions (Hill &
O'Grady, 1985). A tape of the therapeutic session is
stopped after each time the therapist completes a speaking
turn, and then the therapist identifies the reason for
making the statement. The therapist is allowed to choose up
to three intentions from the following list: set limits,
get information, give information, support, focus, clarify,
hope, cathart, cognitions, behaviors, self-control,
feelings, insight, change, reinforce change, resistance,
18
challenge, relationship, and therapist needs (Hill &
0'Grady, 1985).
The Client Reactions System is another measure that
uses IPR (Hill, Helms, Spiegel, & Tichenor, 1988). Clients
are asked how they felt throughout the session by responding
to no more than three reactions. Positive reactions include
understood, supported, hopeful, relief, thoughts, self-
understanding, clear, feelings, responsibility, unstuck,
perspective, educated, new ways, and challenged. Negative
reactions include scared, worse, stuck, lack direction,
confused, misunderstood, and no reaction.
The procedure of the cognitive mediational paradigm
begins with the client and therapist viewing a videotape of
their session. They are then asked what they were thinking
or intending during the session. The responses are open,
not force-choice.
Critique. With interpersonal process recall, one has
to reflect and remember what happened in order to explain
what one was feeling, thinking, or intending during the
session. Children's limited vocabulary, understanding, and
possible lack of memory would affect their responses in this
type of interview, and, 1 believe, the structure imposed by
this technique would further restrict their responses.
Additionally, I am more interested in the overall
experience, rather than what was happening in a particular
session.
19
Interactional Influence Theory
A recent trend in process research is the measurement
of dominance or unequal influence (Wampold & Poulin, 1992).
This is taken from Strong's (1968) view of therapy as an
interpersonal influence process. His view is based on
opinion-change research in which it was found that change is
controlled by a communication discrepancy in which the
communicator is viewed as an expert who is trustworthy,
attractive, and involved. The main technique to induce
change is through verbal communication.
Based on this view, studies have been conducted which
focus on the complementary/symmetry aspect of a relationship
(Tracey, 1985, 1987; Tracey & Ray, 1984). A complementary
interaction is "one marked by an unequal status between the
participants— that is, one participant has the ability to
determine or constrain the behavior of the other in an
interaction" (Watzlawick, Beavin, & Jackson, 1967, p. 69).
A symmetrical interaction is "marked by equal status between
the participants; neither participant has more ability to
determine or constrain the behavior of the other in an
interaction" (Watzlawick et al. 1967, p. 69). This seems to
coincide with the current political vision of therapy which
regards change in terms of the client's empowerment and
autonomy (Orlinsky, 1990).
Instrumentation. With this system, tapes of the
sessions are rated by trained raters on the continuum of
20
complementary and symmetrical interactions referred to as
complementarity. This continuum is an aid in
conceptualizing the harmony or conflict of communications
within a relationship. An interaction is considered to be
complementary if the second participant chooses to follow
the initiated topic of the first participant. This is
considered to show an unequal status because of the
initiation of one and the acceptance by another. A
symmetrical interaction, however, has equal status, because
the topic initiated is not accepted. This process research
is closely related to outcome research with either
complementary or symmetrical interactions having different
influence on the change process depending upon the timing
within the overall therapy duration.
Critique. Because of the inherent power disparity in
the dyad of adult therapist and child client, this type of
research would not produce the same results with children.
Its focus is based on a theory of change which does not
address the phenomenological experience of the client. The
instrument would not be appropriate to answer the question
proposed in this dissertation.
Session Impact
Stiles and Snow (1984) developed a scale to measure
session impact. Session impact is defined as "a counseling
session's immediate effects, including the participants'
evaluations of the session and their postsession affective
21
states" (p. 3). Impact is considered to be a mediator
between process and outcome. This exemplifies a more recent
trend in process research in which process research is more
closely linked to outcome research, differing from the early
years of process research in which process research was
clearly separated from outcome research. This change
occurred, because, throughout the years, outcome researchers
came to realize that it was necessary to understand what it
was in the session that made a change and how it worked.
Concurrently, process researchers arrived at the conclusion
that their findings were irrelevant unless linked to outcome
(Greenberg & Pinsof, 1986).
Instrumentation. The Session Evaluation Questionnaire
is a self-report instrument to measure session impact by
reporting the participants' perceptions of the sessions and
their mood after the session. The therapist and client are
each asked to describe the session and their current
feelings from a list of bipolar adjective pairs, such as
deep— shallow, valuable— worthless.
Critique. Although this instrument is currently in
wide use to determine the experiences of adult participants
in a psychotherapy session, it is not appropriate for
children. The vocabulary used for the bipolar adjective
pairs is too sophisticated for children. It again is based
on adult perception of the experience of psychotherapy, so
22
one cannot be sure if these adjectives are descriptions
relevant to children.
Conclusion
All of these scales are based on a talking therapy. As
play therapy with children has many components besides
verbalization, the instruments do not encompass all that is
involved within children's psychotherapy sessions.
Additionally, some of the methods just reviewed in
adult process research do not address the question of the
phenomenological experience of the client. Of those that
do, the scales use vocabulary which is too sophisticated for
children and require an understanding of concepts which are
above the level of children's capabilities. Before
modifications of these scales can be made to adapt them for
use with children, it is necessary to know what features of
the adult psychotherapy experience are also relevant to
children. This can be ascertained by going directly to the
children as a source of information.
Process Research with Children
Little has been done in exploring the process of child
psychotherapy, particularly in recent years. In the 1940s
and 1950s a few studies were conducted. For the most part,
this early research did not build upon the findings of
previous research, so each study is unique in its focus.
Furthermore, there is no evidence that in more recent years
research using these findings have been explored. Process
23
research with children, therefore, can be seen as consisting
of a few isolated studies.
In the following section, I will review those early
studies and the one recent study, which have been conducted.
I will critique these studies as to why they would not be
appropriate models for the present investigation of the
child's experience of his or her course of therapy. An
early study, which uses a similar approach to that which I
am intending to use, will be reviewed.
Early Studies
As with adult process research, child process research
was under the influence of Carl Rogers in the early stages
with the predominant interest being in nondirective play
therapy. At the beginning, as with adult research, content
was the focus.
Objective analytical approach to nondirective play
therapy. One early study was by Landisberg and Snyder
(1946), which, using four play therapy cases, categorized
each statement and response of the participants. The only
description of the children was that three had a successful
experience of play therapy, and one had an unsuccessful or
possibly incomplete treatment. Categories for the therapist
were based on content and for the child/client were based on
content and feeling. The client categories, which were
taken from previous work with adults, were divided into
three major categories. Content categories referred to
24
simple responses, such as asking for information, rejection
of clarification of feeling, avoidance of response, etc.
Attitude categories included positive, negative, and
ambivalent attitudes toward the self, counselor, others, or
situations. Activity categories, which covered the content
and feeling of activity, included positive, negative, and
ambivalent actions toward the self, counselor, others, or
situations.
Using these categories, Landisberg and Snyder explored
what percentage of time was used by the therapist and client
in different activities. They found that 60% of the
responses were made by the client, and 40% were made by the
therapist. Thirty percent of the statements were
nondirective counselor statements, 25% were statements
wherein the client gave information, and 24% were the
client's taking some positive play action.
They also sought the sequential relationships between
different therapist statements and the client's immediately-
following statement or behavior. Finally, they used their
categories to divide the entire treatment process into
sections. They found that as the child became more
comfortable, less statements of acquiescence and more
actions expressing feelings were made.
Children's statements in analysis of nondirective plav
therapy. Lebo (1953), in reviewing research on nondirective
play therapy, cited Finke (1947) as being interested in
25
categorizing statements. Finke obtained categories by the
analysis of children's statements, rather than using
categories from previous adult research. Her subjects
consisted of six children, ranging in age from five to 11,
who were referred for behavior problems. Although the
categories she found were not specified, it was stated that
she emphasized expressions of feeling in the belief that
they would reflect the children's changing emotional
reactions. Importantly, she found that "verbal
characteristics of adult counseling sessions did not appear"
(Lebo, 1953, p. 178). Finke additionally discovered that,
in all the cases she studied, there was a characteristic
pattern of events within the play therapy. Initially, the
child was either reticent or extremely talkative and
explored the playroom. If the child showed aggression, it
was shown the most at this stage. During the middle stage,
if aggression was previously shown, it lessened. The child
tested limits and used imaginative play. In the last stage,
the child made an effort to establish a relationship with
the counselor, often by having the counselor join in the
play.
Lebo (1953) elaborated on Finke's use of categories
based on children's statements. He hypothesized that there
would be differences in statements made by the children
based on their chronological age. By analyzing what was
said by children between the ages of four and 12, he found
26
that the level of maturity does affect the types of
statements used in a therapy session.
As the children became older, they told the
therapist fewer of their decisions. They
spent less time in exploring the
limitations. They made fewer attempts to
draw the therapist into their play and they
expressed more of their likes and dislikes.
(Lebo, 1953, p. 179)
Quantification of the nondirective plav therapy
process. Lebo (1955), at this early stage of process
research with children, also voiced the complaint about
"... the dearth of research on quantitatively determining
the child's feelings during play therapy ..." (p. 375).
It was his intention to expand Finke's categories. His
categories subsequently included curiosity about the
situation and things present in it; simple descriptions,
information, and comments about play and play room;
statements indicating aggression; story units; definite
decisions; inconsistencies, confusion, indecision, and
doubt; exploring the limits of the play room; attempting to
shift responsibility to the therapist; evidence of interest
in and attempting to establish a relationship with the
counselor; negative and positive statements as well as
straight information and stories about the self, family,
school, things made or present in the play room, the
situation, activities, pets, teachers etc.; information,
questions or comments pertaining to time during the
interview; exclamations; unclassifiable; insightful
27
statements revealing self understanding; ambivalent
statements; sound effects; and mumbling or talking to self
in a voice too low to be heard.
Objective measurement and analysis of child-adult
interaction. Moustakas, Sigel, and Schalock (1956)
attempted to find an objective measure for child-adult
interaction by constructing 89 adult and 82 child
categories, derived from previously researched categories
and the authors' experiences. They did this by observing
parent-child interaction at home and in a playroom and
therapist-child interaction in the playroom. No
descriptions of the children were given. Their resulting
categories included items such as nonattention, recognition,
offering information, seeking reassurance, etc. In addition
to the categories, they formed anxiety-hostility ratings to
be used during therapy sessions.
Later, Moustakas and Schalock (1955) used these
categories to compare the interactions between the therapist
and child with a group of emotionally disturbed children and
a group of children without emotional problems. Their
purpose was to expand existing knowledge by including the
child's influence on the therapist and to note if there were
any differences between the two groups in their interacting
behavior. Their most interesting finding was that the two
groups were more alike than different.
28
Ratings of accurate empathy, nonpossessive warmth and
genuineness in psychotherapy with children. Wright, Truax,
and Mitchell (1972) conducted research with children, based
on adult research, that measured the degree of accurate
empathy, nonpossessive warmth, and genuineness exhibited by
the therapist. No specific descriptions were given of the
children. The study was based on raters viewing videotape
segments of psychotherapeutic sessions with children. The
reliability scores were weak, compared to those commonly
found with adult studies. They concluded
that the lower reliability was because of the nonverbal
aspect of psychotherapy with children.
Critigue of the early studies. None of these early
studies address what I see as the starting point of process
research with children, i.e., what the children experience
in the course of their therapy. Landisberg and Snyder
(1946) used sequential statements to categorize the process.
Finke (1947) and Lebo (1955), although using categories
based on children's statements, were still analyzing speech
in determining the process. Moustakas et al. (1956) and
Moustakas and Schalock (1955) used categories to determine
the interactions between the therapist and client. Wright
et al. (1972) looked for empathy, warmth and genuineness of
the therapist when working with children, measured by
raters. None of the studies directly focused on the
experience of the child.
29
Development of Child Psychotherapy Process Measures
The only recent study that considered the child's
perspective was one by Smith-Acuna et al. (1991). They used
a survey based on the Therapy Session Report, developed by
Orlinsky and Howard (1975), which was previously described.
The sections used from the client-experience portion of the
instrument included emotions relating to the child's
experience (e.g., safe, bored, liked, etc.), the child's
perception of the therapist's behavior (e.g., My therapist
played with me a lot this session), and the child's
perception of the therapist's feelings (e.g., safe,
stubborn, proud, etc.). Each child used a Q-sort technique
to demonstrate the relationship between the description and
his or her experience. The child's personal goal for each
session was asked in the form of an open-ended question and
further probed if clarification was needed. Information
regarding the child's personal goal did not produce usable
data, so the results of this subscale were not presented.
The purpose of this study was not to report the child's
or therapist's perspectives, but to introduce possible
measures for evaluating child process therapy. Therefore,
the results of the study did not include the content of the
questions, but were limited to the evaluation of the
instrument. It was found that the client and therapist
subscales were more reliable than the adult version, but
30
that there were no significant correlations between the
child- and therapist-completed measures.
Critique. The researchers (Smith-Acuna et al., 1991)
themselves suggest that as no significant relationship
between the child and therapist measures existed, multiple
perspectives need to be explored. It is my belief that what
is important from the child's point of view is what first
needs to be discovered. Smith-Acuna et al. used their
discretion in choosing what portions of the Orlinsky and
Howard instrument would be used and modified those portions
for children. By arbitrarily selecting which aspects of the
therapeutic process to examine one cannot be certain that
one is exploring what is actually most relevant to the
child.
A Model from a Previous Study
Two studies by Axline (1950), which most closely
resemble the design to be used in this research project,
used an open-ended question with children to discover their
experiences. In the first study (Axline, 1950), the 22
children who were interviewed were selected from a group of
children who had successfully completed treatment years
earlier. The child's own therapist met with him or her in
an interviewing room and asked only one introductory
question, "Do you remember me?" Any other questions that
were asked were based on the child's responses. An excerpt
from one of the follow-up interviews was used to demonstrate
31
the significance of the experience by showing that the child
recalled what had happened vividly.
In the second study (Axline, 1950), the participants
were 37 children, who had experienced reading problems. The
children met the teacher-therapist, who had helped them five
years earlier. Upon being asked what they remembered, they
responded in a manner similar to those of the first study.
The children vividly recalled themselves as becoming
"feeling" individuals, which heightened their self-
awareness. Original transcripts of the play therapy were
also reported to show the close relationship between the
remembered experience and the statements made during the
actual experience. Examining the children's experiences was
used to support the theory behind nondirective play therapy.
Critique. These studies come closest to the procedure
used in this dissertation. By using an open-ended question,
the participants were free to respond in any way that was
relevant to them. However, two aspects of these studies are
different from the current study. One is that the purpose
of Axline (1950) was to substantiate her theory of the
effectiveness of nondirective play therapy. In the current
study, the purpose was not to support any theory, but to
investigate the child client's experience. Additionally,
Axline chose to interview the children some years after
their therapeutic experience, in part to judge the outcome
of the treatment. This study's focus was on the process of
32
psychotherapy. Therefore, the participants were interviewed
while being currently involved in psychotherapy in order to
explore impressions of the client at the time of treatment.
With the preceding review of process research with
children, it is apparent that there exists a considerable
void in the literature regarding children's experiences of
psychotherapy. The majority of studies that have taken
place were completed over 40 years ago. Because of the
substantial number of children who now receive
psychotherapeutic treatment, the need for this information
is paramount.
33
CHAPTER THREE
Research Methods
Within this section, I shall first review the reason
for choosing the phenomenological interview design and then
discuss the interview process in regard to the qualitative
interview and interviewing children. A description of the
procedure of the present study will follow. In it will be
discussed the participants, the counselors, the interview,
the questions, and finally the data analysis and
interpretation.
Research Design
Basis for Choosing Phenomenological Interview Design
The question of how children perceive psychotherapy can
best be answered by using a qualitative method. I have
shown in the Literature Review that previous research has
not resolved what the salient variables are for describing
the process of therapy with children from the child's point
of view. If a rating system is used, it is, again, taken
from an adult viewpoint to be answered by children. In
order to discover what is of importance to children, one
needs to approach the children directly. This suggests that
the method of choice is the interview.
An additional argument for the use of a qualitative
method is that to use a quantitative design, one must
generate a testable hypothesis from predetermined variables.
The variables to use in discovering the child's experience
34
of psychotherapy are, at present, unexamined by research.
Because of this, there is insufficient information available
to allow for the use of quantitative measures and
quantitative design. In this type of situation, an
exploratory type of research is necessary (Patton, 1987).
Qualitative methodology allows for exploration.
Use of a phenomonological approach, in which one
explores the experiences of the participants, is one of the
historical bases of qualitative research. When using this
approach, as in interviewing children regarding their
experiences of psychotherapy, important themes should be
discovered. This discovery, which Marshall and Rossman
(1989) suggest is one of the purposes of qualitative
research, leads to another purpose, i. e., producing
hypotheses for further investigation.
Interview Process
The Qualitative Interview. The objective of the
qualitative interview is to allow the participants to
express their own understanding of the phenomenon under
study, using their own terms (McCracken, 1988; Patton,
1987). As such, the interviewer asks questions related to
themes rather than direct, specific questions (Polkinghorne,
1989). The format, then, is more like a conversation than a
conventional, structured interview (Marshall & Rossman,
1989) .
35
Following the design of qualitative research, the
beginning questions are more general (Ely, Anzul, Friedman,
Garner, & Steinmetz, 1991), but are based on straightforward
descriptions (Patton, 1987). Subsequent questions become
more focused, based upon the information provided by the
participant. In addition to following the lead of the
participants, questions are asked about needed information
as reflected by related studies in the area of interest
(McCracken, 1988).
Immediately after the interview, observations that
would help in establishing a context of interpretation and
in making sense of the interview are written down by the
interviewer (Patton, 1987).
Interviewing Children. The suggested manner of
interviewing children fits well with the style of the
qualitative interview. Hughes and Baker (1990) explicitly
advise that the most effective way of obtaining information
from children is by using a conversation-type, rather than a
structured, interview. They suggest that the interviewer
use fewer direct questions and more comments and reflective
statements. It has also been stressed that in order to have
a successful interview with children, it is essential to
give a definitive explanation of the purpose of the
interview (Garbarino, Stott, & faculty of the Erikson
Institute, 1992; Hughes & Baker, 1990, Yarrow, 1960). In
his classic text in interviewing children, Yarrow (1960)
36
emphasized that one should also clarify for the child the
interviewer's expectations and role.
When interviewing children, it is also important that
the first question be one which children can answer easily
without embarrassment (Yarrow, 1960). Studies (Garbarino et
al., 1992) have found that children
respond better to open, indirect questions,
which leave a substantial (but not infinite)
range for response, and to questioning
sequences that let the child exercise some
control by initiating and terminating the
discussion of new topics at least as much as
the adult. (p. 188)
Additionally, when interviewing children, Bierman and
Schwartz (1986) advise to keep in mind that children at
diverse developmental levels process and conceptualize
emotional events and interpersonal relationships differently
from adults. The interview format needs to allow for the
influences of the developmental level on the interpersonal
orientation and verbal skills of each child.
As children between the ages of seven and 12 are in a
phase of peer identification that may cause a tendency to
withhold information from adults (Parker, 1984), the
experience for some may be "not unlike an adult faced with a
tax auditor" ( p. 21). Therefore, it is important to
maintain a permissive, casual, and accepting attitude toward
the responses of the child. Bierman and Schwartz (1986)
suggest avoiding intensive eye contact with the child in
37
order to lessen intimidation/ which may be caused by the
face-to-face interview.
Procedure
Participants
The participants were selected from a therapeutic, non
public school in which the researcher was currently a
counselor. The school specializes in serving children who
are learning disabled and/or seriously emotionally
disturbed. Most of the children attend this school because
their behavior is too disruptive for a regular mainstream
public school classroom. They need a more restricted
classroom situation where there are fewer students and a
smaller adult to student ratio. Their emotional impairment
is manifested in their acting-out behavior.
In addition to the small classroom size, this setting
provides weekly individual psychotherapy for the students on
the premises. These students were particularly suitable for
this study, because their diagnoses were more consistent
with a clinical population than with a general mainstream
public school population. This follows the criterion for
qualitative research in which the data sources are required
to be prototypical of the phenomena to be studied
(Polkinghorne, 1991).
The original intent of the study was to select children
between the ages of seven and 12. The low end of the age-
range was selected, because of the necessity of the
38
children's reaching a cognitive level where they were able
to understand and give more appropriate responses to the
interview questions. The age of 12 was chosen as the high
end of the range to allow for a psychotherapy experience
that incorporated more than the standard talking therapy,
which is most commonly used with adults. Additionally,
there is generally a recognized division of children between
the age of 12 and adolescents throughout the literature.
According to Kazdin (1988), there are now over 230
types of play therapy for children. This study did not
limit the participants a certain type of play therapy. The
assumption was that, because of their ages, the
psychotherapy would involve some type of play therapy and
would not be limited to the more talking-type of therapy
which is usually used with adults.
All children who attended the school between the ages
of seven and 12 were invited to participate. The total was
16 children. After the study began, it was decided that one
13-year-old boy would also be asked to participate. His
inclusion was at the suggestion of his former teacher, who
knew he didn't have "anything good to say about teachers or
counselors." Although he was older, he was a cohort of the
12-year-olds who were asked to participate. His
descriptions of his experience were anticipated to be an
interesting contrast to the majority of the children.
39
The parent or guardian of each of the children, who met
the requirements for the participants, was sent a letter of
introduction from the Director of the school, a letter from
the researcher asking for permission for the child to
participate in the study (see Appendix A), and a consent
form (see Appendix B). The ethical responsibility to report
child abuse was addressed in the letter from the researcher.
The rights of the participants were stated in the consent
forms. In addition, it was stated that if a child were to
reveal that he or she was feeling uncomfortable, or if
traumatic issues were brought up, the counselor, who was
currently treating the child, would be notified.
After three weeks, only three permission slips were
returned. The Director of the school advised me to call the
parents to verify that they had received my letter. At that
time, I was requested to resend several letters, although
only one parent had not received it. Two families did not
wish to have their children participate. One child, who was
a ward of the court, was not allowed to participate. Three
children's families never responded, and it wasn't possible
to reach them.
Of the total 17 children asked to participate, 11
children between the ages of eight and 13 became a part of
the study. The participants consisted of one nine-year-old
African-American girl and 10 boys between the ages of eight
and 13. Four of the boys were African-American, one was
40
Hispanic, and Five were White. See Table 1 for a brief
description of the participants. They have been given
pseudonyms.
41
Table 1
The Participants
Name Age Years in Counseling # of Coun
Antoinette 9 2 4
Michael 11 5 5
Dion 8 1 2
Andrew 10 4+ 3+
Ryan 10 1 2
Dontae 8 1 3
Nathan 12 4 20
Jon 11 4 5
Harrison 11 1 2
Adolfo 11 1 2
Richie 13 5+ 4+
42
Counselors
To obtain background information about the children's
counseling experiences, each child's counselor completed an
information sheet about herself and the child (see Appendix
C).
All of the children's counselors were women.
Antoinette, Dion, and Dante's counselor was a predoctoral
intern with a MFCC (Marriage Family and Child Counseling)
license. She had a B.A. and M.A. in clinical psychology and
an M.S. in MFCC. She had eight years experience in
counseling with children and was seeing a total of eight
children/adolescents at the time of the study. Her
orientation was Family Systems.
Michael, Ryan, and Jon's counselor was a postdoctoral
intern with a Ph.D. in psychology. She had previous
experience with preschool children and adolescents and was
seeing 14 children/adolescents at the time of the study.
Her orientation was Cognitive Behavioral/Psychodynamic.
Andrew and Richie's counselor was a licensed
psychologist with a Ph.D. in counseling psychology. She was
seeing four children. She described her orientation as
Cognitive Behavioral, Family Systems, and Humanistic.
Nathan, Harrison, and Adolfo's counselor received her
Ph.D. in counseling psychology during the time of the study.
She had previous experience with inpatient adults, college
students, and abused children and was currently seeing 11
43
children/adolescents. She described her orientation as
"Psychodynamic— Object Relations/Self Psychology,
specifically, with a smattering of Humanistic/Existential
and Cognitive philosophy."
The theoretical orientation of the facility was
cognitive behavioral. Although each counselor was allowed
freedom to apply other theories within her work, the
arrangement of the counseling services and the supervision
was tailored toward cognitive behavioral theory.
Interview
Each of the participants was interviewed individually
in my office at the school. Taking the child from the
classroom was a typical procedure for the students, because
children leave the classroom on a daily basis for
counseling, speech therapy, adaptive physical education,
and/or testing.
Before beginning the interview, I explained to the
participants that I was conducting a study to find out what
counseling is like for children. Some of the children had
been told by their parents or guardians about the study, and
some had not. I also explained to the participants that
there were no right or wrong answers, and that their answers
were important, because they were the experts regarding this
topic. I asked each child if there were any questions about
what we were going to be doing. I then read the Child
Consent Form (see Appendix D), which was a requirement of
44
the school, to the participant. After the participant
signed the consent form, I began the recorded interview (see
Appendix E).
Although each child was asked the predetermined
questions, the format of each interview proceeded in an
open-ended fashion, depending upon each participant's
responses. Follow-up questions, which were based on the
answers to each question, became more personal. For
example, after the child answered the question of why people
go to counseling, the child was asked why he or she went to
counseling.
After the child had been returned to the classroom, the
researcher made notes of observations of the child's
behavior while being interviewed.
The children seemed to make a sincere effort to respond
to the questions to the best of their ability. None of the
children were reluctant to answer, but the sophistication of
the responses was limited due to their learning
disabilities. Children with learning disabilities have much
more difficulty expressing themselves and conceptualizing
ideas than others of the same age. It seemed to me that
within the first interview they said all they had to say as
well as they could possibly say it. Consequently, I only
saw each child once, except for Nathan, who had so much to
say that it took two sessions to complete the interview.
45
The Questions
Various considerations were made in choosing the
questions (see Appendix E) for the interview. As a
psychotherapist, who works with children, I had not received
the verbal feedback of the client's perceptions, as I had
when working with adults. However, as a participant in
sessions with children not in this study, I had an idea of
what seems to be relevant to the child's experience. Some
of the questions were based on topics from adult process
research, while others were chosen more as a gauge of the
child's understanding of psychotherapy.
Because of the terminology used at the school, the
terms "counselor" and "counseling" were used during the
interview instead of "therapist" and "psychotherapy".
Throughout this study, the terms will be used
interchangeably.
The first question was designed to obtain the child's
general view of psychotherapy. The question did not ask
about any specific aspect of psychotherapy, so it was
anticipated that the response would show which features of
psychotherapy seemed most striking to the child.
The second question seemed important in studying a
child's perspective, because a child is rarely self-
ref erred. One purpose of this question was to see if the
child understood why people, as well as the child, go to
psychotherapy. A second purpose was to discover if the
46
child related the reason for going with the experience of
being in psychotherapy.
Although research with adults has asked for the
client's perspective of many features of the
psychotherapeutic experience (e.g., Elliott, 1986, Orlinsky
& Howard, 1975), adults have not been asked directly what
they do when in a session. This third question was
selected, because children are involved in many more
activities than are characteristically found in adult
psychotherapy.
The fourth question covered a topic that has been
researched extensively in studies with adults (e.g., Fiefel
& Eels, 1963; Orlinsky & Howard, 1975). As findings
(Norcross, 1986) across theoretical orientations have
established the importance of the psychotherapist in helping
the client to change, a child's perception of his or her
psychotherapist seemed valuable to compare with the findings
of adult research. Of particular interest was whether
children would characterize the psychotherapist as
demonstrating the equivalent of Rogers' (1957) conditions of
empathy, unconditional positive regard, and genuineness.
These are, for the most part, currently viewed as being
essential to the change process, regardless of one's
theoretical orientation (Orlinsky & Howard, 1986).
Because change is the goal of the psychotherapeutic
process, the fifth question was designed to explore the
47
manner in which a child perceives, if, in fact, he or she
does perceive, this important aspect of psychotherapy.
The sixth question was based on most theoretical
orientations' emphasizing the importance of feelings within
the change process (Corey, 1991). A considerable amount of
research has been conducted to explore adult clients'
feelings or states during the therapy session (e.g.,
Orlinsky & Howard, 1975; Stiles & Snow, 1984). This area
seemed as if it would have similar importance to children.
The purpose of all the questions was to convey what the
final question asks explicitly, that is, what is most
helpful about the psychotherapeutic experience for the
child. This question was chosen to address anything which
may be of importance to the child, which was not covered
through previous questioning. If that aspect of
psychotherapy was covered in the interview earlier, it gave
the child an additional opportunity to relate what was most
significant to him or her.
Because the children unexpectedly seemed to understand
psychotherapy so well, I consistently included two ending
questions. One asked the children if they had any
suggestions to counselors of how counselors could do a
better job. The other asked if they would like to add
anything that hadn't been covered.
48
Interpretation and Analysis
The analysis of the data followed the grounded theory
approach suggested by Strauss and Corbin (1990). This
method "uses a systematic set of procedures to develop an
inductively derived grounded theory about a phenomenon"
(Strauss & Corbin, 1990, p. 24). In other words, the theory
emerges from the data. Concepts used in questions, which
have been derived from preconceived ideas, may not be the
concepts which are relevant when statements made by the
participants are categorized.
By following this procedure, data analysis was
concurrent with data gathering. Data consisted of the
transcripts of each interview, the behavioral observations
of each child, the forms from the counselors, the Individual
Education Plan (IEP), and notes taken by the researcher.
The IEP is a document used in a nonpublic school to
personalize the child's curriculum. The counseling goals,
along with other educational goals, were that are listed on
the document were generated at an IEP meeting that was
convened to discuss the special needs of the student. Prior
to the meeting an assessment was made of the child in order
to determine the child's eligibility for such a program, to
develop the goals needed for the child, and to recommend a
placement where the goals may be accomplished. The process
is governed by federal and state laws. The IEP, which is
the name of the contract as well as the process, was agreed
49
upon by both the committee members (which can include
teachers, counselors, school psychologists, speech
therapists, school district representatives, etc.) and
parents.
The researcher's notes, as suggested by Fetterman
(1989), consisted of observations as well as the
researcher's mood, attitude, or speculations. Because
qualitative procedures rely on the investigator's judgment,
a detailed record is required of not only what and when
something was done, but also an explanation of why it was
done (Polkinghorne, 1991). This information was also
included in the notes.
Each recording was transcribed by the researcher as
soon as possible after the completion of the interview.
Often this occurred after one interview and before the next,
but, at times, two or three interviews were given before
they could be transcribed.
For the first six interviews, the transcript was read
and coded as soon as the interview was transcribed. The
codes described the identification of themes which occurred
within the data (Polkinghorne, 1991). Because of the
simplicity of the children's language, codes were made in
terms of each thought, which, at times, covered one sentence
and, at other times, several sentences. For ease in
identifying the various codes within each transcript, each
code was designated by a different colored pencil. A memo
50
was then written, naming the codes found in each transcript
and underlining each code with the designated color. The
pencils were taped with the name of the code they
represented. For the most part, the initial category names
reflected concepts asked by the questions.
After the first four interviews, I went through the
memos and tabulated how many times each category was
represented in each interview and in how many different
interviews the category occurred, in order to gain a picture
of the dominant themes. Glesne and Peshkin (1992) suggest
that what each participant says may help in developing more
specific or relevant questions to be used with subsequent
participants. This was relevant to the tabulations. I
found that all four participants had talked about receiving
gifts or rewards from their counselors, although no question
had been asked concerning the topic. I decided that this
was perhaps a part of psychotherapy uniquely relevant to
children. I, therefore, chose to include the following
questions in the subsequent interviews: "Does your
counselor ever give you anything? What does this mean to
you?"
After coding the fifth interview, I exceeded the 36
colors of my pencils by surpassing that number of codes. I
then decided to combine some codes into larger categories.
I found that some ideas were given a certain code in one
interview and similar ideas were given other codes in
51
subsequent interviews. For example, a statement labelled
counseling characteristics in one interview was similar to a
statement made and labelled counseling process in another
interview. By combining the categories, as in this example
to counseling sessions, a better comparison of experiences
was made.
After completing the seventh interview, in which the
language was much more sophisticated and adult-like, I saw
how complicated coding could become. I decided to wait to
code this interview until I had coded the remaining
interviews so that I would be more readily familiar with the
coding terms I was using. As I finished the interviews, I
also decided I wanted to wait with the last interview
because of the contrasting opinions.
Using the other nine interviews, I took phrases
representing the code from each interview and typed them
under their category heading with the reference to the
interview number and the page number of the interview. By
doing this, I found that some phrases belonged with a
different category than the one I had originally given it.
For example, some statements that I previously categorized
as counselor responsibilities fit better under the new
category of attention. Looking at the statements that the
children had made after grouping them together under one
heading, helped in distinguishing the relationships between
the categories. I then attempted to draw in diagram form
52
the children's perception of therapy. By doing this,
entirely new categories were conceived, which were not based
on the categories covered by the questions. Ideas were
rearranged to fit with my concept of the children's
experience.
53
CHAPTER FOUR
Results
On the most superficial level, it was not surprising to
find that the majority of the children found psychotherapy
to be "fun" and the therapists to be "nice". What was
surprising, however, was the understanding and
insightfulness the children displayed when asked about their
experiences. Consequently, a much more complex picture
arose when the data were analyzed.
I will begin by giving a more detailed description of
each participant, including the participant's race, how the
child was referred to the school, the child's diagnosis,
what techniques were used with the child, and how the child
relates to the counselor. Included in the descriptions are
the treatment goals the child has been given according to
his or her Individual Education Plan (IEP).
Because there is so much playing involved with child
psychotherapy and because children rarely talk about or
critique their psychotherapy sessions with their therapists,
I found the children's understanding of the general and
personal purposes of counseling to be most exciting and
validating. Most of the children articulated how helpful it
was to them to be able to talk about their feelings. All
children, but one, gave something connected to problems as a
reason why people go to counseling. All, except one, saw
how they personally needed counseling. Each child's idea of
54
the purpose of counseling will be included with each
participant's personal description. This is to illustrate
the understanding of each child and to provide a feeling of
what each participant was like. I will also give some
description of the child during the interview. The
participants' names are pseudonymous.
Following the individual descriptions, I will explain
my theory of the manner in which the children perceived
psychotherapy using quotes from various participants to
illustrate each point.
I will conclude with additional findings. First I will
quote the children's responses to the process of
psychotherapy. I will also comment upon the influence of
the various counselors, the age of the children, and their
experiences of counseling.
The Interviewees
Participant #1
Antoinette, a nine-year-old African-American female,
had been referred to the school by a social worker after
being hospitalized for suicidality. She had been in
counseling over two years with four different counselors.
Her diagnosis was Dysthymia. The counseling goal of her IEP
was to "improve emotional control". The treatment currently
used was play therapy with a focus on learning social skills
and improving self-confidence. Her counselor, who had been
seeing her for a little over two months, stated that
55
Antoinette related well to her and that they were
establishing a trusting relationship.
Antoinette was friendly the moment I picked her up.
After the interview, she wanted to hear her voice on the
tape recorder, then covered her face and laughed. She spent
some time looking at and holding the stuffed animals and
dolls in my room.
Antoinette thought the reason people go to counseling
was to "talk about their problems". Personally, "it helps
me keep control of my temper. I have meds. It kind of
helps, but it doesn't work that good." She explained how a
person can be changed by counseling
. . . because you get to talk about your
feelings, and, urn, you can talk them out
right, and so that, so that they won't stay
inside you, and you won't get mad, and, try
and, um, hit somebody, or try to kick them,
or something like that.
Participant #2
Michael, an 11-year-old White male, had been referred
to the school by his school district because of problems
with auditory processing, receptive and expressive language,
as well as poor social skills and relationships. He had
been in counseling over five years with five different
counselors. His diagnosis was Overanxious Disorder, Organic
Personality Syndrome, and Static Encephalopathy (seizures).
The counseling goal of his IEP was to "increase self-esteem,
independence, and self-reliance". His current treatment
focused on working with his control issues, increasing his
56
self-confidence, and modeling appropriate social behaviors
for him. His current counselor, who had been seeing him for
a little over two months, said that Michael related to her
well and seemed especially to appreciate the freedom given
to him during the sessions and also the attentiveness of the
counselor.
When I went to get Michael from his room, he was
pouting. His teacher said I could try to interview him.
When we got to my office, I had trouble with the plug of my
recorder. By the time I got it fixed, he had looked around
the room and started a friendly conversation. He appeared
quite thoughtful during the interview.
Michael described the reason for counseling as "mostly
so they don't get into a lot of trouble with their
teachers." His personal reason was "so I can be helped with
my attitude and controlling myself". He described his
attitude as "Well, if someone hurts my feelings, I usually
blow up and try to hurt them or say something that I'm not
supposed to say to them. It usually gets, gets me more hurt
than the other person." He found talking with his counselor
helped him talk better with others so that his greatest
benefit was "talking in, in, my nice, polite sort of way".
Participant #3
Dion, an eight-year-old African-American male, had been
referred to this current school by his school district as
being both learning disabled and seriously emotionally
disturbed. He had been in counseling for a little over a
year with two different counselors. His diagnosis was
Conduct Disorder and Attention Deficit Hyperactivity
Disorder. The counseling goal from his IEP was to "decrease
negative self-statements and increase self-esteem". His
treatment was play therapy with a focus on social skills and
ways of coping with his anger and frustration. His current
counselor, who had seen him for a little over two months,
said Dion related to her well, but seemed to perseverate
about his last counselor and was bothered if things were not
done the same way.
Dion came with me readily and enthusiastically. He was
very eager to help me out. Although he answered all the
questions throughout the interview, Dion was distractable,
asking questions about various objects in the room. He was
also physically active, spinning in his chair or walking
around the room, picking up toys.
Dion was different from the other participants, because
his thinking was so concrete. However, I wish I could
convey on paper his voice when he said, "I lo-o-o-o-ve
counseling1" He thought the reason people went to
counseling was "because its fun at counseling". He
described the reason he went as "they said that was my new
counselor . . . and that's why I go to counseling".
58
What was surprising was that after giving some answers
that were so childlike they barely made sense, he clearly
knew the benefits he derived from counseling.
'Cause it helps me stop and think myself,
and it helps me no cheating, and it helps
me do not cheat, and it helps me, it helps
me, urn, don't get angry at myself or at
people, at other people.
Participant #4
Andrew, a 10-year-old White male, had been referred to
the school by his school district after having been
suspended from his previous school four times in five weeks.
He had been at this school for over four years with three
different counselors. Andrew had also been under treatment
with at least one psychiatrist, and one family therapist.
Additional treatment was unknown. His diagnosis was
Attention Deficit Hyperactivity Disorder, predominantly
Hyperactive-Impulsive, Reading Disorder, and Disorder of
Written Expression. The counseling goal from his IEP was to
"improve self-esteem and reduce aggressive and impulsive,
acting-out behaviors". His current treatment consisted of
cognitive therapy, parts of Kendall's Stop and Think for
Impulsive Kids workbook, supportive play therapy, and
modeling of social skills. His current counselor, who had
been seeing him for over a year, said Andrew related to her
exceptionally well.
During the interview, Andrew was cooperative,
thoughtful, insightful, and quite sweet. This was
59
astonishing to me, because I had never spoken to him before.
I had just seen him on the playground, where he often
appears very angry and distressed.
Andrew said people go to counseling "so they can talk
about their feelings and what's going on in their life". He
personally goes " 'cause I have a lot of problems". He
stated, "Counseling changes people's minds and, and makes
them understand what they've been doing and what they can do
to help themselves". He described talking to his counselor.
"You just get to talking and try to make a good conversation
and tell the counselor how I feel, and what I want done, and
this and that." He said it helped "because I get a lot of
stuff out." When asked what would happen if he didn't get
it out, he replied, "Then I'd be going crazy". With
counseling, he stated, "I feel a whole lot more better."
Participant #5
Ryan, a 10-year-old White male, was referred to the
school by his school district for both learning and
behavioral problems. He had been in counseling about a year
with two different counselors. His diagnosis was Post-
Traumatic Stress Disorder, having been a possible victim of
early childhood sexual abuse. The counseling goal from his
IEP was to "improve anger management and peer and other
relationships". Current treatment consisted of role-playing
alternative solutions to difficult situations and giving him
feedback on the consequences of his behavior. His current
60
counselor, who had been seeing him for about three months,
stated that she thought Ryan liked her, but he had been
testing limits to see how far he could or couldn't go.
Ryan was different from the other children in that he
picked up some toys and started playing as soon as we walked
into my office. However, he was ready to start after a few
minutes and became friendly and cooperative. During the
interview, it was apparent that Ryan was very needy, and he
at times got into his personal counseling issues.
Ryan said the reason people go to counseling "is
because they have like problems in their life. Something's
not right sometimes." Although he stated a person could
talk to family members or friends, he added, "Sometimes
counseling's the only thing to do when things really are
bad, [because it's] better to talk with someone who
understands what you're feeling, what you're going through."
His personal reason for going was
Because of my behavior in my other school,
and what I did to other, um, what I did to
the teachers, how many suspensions I had.
I mean if you look at my record, you'd say
I'm the worst kid that ever lived. I
didn't do any work. I was class clown
every day. I beat up kids every day.
He also stated, "I have like a really bad attitude, and I
should work on it . . . I was just a cussing machine."
When describing counseling, Ryan said besides playing,
he talks a lot.
Something we enjoy, we talk about, and
something that we hate, we talk about.
61
Something that we don't like, we talk
about. Something that's not right, we
talk about.
Since being in counseling, he noted the following changes in
himself. "I do my work now." "It helped me like, I used to
have no control over my anger. Now I have some control over
it."
Participant #6
Dontae, an eight-year-old African-American male, was
referred to the school by his school district after having
behavior problems in three previous elementary schools. He
had currently been in counseling for seven months, but had
previously been seen by two other counselors. His diagnosis
was Conduct Disorder and Attention Deficit Hyperactivity
Disorder. The counseling goal from his IEP was to "increase
self-esteem in addition to learning to get along better with
peers". His current treatment was play therapy focused on
social skills and raising self-confidence. His current
counselor, who had been seeing him for about three months,
described Dontae as relating well to her, and she felt they
had a good relationship.
By his actions, as well as his responses during the
interview, Dontae was definitely into playing. During the
interview, he seemed like he was trying to be cooperative,
but the questions were beyond him.
Dontae saw counseling mostly as it related to school.
People go to counseling "to help them in school". He
62
thought counseling helped him most in doing his work in
school. It changes people by making "you real good, and not
bad".
Participant #7
Nathan, a 12-year-old African-American male, was
referred to the school because of suicidal ideation, for
which he was hospitalized twice, physical aggression toward
peers, and problems with authority. By his own estimation,
he has had 20 counselors. His diagnosis was Dysthymic
Disorder, Early Onset. The counseling goals of his IEP were
"to achieve more moderate behavioral expressions and less
negative interpretations of the world— lessen extremes of
behavior" and "to reduce his chronic problems with
depression". His current treatment was cognitive
behavioral, pointing out discrepancies in his behavior and
his expectations of others. Nathan was described as
generally preferring to talk, rather than to engage in
activities. His current counselor, who had been seeing him
for about three months, stated that Nathan "respects me as
an authority (not easy for him) and a friendly, helpful
person, but I get the feeling that if I ever disappointed
him he would have no trouble in 'disconnecting' himself from
me and viewing me as the enemy."
During the interview, Nathan was thoughtful,
insightful, and extremely articulate, which was the same way
his counselor described him in his counseling sessions. His
63
interview greatly exceeded the other participants' both in
length and sophistication of response. Nathan frequently
talked about his personal problems, but they often tied into
what was pertinent to the study. He was a gold mine of
information. For example, he talked some about suicidal
ideation. His advice for counselors, as a response to
someone who is threatening to kill him/herself, was to ask,
"Is there anything I can do to stop you?"
Nathan was a participant who had a lot of experience
with psychotherapy. The questions I asked merely sparked
additional ideas for him, so his answers to the specific
inquiries regarding the purposes of counseling were brief.
He started by saying some people go to counseling "because
their parents feel that they need to talk to someone". That
led him to discuss how the person may not be ready to talk.
He said his personal reason for going was " 'Cause I had a
lot of worries. I have a lot of worries." He thought the
way counseling changes people was dependent upon the
relationship with the counselor. "Well, it can make you
more open sometimes. Sometimes it will close you up." He
went on to say how if you see a counselor who begins
counseling by referring to your previous bad behaviors found
in your file, you may not want to share any more information
with him or her.
And when you hear the stuff about yourself,
you can't believe it's you. Like it don't
sound like you. Like it make, it make you
want to say nothing else to nobody, 'cause
64
if that's, that's what you are, you don't
want anybody else to know . . . the way they
read it, it sound like you're just the worst
person in the world.
For him the greatest benefit was the chance to talk with
someone.
Participant #8
Jon, an 11-year-old White male, was referred to the
school by his school district because of a pervasive
developmental disorder with serious associated symptoms that
put him at risk emotionally, socially, and academically. He
had been in counseling for four years with four different
counselors and a psychiatrist. His diagnosis was Dysthymia,
Developmental Reading Disorder, and Developmental
Coordination Disorder. In addition, he had retinal
detachment, overall visual deterioration, and orthopedic
problems. His school district did not have a counseling
goal on his IEP. Jon's current treatment was working with
Legos in cooperation with his counselor to help with his
inability to bond. They also had played the game
Communication to help him with the social skill of
communicating. His current counselor, who had been seeing
him for three months, described Jon as "the one client of
mine where I feel like he isn't in a relationship with me
that he values."
During the interview, Jon was cooperative, but seemed
very stiff and guarded.
65
Jon saw the reason people go to counseling was "that
they have problems and get to talk about them." Personally,
he went "probably because I, um, have trouble getting along
with other people". He felt the counseling experience
helped persons "to trust other people, like they trust their
counselor". He said counseling "helps me with, um, my
difficult problems . . . and it helps me avoid obstacles."
He also talked about the benefit of expressing feelings.
"What's good is I get to express, um, anything of the
problems I have and get it out of my system and know that I
talked to it with someone." When asked what would happen if
he didn't do that, Jon replied, "It would just be trapped
inside me, and I'd feel really guilty about it."
Participant #9
Harrison, an 11-year-old African-American male, was
referred to the school by his school district for poor
attendance, verbal and physical aggression toward peers,
inappropriate sexually-oriented talk and behavior, and
possible molestation. He had just started at the school,
but had been in counseling the year before with another
counselor. Harrison had not yet been given a diagnosis.
The counseling goal on his IEP was "to develop and evidence
ethical behavior and to improve self-esteem". His current
treatment consisted of building a relationship with his new
counselor. They had only seen each other for three
sessions, but she described him as relating well, being very
66
pleasant, verbal, and enthusiastic with a good sense of
humor. However, she further described him as seeming
unaware of the reason for his being in counseling and
dependent upon her to "tell him" about himself.
During the interview, Harrison was very cooperative,
friendly, and polite, but had some trouble expressing
himself.
Harrison stated his personal reason for going to
counseling was the same as the reason people in general go.
Um, to, um, to go to counseling is for,
like to, um, play games, talk if we have
something wrong, or like draw, have, you
know, have fun things, or like you have sad
things to say, and talk to her, talk to him
or her.
He, personally, "used to go around cuss people out, or like
I used to hit on people if they were bothering me." He
thought counseling changed people "In a good way. Um, it
turns them in a respectful way. And, and, and it makes them
more like they feel, they feel good." For himself, he said,
"First I was bad. Now I've changed. I've changed my whole
life back to good". Counseling helped him "to be respectful
to people, or like, or, or like, the, uh, don't do bad
things. Don't do disrespectful things to the grown-ups.
Don't fight back against the teacher." His change was
achieved "by talking to me. Letting me know what's going to
happen to me if I don't turn myself around."
67
Participant #10
Adolfo, an 11-year-old Hispanic male, was referred to
the school by his school district for his disruptive,
uncontrollable behavior. He had only been with his
counselor at the school for three months, but had had
previous counseling with one other therapist. His diagnosis
was Oppositional Defiant Disorder and Attention Deficit
Hyperactivity Disorder. The counseling goal of his IEP was
to "reduce negative behavior that interferes with social and
academic functioning". His current counselor was having
difficulty with him in treatment, describing Adolfo as "a
serious, unsmiling boy that has trouble expressing feelings
and closeness, often regressing to immature behavior and
silence".
During the interview, Adolfo was cooperative, but often
became distracted and had difficulty expressing himself.
For example, after asking him the first question, his
response was, "Huh?"
Adolfo saw counselors as teaching a person how to solve
problems. Change occurs "by, like your counselor try to
talk to you. To tell you, she's trying to talk to me by
telling me, um, why, why do I act like the way and that".
He said counselors help solve problems. When asked how the
do that, Adolfo replied, "By, um, by helping me out. Like,
uh, what's the best thing for, for her to do, 'cause, so I
can be good." When asked if he had changed, he replied,
68
"Uh, she's trying." At the conclusion of the interview when
asked if there was anything he'd like to say, he answered,
"I want to say, um, that, urn, I hope I pretty soon that I
can be good."
Participant #11
Richie, a 13-year-old White male, was referred to the
school after having been in residential treatment for two
years. The total number of therapists he had seen was
unknown, but he had had three counselors at the school and
was currently also seeing a family therapist. His diagnosis
was Obsessive-Compulsive Personality Disorder, Reading
Disorder, and Disorder of Written Expression. The
counseling goals from his IEP were to "improve interpersonal
problem-solving skills including listening skills" and to
"improve self-esteem". His current treatment was
relationship-based cognitive therapy. His current
counselor, who had been seeing him for four months,
described Richie as "guarded, yet friendly" and thought he
was slowly opening up.
During the interview, Richie was cooperative, but had
to be in control. For example, he acted reluctant to sign
the consent form, because he said he did not want to be
anonymous, but wanted his name to appear in the study.
Next, he stopped me several times after I turned the tape
recorder on, but before I started, to express various
opinions. It appeared many of his statements were made
69
primarily to shock, to show how powerful he was, and to show
disdain for counselors. He began the interview with his
arms folded, but by the end was very talkative and did not
want to stop. After I brought him back to his class, he
returned to my office to tell me more about his personal
experiences.
Richie, as mentioned, was the child who had a negative
view of psychotherapy. However, in regard to his current
counselor, he said, "She's OK. The only reason she hasn't
stabbed me in the back so far, I believe, is I haven't told
her nothing." When asked why people go to counseling, he
replied, "Well, some people have problems. Um, a whole
bunch of problems they could . . . they don't get along with
children. Something happened to their family. Um, they're
disturbed. They don't work in class. A lot of reasons."
His personal reasons were "I walk out of class. I don't
like doing my work. I (pause) a whole bunch of reasons
. . . and family problems". When asked if counseling
changes people, he answered, "I have a little problem. I
know it does, but 1 haven't seen it yet." What he saw as
the greatest benefit of counseling was "I get to get out of
class. That relieves some of the pressures. I think every
kid should have a period when they can just walk out of
class and chill out."
70
The Psychotherapeutic Experience/Relationship
When analyzing the relationships among the data, it
became apparent to me that the essence of the
psychotherapeutic experience to the child was the
relationship the child had with the therapist. The type of
relationship colored all other perceptions of the
psychotherapy. The majority of the children in this study
had good relationships with their counselors, not only by
their own report, but by descriptions given by their
counselors. The children were never ambivalent, but
described psychotherapy with the dichotomy of good-bad,
being either one extreme or the other. Their views of their
counselors affected both what happened during counseling
(process) and the benefit they said they derived from
counseling (outcome).
The core category, therefore, became the relationship
between the therapist and child. It was conceptualized to
represent "the central phenomenon around which all other
categories were integrated" (Strauss & Corbin, 1990, p.
116) .
The relationship from the child's point of view seemed
to be formed on the basis of two other categories— the
perceived respect the therapist gave the child, as
demonstrated through the therapist's actions, and the
subsequent trust the child had in the therapist.
71
The level of respect the child felt was based on the
perceived attention given by the therapist as well as
through the therapist communication. The manner in which
the therapist handled confidentiality seemed to have the
greatest impact on trust.
These therapist actions combined with non-verbal cues
both from the therapist and from the environment formed the
child's perception of the therapist's characteristics. The
perceived level of respect also formed the child's feelings
toward the psychotherapeutic experience. In response to the
therapist's actions and the subsequent child evaluations of
them, the child formed trust toward the therapist.
Playing was found to be necessary in giving the child
time to build trust. Gifts/rewards were an additional
aspect of children's experience. The children's attitudes
toward gifts or rewards were influenced by their feelings of
trust.
Figure 1 forms a graphic display of the
psychotherapeutic experience/relationship. How the
therapist attends to the client, communicates to the client,
observes confidentiality, and gives non-verbal cues all lead
to the client's perceived respect by the therapist. The
arrows from Therapist to Attention, Communication,
Confidentiality, and Non-Verbal Cues and from those
categories to Respect show that it is through the
therapist's actions that these categories are evaluated as
72
to the level of respect. Non-Verbal Cues are also
influenced by the Environment, as shown by the arrow.
The perceived level of respect influences the child, so
that an arrow is displayed from Respect to the Child/Client.
This amount of respect shown affects the child's perception
of the therapist, the child's feelings regarding
psychotherapy, and the level of trust the child has toward
the therapist. Therefore, it is displayed graphically that
arrows go from the child to Perceived Therapist
Characteristics, Feelings, and Trust. The level of respect
the child feels from the therapist along with the trust the
child feels toward the therapist forms the relationship.
Thus, an arrow is displayed from Trust toward the Therapist.
Other categories, pertinent to children, were connected
to trust. Playing was used as a vehicle to get to know the
therapist and establish the level of trust. Playing,
consequently, is shown, through the arrow, as influencing
trust. A child's opinion of being given a gift or reward by
the therapist was influenced by his or her feeling of trust
toward the therapist. Therefore, an arrow goes from Trust
to Gift/Rewards. Although it was not the subject of the
present study, the trust the child felt toward the therapist
affected the outcome of the treatment. Thus, an arrow is
drawn from Trust to (Outcome).
Figure 1. The Psychotherapeutic Experience
73
Psychotherapeutic Experience/Relationship
Respect
Attention
Communication
Confidentiality/
^ Non-Verbal Cues
Therapist Child/Client
Environment
/Perceived \
/ Therapist \
Characteristics,
Feelings
Trust
Gift/Rewards (Outcome) Playing
Respect
Respect, as defined in the dictionary (Webster's New
World Dictionary of the American Language, 1968), is "a
feeling of deference, honor, or esteem; a state of being
held in honor or esteem; consideration; courteous regard"
(p. 1240). This best describes what the children, in their
inherent one-down position, implied as needed in order to
form a positive relationship with their therapist.
The level of perceived respect was derived from the
child's perception of the quality of attention s/he
received, that is how s/he perceived the therapist as
talking to and listening to him or her. Respect was also
shown by the therapist keeping the child's psychotherapeutic
sessions confidential. The breaching of confidentiality was
considered to be very disrespectful by the child and was the
most certain way of losing the child's trust. The perceived
level of respect toward the child was also obtained through
non-verbal cues given by the therapist and as well as part
of the environment.
Attention. The attention given a child was one of the
attractive attributes of psychotherapy. The special
attention was described by Andrew as something that made his
therapist different from all other adults. He said, "...
she like doesn't concentrate on something else. She just
concentrates on the kid that she's seeing." He concluded
that "... that's what I like about her— that she doesn't
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bring up someone else all the time." Andrew also included
attention-giving when asked if he had any suggestions for
counselors in ways to improve. He said, "You have to, have
to, have to focus on the kid and not focus in your mind on
what you're going to do next or something like that."
Nathan also liked attention focused on him. He stated, "I
don't like talking about other people outside in the world."
Also related to attention was consideration shown to
the child if attention toward him or her was to be diverted.
It was considered a measure of respect when the therapist
asked for the children's permission to see another child in
crisis when the crisis occurred during their regularly
scheduled time. Additionally, it was important to the child
that if the therapist was unable to make the appointment,
the child could be certain that the therapist would make up
the time. Conversely, some children reported being angry
with their therapists in situations where the therapists did
not keep appointments and did not notify the children.
In the school situation that the interviewed children
were in, they also had the opportunity to see the therapist
around the campus outside of the psychotherapy sessions.
How they were then treated outside of their regular sessions
influenced their perceptions of their therapists. They
appreciated their therapists coming to watch them in the
classroom. How they were greeted or acknowledged was
important. Nathan complained of not being treated as
76
someone special by one of his counselors. He described it
as, "So like two times out of the week he was my counselor.
The rest of the time I was somebody he'd just pass by."
Obviously, talking on the telephone during a child's
counseling time was regarded as disrespectful. The
importance of attention was summed up in Nathan's angry
response to the lack of it.
.. . if you were like talking on the phone,
and I was trying to get you to listen, and
you just wouldn't listen, I'd just say I'm,
I'm going to throw something, or I'm going
to throw something over. I want to hit
somebody. I want to kill somebody. I want
to kill you. I want to kill something. I
want to do something bad. Then you say,
hold on a second. Then you look at me. I
want that. I want some attention, so I'll
call attention to me.
Positive or negative feelings were reported by the
children in response to the perceived amount of time their
therapist spent with them. The more time spent, the more
positive the feeling. Andrew said of one counselor, "He
just didn't help. He just didn't take a lot, lot of time."
Therapist Communication. The manner in which the
therapist talked to and listened to the child influenced the
child's impression of the therapist and the perceived level
of respect. The consensus from the data was that children
preferred someone who "didn't talk to you like a counselor.
They talked to you like a person." Therapist or counselor
talk was described by Nathan as follows:
And like they sit there with their legs
crossed, real far away. "_______, is your
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name? Um, you have, would you say you are
um a depressed person? OK. Would you say
that you have bad thoughts against the
world? Would you say that ..." They
actually direct yes or no questions. Like
they don't, OK, like they don't put the pad
down and say, "Look, OK." Don't talk to me
like, like I've been to college just like
you. Everybody hasn't been to college and
have a Ph.D. and talk like you.
Nathan didn't like the counselor writing information
down on a tablet. "When they write it down, you feel like
they don't want to tell you nothing, 'cause it's all on a
piece of paper. It's not in their head. If they really
cared, they wouldn't forget it."
Nathan continued with the related complaint of
therapists being so other-than-real that one could mention
suicide or murder and get a blase response.
And sometimes I, like when I tell them
something, like their expression on their
face doesn't change. Like when I told
them, I told them that, that, uh, I wanted
to kill somebody like, "Uh hmm". Like it's
a normal thing. Some counselors will go,
"Why??" like that. That's what I'm looking
for.
The children felt more comfortable with therapists,
whom they felt they knew through the therapists' self
disclosures, again someone they described as a "real
person". "I want to know them as a real person, not just as
a counselor. Not how many people you saw. What do you do
when you go home?" Nathan described his reason for this.
They want you to open up your heart and
soul to them like pulling your chest open,
but you don't know hardly anything about
this person. You don't want to do that.
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Like if you tell them so personal things,
personal to the point where you want to
die, then I don't say they have an
obligation, but if they want to get
somewhere ....
He went on to advise, "But you've got to make them feel
like, like you're both opening up to each other, instead of
they just opening up to you. Like if you start off first,
they'll follow a little at a time."
Some children suggested their favorite counselors and
the ones with whom they felt most comfortable were those
that understood what it was like to be a child. Andrew
described the best way to talk to a child was for the adult
to reach the child inside him or her.
And you, and you, and you have to like,
'cause inside, inside you're a kid . . .
Well, inside of her she has a kid, because
she used to be a kid . . . you have to,
inside you, you have to talk like a child
does or a kid, and it's not that hard when
you put your mind to it.
The children also offered advice to therapists on how
to handle a child who is reluctant to talk. Nathan advised
that as long as the child is there, s/he will probably talk.
"If they really don't want to talk to you at all, they'll
leave".
He also advised that if a child doesn't want to talk
about something, don't insist. The child will go back to it
when s/he is ready. When the child does go back to it,
don't interrupt, but let him/her finish. The child really
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wanted to talk about it, but didn't want to lose his/her
pride.
Richie had strong feelings about the matter.
. . if a kid doesn't like what they're talking about,
you're disturbing them. I'll give them this much— they can
ask why. If the kid says, 'I don't want to talk about it,'
lav off 1"
Nathan's advice was not to talk to a child when he or
she is extremely upset.
Wait until they calm down, because they
might say things that might make you just
want to give up. They might say stuff
like, "I hate you. I wish you were dead.
When I get up, I'm going to kill you.
I'll stab you." All kinds of stuff. But
you can't . . . some counselors believe
them, but you can't believe nobody when
they're like that.
The children described therapists who were difficult to
talk to as being the worst therapists. Andrew said of one
counselor he had at the school
[He] was really weird. He, like, there
wasn't really a way that you could talk to
him . . . I mean he'd listen, but he
wouldn't do anything . . . Like I wanted him
to like, like help me, like with my problems
and stuff, but he doesn't. He just says,
"OK, OK". That's all there is.
Nathan described one type, who "go[es] by the books all
the time [and] don't know people". They were described as
". . . not interpretive. Everything you say they just write
it down. And then like they don't ask you questions
80
pertaining to what you said. They ask you far out
questions. Like what's in the manual that they're doing."
Nathan also said
[Good counselors] listen instead of always
talk. Some counselors, they don't let you
talk. Like they cut you off when you're
saying something . . . You feel real
uncomfortable talking to anybody that won't
let you finish, 'cause they're going to cut
you off so many times, and you say 'forget
it'. Like you don't get out what you was
going to say, and they never know ....
A therapist, who was liked very much, was described by
Andrew as validating what the child said, "whatever I say
she agrees, she tries to agree on". In contrast, Nathan
described the "worst counselor" as being someone who
negated what the child said.
Like when I said around where I live at,
a lot of people feel this way, they just
don't come in. They just don't want to
talk to you, and you ain't going to find
out until they're in a body bag. And he
wanted to know that's not true. He didn't
believe me. He thought I was like, that's
not true. Then like I don't want to talk
to him, and he said, "Fine. If you don't
want to talk to me, go out and be a bum.
Go out and kill yourself. I don't care."
That made me so angry that I really wanted
to hurt him. I really wanted to hurt him.
Nathan also complained about counselors, who "tell you
about yourself, and they don't even know you." Instead he
prefers ones that say, "'Well, I'm sorry. What are you
like?' 'If I'm wrong, correct me'."
Confidentiality. The concept of confidentiality was
not addressed directly with the interview questions, yet
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many of the children spoke of it. Dion's idea of
confidentiality was that he and his counselor kept his
earning a reward a secret, because "[the other children
would] feel sad, 'cause they don't have what I'm getting
from my counselor".
The other children, however, discussed it in terms of
how their therapists handled it. How it was handled had a
major impact on their levels of trust. On the positive
side, Andrew described how he infrequently invited other
children to join his session (a fairly common practice at
the school), because he couldn't talk freely about his
feelings with other children present.
I never take anybody with me to counseling
any more. It just sucks. There's nothing
being done, and you can't talk about your
feelings or anything, so why take them?
. . . if I talk about my feelings, then
they'll say it on the bus or something like
that, so that's why I just don't take them.
He went on to say what he appreciated about his therapist
was that she doesn't tell anybody what he said "unless I
want her to . . . she gave me the permission to tell, to
have her tell somebody, or she doesn't tell at all."
Ryan described confidentiality as "It's like you can
tell them like you are, and they'll keep it a secret." He
went on to explain, ". . .they won't snitch. When somebody
snitches on you, it's like he's not your friend."
The children, who described negative counseling
experiences, primarily attributed them to what they felt was
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a breach of confidentiality. This topic evoked extremely
strong negative affect. Richie stated, "... I've been
betrayed by counselors. Oh, this doesn't leave the room,
this, that, and the other thing. The next thing you know,
your parents find out, so that's why I don't trust a single
counselor."
Nathan stated
And they try to make you like attached to
them, like I can be your friend. And when
they're supposed to be your friend, they
say something to your mother. It's not
right. They don't tell her exactly, but
they give her hints. And like if you
wanted to tell your mother, you wouldn't
be there. You'd tell her, if you wanted
to tell her, if you wanted her to know.
Non-Verbal Cues. Some of the children's impressions of
the therapists came from non-verbal cues. Dontae, who was
not as articulate as the other participants, when asked how
counselors could do a better job, replied, "They could, um,
like when I, um, go to counseling, they be mad at first and
then happy." Upon further questioning, he described seeing
not only his current counselor, but his past counselor, as
looking angry when they came to pick him up and then looking
happy after spending some time together. He suggested that
counselors should look happy all the time, because when they
look mad, he felt sad.
Nathan, who was particularly sensitive to non-verbal
cues, gave several interesting descriptions of how he was
affected by them.
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And then some counselors have a straight
face like they going to kill you, because
they don't know a thing. Like they look at
you like you're, like, like, a mean face,
and they stare you down, and examine you,
like, like something's wrong with you or
something like. They like look at you.
They look at your face. They look at your
expression and just stare. They just study.
And they're not even really listening to
what you're saying, just "Uh hmm, uh hmm",
just writing it down word for word and not
really listening.
He also described from non-verbal cues how one can tell
if a therapist distrusts his or her client.
Because counselors, well, they stay away
from you kind of. They don't like sit
close to you. They sit like at their desk,
real far from you. They have you sit way on
the couch. Um, they hand you things from a
distance. They don't get up and come over
where you're sitting. They hand you things
from a distance. Um, like they, uh, a lot
of times they ask you things. They sit at
their desk and while you're talking, they
like lean back. And at the end, they might
shake your hand, but you guys are not close
enough to where you could do any harm.
Nathan also made a point that the environment can make
one feel comfortable or uncomfortable. For him, well-lit
rooms are uncomfortable. "Very, very well, I mean, bright,
bright, bright colors on the walls, bright posters, bright
everything, bright wood, bright chairs, leather. That kind
of thing doesn't appeal to me." When questioned why, he
replied "Too, too, too happy. I'm supposed to be talking
about bad things." He also disliked "... the furniture
to be black leather, and it makes a squishy noise when you
sit down, and have all these artifacts around me. I feel
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like I'm in a museum". He also stated he didn't like
feeling he was in a doctor's office. What he did prefer was
a comfortable, inexpensive, cloth couch. He advised, if a
therapist has one of these "[the clients'll] probably feel
comfortable. They might lay back a little bit. They might
talk to you more open, so that's a good idea."
Andrew suggested that counselors may use non-verbal
cues also when trying to establish rapport. "You, you can
watch a person by just looking at them. Then you know what
they want and the kind of questions you can ask."
Trust
Whereas the respect component of the relationship came
from the therapist, the trust component was from the child
to the therapist. From those aspects of the therapist's
actions previously described, the child formed his or her
perceptions of the therapists' personal characteristics.
The child's feelings during the session also were influenced
by how respected he or she felt. Andrew described
counseling without trust. "Counseling can suck, if you
don't, if, if you don't believe what the counselor says."
Therapist Characteristics. Descriptions of the
therapists were for the most part very positive. They were
described as "nice", "they care", "fun to be around", "they
can be trusted", "they're pretty good people if you get to
know them", "they understand", "likes to play and likes to
85
work", "she knows kids", and "they understand that you're
not doing this just to do it".
Michael stated, "She tries to help you a lot. She
usually stays in control with you, and she doesn't lose her
patience."
A few of the children's descriptions were more
concrete, addressing appearance traits (e.g., "curly hair,
white, has glasses on") or toys she had.
Both Nathan and Richie, who had had the worst
experiences with psychotherapy, stated that they preferred
female counselors, because they were "more sensitive".
Nathan said, "Some [male counselors] are a little brutish
. . . they talk tough."
Richie's negative descriptions included "annoying";
"going against what I want"; "... don't respect my wishes
. . . manipulative . . . they're your friend, then when you
trust them, sometimes, like I said, they turn around and
stab you in the back".
Although Antoinette described therapists as "different
from everybody else", some children considered them to be
most like a friend, while the majority thought they were
most like teachers, because of teaching how to solve
problems. Harrison described it as, "She teach, you know,
she teach in a way, she, she give me things I don't know in
a way what I can understand it."
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Ryan described therapists as a combination of
"teacher", "assistant mother", and "friend". He stated his
reasons for this as
. . . they teach you what they do . . .
they like want to know what you feel
inside, like um, like a mother does. Like,
did you get your feelings hurt? And, uh,
like a friend, like being there for you and
stuff, like I'll help you and stuff.
Dontae said his counselor reminded him of "my little
baby brother". When asked in what way she reminded him of
his brother, he replied, "Playing."
Richie described therapists, in a word, as
"sleazebags", because "They stab you in the back. They
annoy you."
Children's Feelings. Most of the children described
themselves as feeling happy while in counseling. Ryan
described himself as feeling "great" . He further
explained, "It's fun at counseling, real fun."
When asked how he felt during counseling, Dontae
replied, "fun".
Dion said he used the feeling chart to describe himself
in counseling as "happy", "proud", and "silly". He also
concurred that "It's fun at counseling . . . I love to go to
counseling with my counselor".
Jon answered, "I, um, feel, um relaxed, and I feel
like, um, I can talk about things in that room."
Michael added another feeling— "safe".
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The following exchange with Harrison best exemplifies
the consensus of the others.
I: How do you feel when you're at counseling?
P: If I feel happy.
I: All the time?
P: Yes, all the time.
Is What if you're talking about, you mentioned talking
about sad stuff.
P: I feel kind of sad.
I: At the time, huh?
P: Yeah.
I: But in general, it makes you feel happy?
P: It makes me feel happy.
Richie described his feelings by saying, "... with a
good counselor, like the one I'm having right now, I feel
like a burglar who's set free. I'm not in school. I get to
have time to chill out." However, with a counselor he
didn't like Richie felt "like a wild animal would if you
shoved him in a cage . . . like, what is the word for that?
Trapped."
Nathan covered all experiences.
It depends on who your counselor is.
Sometimes I feel open. Sometimes I feel
closed. Sometimes I feel in the middle,
half foot in, half foot out. Sometimes I
just feel like saying, "I don't want to be
here. I want to go home. I don't want to
come here. I don't like you. I don't
like your counseling room. I don't like
you. I don't like anything about you. I
want to go home."
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The children who had negative experiences with
psychotherapy all described having had poor experiences at
the present school. However, each had previously been in a
hospital setting where their worst experiences occurred.
They described how they felt in these circumstances as being
non-human.
Nathan described his feeling in the hospital. "You
feel like an animal, locked up in a cage, because they don't
really care about you actually." Nathan also described a
situation when the therapist did not sit close when he was
crying. He said it made him feel distrustful and "like you
are a rabbit or something in an experiment".
Other Experience Components
Plavina. Playing, of course, is part of psychotherapy
with children, and all of the children talked of it when
describing their counseling experiences. Activities
described were games, drawing, art, coloring, painting,
Legos, kickball, basketball, pool, puppets, cards, and going
for walks. One can tell from the following words how
meaningful playing can be.
I believe he worked with me for a little
while, and after he did that, he asked me
what did I want to do. 1 said kickball,
'cause that's what I used to like. So we
went in the back of his office. It wasn't
a field. It wasn't nothing— the side of
the office, just like almost here, the side
of the office. And it was like playing
kickball on a little bitty side of an
office. That was where we played, and he
took off his suit jacket, and he played
kickball with me.
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When asked what playing had to do with psychotherapy,
the insightfulness of the children was surprising. One type
of response was that it was relaxing, therefore making it
easier to talk. Andrew responded, "It just gets my mind
going on things. So if somebody asks me something, I can, I
can tell them real quick. It goes bingl" Jon added, "It
helps you express your feelings out if you're more relaxed."
Another response was it was something to engage in
while getting to know each other. ". . . [it's] just to get
to know them a little more better . . . and get more trust
in them". ". . .to get to know your, like, counselor".
Andrew described the importance of getting to know each
other while playing in the following advise to counselors:
It's, it's just the more you find out, the
more you can help. But if you don't find
out a lot of stuff, and the kid don't want
to talk to the counselor, then, then he's
going to keep it all inside. And then one
of these days when he gets one more thing
in there, and he can't take it, he's just
going to blow . . .
When asked what a counselor could do to make a child
want to talk, he responded, "Play a game."
Some children saw playing as skill-building. They
admitted that they had trouble getting along with other
children while playing, so viewed the playing with their
counselor as teaching them how to play.
Another viewpoint was that playing was for enjoyment.
Harrison said, "Um, they enjoy, have fun, and, um, talk
about things".
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When asked what playing had to do with counseling,
Richie had a unique response. "Nothing. That's why I like
doing it."
Gifts/Rewards. A topic initiated by the children was
the gifts or rewards they received from their therapists.
These included stickers, postcards, happy faces, doughnuts,
candy, cookies, pogs, slammers, a bracelet, and teddy bears.
Some were given as rewards for good behavior or for
achieving a goal. Some were given as remembrances at the
end of therapy. Some seemed to be offered just out of
kindness.
When asked what they meant to the children, there were
a variety of replies: " a symbol of friendship", "for being
a good student", " she's very nice", " they're a good
counselor", "something you take care of".
Nathan wore a bracelet he received from his first and
"one of his best" therapists, whom he had seen four years
ago. The importance of it was evident in the following
description: "I take good care of it, 'cause I want to
remember it forever. I want to keep, I never took this off,
never, and I never, ever, ever, never took this off."
Some children had indifferent views about gifts or
rewards. Jon said, "I, um, really don't want anything.
Usually I just, um, like to express my feelings with the
counselor."
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Nathan also said he felt uncomfortable when he received
something from a therapist he didn't like. "Like I feel I
owe somebody when I get something free".
Richie again had a unique viewpoint.
I, I like kind of like thinking of it as the
dog method. You know, I'll, I'll do a trick
if, if you'll give me a doggy snack or
something . . . you're not going to do
squat, except make my life miserable, so I
better get something out of it . . . even
with the little information I give them,
that's how a couple of them [therapists]
have stabbed me in the back. Sometimes I
ignore that, because at least I got
something out of it.
The Interview Process
I found the interview process to work very well with
the children. Every child in this study was cooperative,
open, and willing to begin talking right away. They all
seemed to enjoy it. All children said they were willing to
see me again if necessary, except for Michael, who said he
didn't know. A few children approached me on campus after I
had interviewed them to ask if they could do it again.
However, I think the motivation was not that they had more
to say, but that they found the interview to be a more
pleasant experience than being in class.
Additional Findings
Process
When analyzing the data, process, as described within
the adult literature, was not an integral part of the
therapeutic relationship for children. To illustrate how
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the children viewed the process, the following responses to
the question of what they do during counseling are given.
Antoinette said
Sometimes we go play games after we discuss
the, um, stuff about like, about, uh,
what's going on. Like we play games, or we
do, play on the board, or we, um, draw or
do some art of draw, um, color, or paint.
Michael said, "Partially, probably work, um, but it's
got a lot of fun with it too, and the counselors are very
nice. They try to help you. That's how I can describe it."
According to Dion,
See, counseling is like this: Counseling
is you, um, play with the, with the
counselor, like come pick you up Sunday,
Monday, Tuesday, Wednesday, Thursday,
Friday, and Saturday, and then the
counselor calls your name. Then you go.
Then you play a game, or, if you like, play
basketball or a game like Uno, Go for
Broke, uh, Legos. And, and if you can be
bad, you lose your happy face. You go back
to school.
Andrew's description of what he does during counseling
was
Play basketball, or I play pool, or some
other people might take walks, or something
like that. The counselor might buy them
something, or, and get to know them more
better if it's a new counselor, or even if
it's an old counselor just to get to know
them a little better.
Ryan said
Well, sometimes we'll talk, like let out
our expression and stuff. Like my
counseling, she let's me play all through
the time, but we have to talk some. If we
don't talk or just play the game, don't
talk just play the game, then I can't play
at all. But while we're playing a game, we
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have to talk. We talk. We have to talk
through the game. That's what we do,
Dontae described
It's uh, it's fun. It's (pause), it's, you
get to play. You get to play. You get to
talk about how you're doing in school, and,
uh, let me think, urn, (pause) you could be
playing basketball, and I, uh, (long
pause), I don't know all of it.
Jon stated, "I, um, talk to my counselor, and I express
my feelings while I, um, sit down and, um, relax in a
chair."
Harrison said, "I'd describe that as like, like, um,
like he asks questions, or like, or like he learns stuff."
Adolfo described counseling as, "Um, we play cards, and
sometimes we talk about my behavior."
Richie simply stated, "Play games. Go out for a walk."
Although probes were made to all of the above
responses, what was specifically described did not fit with
the classic view of process. What was further described
instead became the categories that were ultimately derived
from the data. The counseling process on its own was not an
important part of the psychotherapeutic experience for these
participants.
Counselors
The descriptions of their psychotherapeutic experiences
showed no differences among the current counselors. None of
the children seemed able to describe specific techniques
used within their sessions, so the possibility of
differences based on theoretical orientation were not shown.
All of the current counselors were liked. Children who
previously had counselors that they didn't like described
their bad experiences similarly.
Aae and Experience of Counseling
The descriptions of the psychotherapeutic experience
did not vary with age. Some of the older children had as
much trouble expressing themselves as did the youngest
children.
Those who were best able to describe their
psychotherapeutic experience, namely Andrew, Nathan, and
Richie, were ones who had the most experience. However,
Michael and Jon, who also had more extensive experience,
were limited in their descriptions.
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CHAPTER FIVE
Discussion
The outcomes of this study will first be discussed in
relation to the findings from adult literature on the
psychotherapeutic process. A review of this literature by
Elliott and James (1989) will be used to compare the
findings of the present study with recent research with
adults. Next the experience of interviewing the children
will be discussed, followed by the study's limitations.
Finally, implications for further research, as well as for
psychotherapeutic treatment, will be made.
Comparison with Adult Research
When reviewing the literature concerning the client
experience in psychotherapy, Elliott and James (1989) found
that the experience, as expressed by the client, could be
grouped into three categories, the clients' experience of
self, of the therapist, and of the psychotherapy. In
comparing the present study with adult research, I will
address each area.
Clients' Experience of Self
One aspect of the experience of self had to do with the
intentions or tasks the clients brought to psychotherapy.
In analyzing the studies, Elliott and James (1989) found
that the most commonly studied was understanding the self
and problems. Following, in decreasing order of frequency
found, were avoiding, getting a personal response from the
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therapist, feeling relieved or better, changing behavior,
getting therapist support, expressing feelings, and
following therapeutic directives or procedures.
The questions in the present study did not ask about
these topics directly, yet many of them were addressed in
the responses from the children. None of the children
talked in terms of understanding themselves, a level of
insightfulness which is beyond the concern of children
(Inhelder & Piaget, 1958). However, many children expressed
that psychotherapy made them feel better and that there was
an improvement in their behavior. They were very concerned
about getting a personal response from the therapist and
therapist support, aspects which I found to be the most
pronounced in their description of their experiences.
A second aspect of self experience studied was the
clients' feelings or states. These feelings can be an
extension of one's general state or can reflect therapeutic
benefit, such as hope (Elliott & James, 1989). The most
commonly measured states were anxious, hostile, depressed,
confident, weak, and physical discomfort. Many instruments
mentioned earlier, such as the Therapy Sessions Reports
(Orlinsky & Howard, 1975), measure the clients' feelings.
Although a few different feelings were mentioned, the
most prominent with the children was "happy". It seemed to
be a reflection of children's tendency to relate to the
97
present and to indicate that the experience of psychotherapy
was pleasant.
A third area of client experience was the client style
of self-relatedness. The most commonly studied element
(Elliott & James, 1989) was openness to therapeutic process
versus defensiveness. In adult research the primary measure
of this was through the perspective of an observer. In the
present study, the attribute was reported by the client. As
was discovered, the children's level of openness, for the
most part, seemed more dependent upon their level of trust
in the particular therapist than on a predisposition to
trust.
The fourth aspect of client experience was in relating
to the therapist. Adult measures had most frequently used
the dimension of interpersonal liking versus disliking.
Client attraction/flirtatiousness had received the most
attention in adult research. With the eight to 13-year-old
age group, this did not appear to be a factor. By the
children's responses to whom the therapists were most like,
it appeared that children, for the most part, view
therapists as more of an authority figure.
The final component of the client experience was the
issues which the clients brought to treatment. "These
issues are the real substance of therapy, from the client's
point of view, as opposed to the relatively content-free
process variables most often studied by process researchers"
98
(Elliott & James, 1989, p. 452). Adult issues most commonly
found were concerns with intimacy, assertion,
sociability/openness, and guilt/conscience.
It was interesting that although none of the children
were self-referred, the majority were very aware of their
reason for being in psychotherapy in terms of their
behavior. Most of the children's issues related to self-
control. They were also cognizant of changes taking place
in behavioral areas. The need to increase self-esteem was
stated in many of their counseling goals. This, being
something not as easily observed, was an area in which they
didn't verbalize an awareness.
Client Experiences of Therapist
In adult literature, clients' experiences of what
therapists were doing (actions) or trying to do (intentions)
had received little attention (Elliott & James, 1989). Of
the studies that had been conducted, those aspects which had
been most frequently been identified were guiding client
behavior, supporting/reassuring, confronting/disagreeing,
revealing, and explaining. In the present study, the
consensus in the data in terms of psychotherapy was that the
therapists were teaching the clients how to behave or what
to do. The children thought the therapists were trying to
help them to "be better".
The predominant area of study in the adult client
experiences of the therapist had been in perceptions of
99
therapist characteristics. The most commonly studied areas
had been with acceptance/warmth, concerned interest,
expert/competent, confidence, empathy, involvement,
independence-encouraging, and genuine/trustworthy. Negative
areas studied had been uninterested/distant,
critical/hostile, and authoritarian.
Research with adults (Orlinsky & Howard, 1986) had
found that, although Rogers' (1957) conditions of empathy,
genuineness, and unconditional personal regard may not be
necessary and sufficient conditions for therapeutic change,
they definitely make a contribution to the relationship
which cannot be ignored. This was supported in the present
study. The children's emphasis on the importance of the
therapist being a "real person" (genuine), the importance of
attention and understanding (empathy), and the importance of
being treated as a person of worth (unconditional personal
regard) certainly corresponded to Rogers' model.
Client Experiences of Treatment
The final consideration of the clients' perceptions was
in the area of impact/satisfaction/outcome and helpful
aspects of therapy. Although the present study was
concerned with the process of psychotherapy, as previously
discussed, the outcome of psychotherapy is only a fine line
away. In the present study, many of the children reported
that they thought their psychotherapeutic experiences were
helpful. From the data, it was concluded that this was
100
primarily associated with the quality of the relationship.
This was in agreement with many adult studies.
Orlinsky and Howard (1986), in their review of process
and outcome in psychotherapy, stated a substantial number of
studies had concluded that the relationship of the
participants had a greater impact on the outcome than the
techniques used. Lorr (1965), in a study of clients'
perceptions of their therapists, found that improvement
related significantly to the characteristics of acceptance
and understanding. In Feifel and Eells (1963) study, it was
found whereas therapists emphasized technique and support as
being most beneficial, the clients focused on the
"importance of sharing uncertainties and urgencies with an
individual who will listen with respect and treat with
dignity their person" (p. 317). Additionally, it was found
(Strupp, Wallach, & Wogan, 1964) that "a warm, respectful,
unstudied attitude" (p. 19) on the part of the therapist was
the greatest indicator of change. The study concluded, "A
conservative interpretation of these results would suggest
that the existence of a generally positive relationship
between therapist and patient is the best single predictor
of therapeutic success" (p. 30). The present study
supported all of these findings.
An area not discussed in the review, but which I found
to be very interesting in the present study was that of
"expressing feelings". Although children's therapy spends a
101
lot of time in activities, many of the children found
expressing their feelings, the talking part of therapy, to
be what was most beneficial to them. It appears that,
although children may need time in order to be able to do
so, the opportunity to talk to another person about one's
concerns is a major healing part of psychotherapy, as in
adults' experiences.
An area not predominant in the Elliott and James (1989)
review, but which I would like to address, was the area of
client factors which affect change. It has been estimated
that about one-third of treatment outcome is due to the
therapist and two-thirds is due to the client (Norcross,
1986). According to Highlen and Hill (1984), one of the
personality variables that influenced outcome was the
client's ability to get along with others, to be able to
form a satisfactory relationship, and to be open to
another's suggestions.
What made the factor of client characteristics in
establishing a relationship, and consequently affecting
change, stand out for me was the interview with Richie, the
boy who had such a negative view of therapists. Although I
could have sworn I was unaffected by his attitude, when I
transcribed his interview, I was shocked to find my tone of
voice with Richie was different from all of the other
interviews. I have quite a girlish voice, so the tone is
usually nonthreatening. However, the "edge" I had in my
102
voice when talking to Richie could easily have been
interpreted as judgmental and disapproving. Although my
voice was back to normal by the end of the interview, I must
admit that I wouldn't have positive feelings toward a person
who talked to me in that tone of voice either.
The Interview Process
The children's responses to being interviewed were
better than expected. Their willingness to cooperate
exceeded what was anticipated. A factor, which appeared to
distinguish the children in this study from children in
general, was their previous experiences in talking with
adults. The interview session was similar in setting to the
counseling experiences they had at the school. All of the
children consequently seemed relaxed with the situation.
The possible exception was Jon, who as previously stated,
seemed guarded. However, this was also the way he was
reported by his counselor as appearing in his counseling
sessions.
The findings of this study, therefore, lend support to
the possibility of using qualitative methodology of
interviewing in research with children. With the growing
number of children seeking psychological services, more
research is needed in the area of child psychotherapy.
Interviewing the children seems to be an appropriate source,
as well as a rich source, of information. The understanding
103
the children had of their experiences surpassed what they
usually convey in the course of psychotherapy.
Both of the eight-year-olds in the study had difficulty
with the questions. Part of the reason could have been that
they are both diagnosed as having Attention Deficit
Hyperactivity Disorder, a condition which often makes the
children less mature in certain tasks than others their age.
It could also have been that the questions were too
sophisticated for the cognitive abilities of eight-year-
olds .
The first planned question and the added last question
(Is there anything you wish to add that wasn't covered?)
were both intentionally broad. The first question was
general in order to obtain the child's view of psychotherapy
with no distinctive prompt. The last question was also to
allow the children to say anything connected to the topic
that they wished. For the most part, the children had
difficulty with these questions. They were better able to
answer questions that were more specific and then to further
elaborate on them.
Limitations
Frequently in qualitative research, data continue to be
collected until what one finds appears to be redundant
(Glaser & Strauss, 1967). However, the approach of this
study was not the saturation approach. A set number of
children were interviewed in an attempt to discover themes.
104
The findings, therefore, are not intended to be generalized.
The purpose of the findings was to discover the experience
of some children and to use these findings as a foundation
for further studies.
Most of the children in this study were learning
disabled. Because of this, their conceptualization of the
psychotherapeutic experience along with their ability to
describe it were less sophisticated than those of the same
age group without learning disabilities. Part of my
excitement about the responses of these participants was
based on the experience with my own clients who are
adolescents. For the most part, the answers of this study's
participants showed much better understanding than I
anticipated. Nathan, whom I quoted extensively, is much,
much more articulate than my clients who are 17 and 18 years
old. Although it would have been thrilling to have all
participants with Nathan's ability to communicate, I feel
the responses of the others are well within the range of the
sophistication of the population one would see in a clinical
setting. This, of course, is well below the level one would
expect to find with the adult population most frequently
used in research.
The results of research are influenced by the
researcher's perceptions. As a counselor at the school, I
know that the majority of the students eagerly look forward
to counseling. In the situation where counseling is taking
105
them away from classroom time, rather than play time as
could be the case with outpatient services, being in the
counseling session is rewarding. Consequently, their
positive comments about counseling were not surprising. I
think the positive comments were made for this reason,
rather than as a result of a social desirability factor, as
these children are quite oppositional and do not seek adult
approval in the way an average child does.
My perspective as a counselor at the school also
affected the category selection. Some of the
conceptualization was based predominantly on Nathan's
comments. It seemed to me that the other children concurred
with his observations, but were unable to put their thoughts
into words as well as he.
The children's views of play were accurate based on the
cognitive behavioral orientation of the school. To get an
understanding of play therapy, wherein the play helps the
child to work through his or her problems, a study needs to
be conducted where a more psychodynamic approach is used.
The process of psychotherapy as described by these
children was very limited. Although they had a variety of
diagnoses, most of the counseling goals of the children were
the same. They were primarily to increase self-esteem and
to reduce inappropriate behaviors. They did not express how
these goals were addressed. This may be because the proper
questions were not asked to evoke this information, the
106
children do not understand this aspect of psychotherapy,
these particular children were unable to relate this part of
the experience, or it is relatively unimportant to children.
Further study is needed to clarify the reasons for the
present responses.
Implications
This study supports the success of interviewing
children directly to ascertain their opinions and
perceptions. Even with these children's limited
expressiveness, pertinent concepts emerged. Further studies
interviewing other children, perhaps more extensively,
should increase the knowledge of this particular subject, as
well as other subjects of interest.
Additionally, variables of the psychotherapeutic
experience, which show importance to children, have been
discovered in this study. These variables may be used in
further studies, where an approach other than the interview
method, would be more expedient.
The implications for treatment were the most exciting
aspect of this study for me. My interest in this also
influenced the quotations, which were chosen to be
presented. I found not only the children's descriptions,
but also their advice, to be invaluable in the understanding
of psychotherapeutic treatment for children.
The findings of this study offer valuable information
for therapists to keep in mind. Much good advice may be
107
found in the comments made by the children in the result
section. General findings are that children like the
special attention received in psychotherapy. They want a
therapist who talks to them like a real person. Breaching
confidentiality affects children's level of trust negatively
more than anything else. Children are sensitive to body
language and environmental cues. Playing is important,
because it's fun, it makes one relax, and it gives children
an opportunity to learn to know the therapist. Children's
responses to receiving gifts or rewards are affected by
their attitude towards their counselors. Children find it
helpful to talk about their feelings. Establishing a good
relationship with the child is most important to ensure a
successful outcome.
108
References
Alexander, L. B., & Luborsky, L. (1986). The Penn help
alliance scales. In L. S. Greenberg, & W. M. Pinsof (Eds.),
The psychotherapeutic process: A research handbook (pp.
325-366). New York: Guilford Press.
Axline, V. M. (1950). Play therapy experiences as described
by child participants. Journal of Consulting Psychology.
14, 53-64.
Barrett-Lennard, G. T. (1962). Dimensions of therapist
response as causal factors in therapeutic change.
Psychological Monographs. 76 (43, Whole No. 562).
Barrett-Lennard, G. T. (1986). The Relationship Inventory
now: Issues and advances in theory, method, and use. In
L. S. Greenberg, & W. M. Pinsof (Eds.), The
psychotherapeutic process: A research handbook (pp. 439-
476). New York: Guilford Press.
Barrnett, R. J., Docherty, J. P., & Frommelt, G. M. (1991).
A review of child psychotherapy research since 1963.
Journal of the Academy of Child and Adolescent Psychiatry.
30, 1-14.
Bergman, D. V. (1951). Counseling method and client
responses. Journal of Consulting Psychology. 15. 216-224.
Bierman, K. L., & Schwartz, L. A. (1986). Clinical child
interviews: Approaches and developmental considerations.
Journal of Child and Adolescent Psychotherapy. 3, 267- 278.
Bloom, B. S. (1954). The thought process of students in
discussion. In S. J. French, (Ed.), Accent on teaching:
Experiments in general education. New York: Harper &
Brothers.
Bordin, E. S. (1979). The generalizability of the
psychoanalytic concept of the working alliance.
Psychotherapy: Theory. research, and practice. 16., 252-
260.
Butler, J. M., Rice, L. N., & Wagstaff, A. K. (1962). On
the definition of variables: An analogue of clinical
analysis. In H. H. Strupp and L. Luborsky (Eds.), Research
in psychotherapy (Vol. 2, pp. 178-205). Washington, DC:
American Psychological Association.
Carkhuff, R. R. (1969). Helping and human relations: A
primer for lay and professional helpers (Vols. 1 & 2). New
York: Holt, Rinehart, & Winston.
109
Casey, R. J., & Berman, J. S. (1985). The outcome of
psychotherapy with children. Psychological Bulletin. 98,
388-400.
Corey, G. (1991). Theory and Practice of Counseling and
Psychotherapy. Pacific Grove, CA: Brooks/Cole.
Edelbrock, C., Costello, A. J., Dulcan, M. K., Conover, N.
C., & Kala, R. (1986). Parent-child agreement on child
psychiatric symptoms assessed via structured interview.
Journal of Child Psychology and Psychiatry. 27, 181-190.
Elliott, R. (1986). Interpersonal process recall (IPR) as a
psychotherapy process research method. In L. S. Greenberg
and W. M. Pinsof (Eds.), The psychotherapeutic process: A
research handbook (pp. 503-527). New York: Guilford Press.
Elliott, R. & James, E. (1989). Varieties of client
experience in psychotherapy: An analysis of the
literature. Clinical Psychology Review. 9, 443-467.
Elliott, R., Hill, C. E., Stiles, W. B., Friedlander, M. L.,
Mahrer, A. R., & Margison, F. R. (1987). Primary therapist
response modes: Comparison of six rating systems. Journal
of Consulting and Clinical Psychology. 55. 218-223.
Ely, M., Anzul, M., Friedman, T., Garner, D., & Steinmetz,
A. M. (1991). Doing Qualitative research: Circles within
circles. London: Falmer.
Feifel, H., & Eells, J., (1963). Patients and therapists
assess the same psychotherapy. Journal of Consulting
Psychology. 27., 310-318.
Fetterman, D. M. (1989). Ethnography: Step by step.
Newbury Park, CA: Sage.
Finke, H. (1947). Changes in the expression of
emotionalized attitudes in six cases of play therapy.
Unpublished master's thesis, University of Chicago.
Friedlander, M. L. (1982). Counseling discourse as a speech
event: Revision and extension of the Hill Counselor Verbal
Response Category System. Journal of Counseling
Psychology. 29., 425-429.
Garbarino, J., Stott, F. M., & faculty of the Erikson
Institute (1992). What children can tell us: Eliciting.
interpreting. and evaluating critical information from
children. San Francisco: Jossey-Bass.
110
Garfield, S. L., & Bergin, A. E. (Eds.) (1986). Handbook of
psychotherapy and behavior change (3rd edition). New York:
Wiley.
Glaser, B., & Strauss, A. L. (1967). The discovery of
grounded theory: Strategies for Qualitative research.
Chicago: Aldine.
Glesne, C., & Peshkin, A. (1992). Becoming Qualitative
researchers: An introduction. White Plains: Longman.
Goldfried, M. R., Greenberg, L. S., Marmar, C. (1990).
Individual psychotherapy: Process and outcome. Annual
Review of Psychology. 41. 659-688.
Greenberg, L. S., & Pinsof, W. M. (1986). Process research:
Current trends and future perspectives. In L. S. Greenberg
and W. M. Pinsof (Eds.), The psychotherapeutic process: A
research handbook (pp. 131-159). New York: Guilford Press.
Heppner, P. P., Kivlighan, D. M., Jr., & Wampold, B. E.
(Ed.) (1992). Research design in counseling. Pacific
Grove, CA: Brooks/Cole. Chapter Fourteen: "Process
Research", pp. 320-372.
Herjanic, B., & Reich, W. (1982). Development of a
structured psychiatric interview for children: Agreement
between child and parent on individual symptoms. Journal of
Abnormal Child Psychology. 10. 307-324.
Highlen, P. S., & Hill, C. E. (1984). Factors affecting
client change in individual counseling: Current status and
theoretical speculations. In S. D. Brown and K. W. Lent
(Eds.), Handbook of Counseling Psychology (pp. 334-395).
New York: Wiley.
Hill, C. E. (1978). Development of a counselor verbal
response category system. Journal of Counseling Psychology.
25, 461-468.
Hill, C. E. (1983). Counseling process research:
Philosophical and methodological dilemmas. The Counseling
Psychologist. 10. 4, 7-19.
Hill, C. E. (1985). Manual for the Hill Counselor Verbal
Response Modes Category System (rev. ed.). Unpublished
manuscript, University of Maryland, College Park, MD.
Hill, C. E. (1986). An overview of the Hill counselor and
client verbal response modes category systems. In L. S.
Greenberg and W. M. Pinsof (Eds.), The psychotherapeutic
Ill
process: A research handbook (pp. 131-159). New York:
Guilford Press.
Hill, C. E. (1991). Almost everything you ever wanted to
know about how to do process research on counseling and
psychotherapy but didn't know who to ask. In C. E. Watkins,
Jr., & L. L. Schneiders (Eds.), Research in counseling (pp.
85-118). Hillsdale, NY: Lawrence Erlbaum.
Hill, C. E. (1992). An overview of four measures developed
to test the Hill process model: Therapist intentions,
therapist response modes, client reactions, and client
behaviors. Journal of Counseling & Development. 70. 728-
739.
Hill, C. E., & Corbett, M. M. (1993). A perspective on the
history of process and outcome research in counseling
psychology. Journal of Counseling Psychology. 40. 3-24.
Hill, C. E., Greenwald, C., Reed, K. R. , Charles, D.,
O'Farrell, M., & Carter, J. (1981). Manual for counselor
and client verbal response category systems. Columbus, OH:
Marathon Consulting and Press.
Hill, C. E., Helms, J. E., Spiegel, S. B., & Tichenor, V.
(1988). Development of a system for categorizing client
reactions to therapist interventions. Journal of
Counseling Psychology. 35, 27-36.
Hill, C. E., & O'Grady, K. E. (1985). List of therapist
intentions illustrated in a case study and with therapists
of varying theoretical orientations. Journal of Counseling
Psychology. 32., 3-22.
Horvath, A. O., & Greenberg, L. S. (1986). Development of
the Working Alliance Inventory. In L. S. Greenberg and W.
M. Pinsof (Eds.), The psychotherapeutic process: A
research handbook (pp. 529-556). New York: Guilford Press.
Hughes, J. N., & Baker, D. B (1990). The clinical child
interview. New York: Guilford Press.
Inhelder, B., & Piaget, J. (1958). The growth of logical
thinking from childhood to adolescence. New York: Basic
Books.
Kagan, N. (1975). Interpersonal process recall: A method
of influencing human interaction. (Available from N. Kagan,
434 Erickson Hall, College of Education, Michigan State
University, East Lansing, MI 48824).
112
Kaser-Boyd, N., Adelman, H. S., Taylor, L., & Nelson, P.
(1986). Children's understanding of risks and benefits of
psychotherapy. Journal of Clinical Child Psychology. 15.
165-171.
Kazdin, A. E. (1988). Child psychotherapy; Developing and
identifying effective treatments. New York: Pergamon
Press.
Kazdin, A. E. (1993). Psychotherapy for children and
adolescents: Current progress and future research
directions. American Psychologist. 48. 644-657.
Kazdin, A. E., Bass, D., Ayers, W. A., & Rodgers, A. (1990).
Empirical and clinical focus of child and adolescent
psychotherapy research. Journal of Consulting and Clinical
Psychology. 58, 729-740.
Kazdin, A. E., Esveldt-Dawson, K., Unis, A. S., &
Rancurello, M. D. (1983). Child and parent evaluations of
depression and aggression in psychiatric inpatient children.
Journal of Abnormal Child Psychology. 11. 401-413.
Klein, M. H., Mathieu, P. L., Gendlin, E. T., & Kielser, D.
J. (1970). The Experiencing Scale: A research and training
manual (Vols. 1 & 2). Madison, WI: Wisconsin Psychiatric
Institute, Bureau of Audio Visual Instruction.
Klein, M. H., Mathieu-Coughlan, P., & Kiesler, D. J. (1986).
The experiencing scale. In L. Greenberg and W. Pinsof
(Eds.), The psychotherapeutic process: A research handbook
(pp. 21-72). New York: Guilford Press.
Landisberg, S. & Snyder, W. U. (1946). Nondirective play
therapy. Journal of Clinical Psychology. 2, 203-214.
Lebo, D. (1953). The present status of research on
nondirective play therapy. Journal of Consulting
Psychology. 17, 177-183.
Lebo, D. (1955). Quantification of the nondirective play
therapy process. The Journal of Genetic Psychology. 86.
375-378.
Lorr, M. (1965). Client perceptions of therapists: A study
of the therapeutic relation. Journal of Consulting
Psychology. 29. 146-149.
Marmar, C. R., Horowitz, M. J., Weiss, D. S., & Marziali, E.
(1986). The development of the therapeutic alliance rating
system. In L. Greenberg and W. Pinsof (Eds.), The
113
psychotherapeutic process: A research handbook (pp. 367-
390). New York: Guilford Press.
Marshall, C., & Rossman, G. B. (1989). Designing
qualitative research. Newbury Park: Sage.
Martin, J. (1984). The cognitive mediational paradigm for
research on counseling. Journal of Counseling Psychology.
31/ 558-571.
Martin, J., Martin, W., Meyer, M., & Slemon, A. (1986).
Empirical investigation of the cognitive mediational
paradigm for research on counseling. Journal of Counseling
Psychology. 33, 115-123.
McCracken, G. (1988). The long interview. Newbury Park,
CA: Sage.
Moustakas, C. E., & Schalock, H. D. (1955). An analysis of
therapist-child interaction in play therapy. Child
Development. 26. 143-157.
Moustakas, C. E., Sigel, I. E., & Schalock, H. D. (1956).
An objective method for the measurement and analysis of
child-adult interaction. Child Development. 27. 109-134.
Norcross, J. C. (1986). Eclectic psychotherapy: An
introduction and overview. In J. C. Norcross (Ed.),
Handbook of Eclectic Psychotherapy (pp. 3-24). New York:
Brunner/Mazel.
Orlinsky, D. E., & Howard, K. I. (1975). Varieties of
psychotherapeutic experience. New York: Teachers College.
Orlinsky, D. E., & Howard, K. I. (1986). The relation of
process to outcome in psychotherapy. In S. L. Garfield, &
A. E. Bergin (Eds.), Handbook of psychotherapy and behavior
change. (2nd ed., pp. 283-330). New York: Wiley.
Parker, W. C. (1984). Interviewing children: Problems and
promise. Journal of Negro Education. 53. 18-28.
Patton, M. Q. (1987). How to use qualitative methods in
evaluation. Newbury Park, CA: Sage.
Polkinghorne, D. E. (1991). Qualitative procedures for
counseling research. In C. E. Watkins, & L. L. Schneider
(Eds.), Research in counseling (pp. 163-207). Hillsdale,
NJ: Lawrence Erlbaum.
Polkinghorne, D. E. (1989). Phenomenological research
methods. In R. S. Valle & S. Hallig (Eds.), Existential-
114
phenomenological perspectives in psychology (pp. 41-60).
New York: Plenum Press.
Porter, E. H., Jr. (1943). The development and evaluation
of a measure of counseling interview procedures.
Educational and Psychological Measurement. 3, 105-126.
Rennie, D. L. (1994). Clients' deference in psychotherapy.
Journal of Counseling Psychology. 41. 427-437.
Rhodes, R. H., Hill, C. E., Thompson, B. J., & Elliott, R.
(1994). Client retrospective recall of resolved and
unresolved misunderstanding events. Journal of Counseling
Psychology. 41. 473-483.
Rice, L. N., & Kerr, G. P. (1986). Measures of client and
therapist vocal quality. In L. Greenberg & W. Pinsof
(Eds.) , The psychotherapeutic process: A research handbook
(pp.73-105). New York: Guilford Press.
Robinson, F. R. (1950). Principles and procedures in
student counseling. New York: Harper and Brothers.
Rogers, C. (1942). The use of electronically recorded
interviews in improving psychotherapeutic techniques.
American Journal of Orthopsychiatry. 12. 429-434.
Rogers, C. R. (1951). Client-centered therapy: Its current
practice, implications. and theory. Boston: Houghton
Mifflin.
Rogers, C. R. (1957). The necessary and sufficient
conditions of therapeutic personality change. Journal of
Consulting Psychology. 21. 95-103.
Seeman, J. (1949). A study of the process of non-directive
therapy. Journal of Consulting Psychology. 13. 157-168.
Smith-Acuna, S., Durlak, J. A., & Kaspar, C. J. (1991).
Development of child psychotherapy process measures.
Journal of Clinical Child Psychology. 20, 126-131.
Snyder, W. U. (1945). An investigation of the nature of
nondirective psychotherapy. Journal of General Psychology.
33, 193-223.
Snyder, W. U. (1963). Dependency in psychotherapy: A
casebook. New York: Macmillan.
Stiles, W. B. (1979). Verbal response modes and
psychotherapeutic technique. Psychiatry. 42., 49-62.
115
Stiles, W. B., & Snow, J. S. (1984). Counseling session
impact as viewed by novice counselors and their clients.
Journal of Counseling Psychology. 31. 3-12.
Strauss, A., & Corbin, J. (1990). Basics of Qualitative
research: Grounded theory procedures and technigues.
Newbury Park, CA: Sage.
Strong, S. R. (1968). Counseling: An interpersonal
influence process. Journal of Counseling Psychology. 15.
215-224.
Strupp, H. H. (1955). An objective comparison of Rogerian
and psychoanalytic techniques. Journal of Consulting
Psychology. 19. 1-7.
Strupp, H. H. (1957). A multidimensional analysis of
therapist activity in analytic and client-centered therapy.
Journal of Consulting Psychology. 21. 301-308.
Strupp, H. H., Wallach, M. S., & Wogan, M. (1964).
Psychotherapy experiences in retrospect: Questionnaire
survey of former patients and their therapists.
Psychological Monographs: General and Applied. 78, p. 1-45.
Tracey, T. J. (1985). Dominance and outcome: A sequential
examination. Journal of Counseling Psychology. 32. 119-122.
Tracey, T. J. (1987). Stage differences in the dependencies
of topic initiation and topic following behavior. Journal
of Counseling Psychology. 34. 123-131.
Tracey, T. J., & Ray, P. B. (1984). Stages of successful
time-limited counseling: An interactional examination.
Journal of Counseling Psychology. 31. 13-27.
Truax, C. B., & Carkhuff, R. R. (1967). Toward effective
counseling and psychotherapy: Training and practice.
Chicago: Aldine.
Wampold, B. E., & Poulin, K. L. (1992). Counseling research
methods: Art and artifact. In S. D. Brown & R. W. Lent
(Eds.), Handbook of counseling psychology (2nd ed.) (pp.71-
109). New York: John Wiley & Sons.
Watson, J. C., & Rennie, D. L. (1994). Qualitative analysis
of clients' subjective experience of significant moments
during the exploration of problematic reactions. Journal of
Counseling Psychology. 41. 500-509.
Watzlawick, P., Beavin, J. H., & Jackson, D. D. (1967).
Pragmatics of human communication: A study of
116
interactional patterns. pathologies, and paradoxes. New
York: Norton.
Weissman, M. M., Orvaschel, H., & Padian, N. (?) Children's
symptom and social functioning self-report scales:
Comparison of mothers' and children's reports. The Journal
of Nervous and Mental Disease. 168. 736-740.
Wright, L., Truax, C. B., & Mitchell, K. M. (1972).
Reliability of process ratings of psychotherapy with
children. Journal of Clinical Psychology. 28. 232-234.
Yarrow, L. J. (1960). Interviewing children. In P. J.
Mussen (Eds.), Handbook of research methods in child
development (pp. 561-602). New York: Wiley.
117
APPENDIX A
Research Introductory Letter
Dear Parent or Guardian:
I am conducting a research study involving the children
who receive educational and counseling services from the
Switzer Center. The purpose of this research is to
understand children's experience of psychotherapy
(counseling).
I would like your child to participate in an interview,
in which he or she will be asked about his or her experience
in counseling. The interview will be recorded to provide a
complete record of what was said. It will take
approximately 30 minutes.
Your child's answers and comments in the interview and
any information obtained about your child will remain
confidential. No information obtained in this study will be
reported in any way that you, your child, or other
participants can be identified. The exception to this is if
the child reports something which would lead to the
reasonable suspicion of child abuse. By state law, persons
who work with children are mandated to report such
incidences.
Your child's participation in this research study is
voluntary. You have the right to refuse to have your child
participate in the research study without penalty or loss of
benefits or services to which you or your child are
entitled.
Enclosed is a form for you to sign, which will give
your consent for your child to participate in the study.
Please sign it and return it in the addressed, stamped
envelope. Your child will also be given a similar form to
sign at the time of the interview. If you have any
guestions about this research study, please call Switzer
Center at (310) 328-3611 and leave a message for Judy
Mahoney to return your call.
A summary of the results of this research will be
available when the study is completed. If you would like to
receive a summary of the results, please provide me with a
self-addressed, stamped envelope.
118
Thank you for your participation in this important
study.
Judy R. Mahoney, M.A.
Principal Investigator
Doctoral Candidate
Counseling Psychology
University of Southern
California
(310) 328-3611
119
APPENDIX B
Parent or Guardian Consent Form
My child has been asked to participate in a research
project which will study what counseling is like for
children.
He/she will be asked to describe counseling in one to
four interviews. Each will take about 30 minutes.
I understand that this interview will be recorded.
I understand that my child's answers and any
information about my child will be kept private.
I understand that I can choose whether or not I want my
child to be in this study without penalty or loss of
benefits or services to which I or my child are entitled.
My child may quit the interview at any time.
I understand that my child is to let Judy Mahoney know
if he/she is having any uncomfortable feelings and that Judy
Mahoney will notify my child's counselor about this.
I understand that this interview is not a counseling
session, but is just asking my child's opinion.
I agree to allow Judy R. Mahoney, M.A. to include my
child in this research study.
Sign your name here Date
Donald E. Polkinghorne, Ph.D. Judy R. Mahoney, M.A.
Faculty Advisor Principal Investigator
Counseling Psychology Doctoral Candidate
University of Southern Counseling Psychology
California University of Southern
California
APPENDIX C
Participant Information
(To be filled out by the counselor)
Counselor Information
1. How many children are you presently seeing?
2. What is your training, i.e., education and past
experience?
3. What is your orientation?
Client Information
1. How old is the child?
2. How was the child referred to Switzer Center?
3. How many counselors has he/she had?
4. How long has this child been in counseling?
5. What is this child's diagnosis?
6. What techniques have you used with this child in
counseling?
7. How does the child relate to you?
121
APPENDIX D
Child Consent Form
I have been asked to participate in a research project
which will study what counseling is like for children.
I will be asked to describe counseling in one, two,
three, or four interviews. Each will take about 30 minutes.
I understand that this interview will be recorded.
I understand that my answers and any information about
me will be kept private.
I understand that I can choose whether or not I want to
be in this study. I may quit the interview at any time.
I understand that I am to let Judy Mahoney know if I am
having any uncomfortable feelings and that Judy Mahoney will
let my counselor know.
I understand that this interview is not a counseling
session, but is just asking my opinion.
I agree to allow Judy R. Mahoney, M.A. to include me in
this research study.
I understand that by signing this form, I am saying
that I agree to participate in this study.
Sign your name here Date
Donald E. Polkinghorne, Ph.D. Judy R. Mahoney, M.A.
Faculty Advisor Primary Investigator
Counseling Psychology Doctoral Candidate
University of Southern Counseling Psychology
California University of Southern
California
APPENDIX E
Interview Questions
Pretend that a new kid has come to school who has never
had counseling. How would you describe to the kid what
counseling is like?
What is the reason people go to counseling?
What do you do during counseling?
What is the counselor like?
In what way do you think going to counseling changes
people?
How do you feel when you are at counseling?
What is the thing about counseling that helps you the
most?

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Asset Metadata

Creator Mahoney, Judy Renee (author)

Core Title Interviews with children: how they perceive psychotherapy

Degree Doctor of Philosophy

Degree Program Counseling Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Psychology, clinical,psychology, developmental

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Polkinghorne, Donald E. (committee chair), O'Keefe, Maura (committee member), Stromquist, Nelly (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c20-606208

Unique identifier UC11227065

Identifier 9616986.pdf (filename),usctheses-c20-606208 (legacy record id)

Legacy Identifier 9616986.pdf

Dmrecord 606208

Document Type Dissertation

Rights Mahoney, Judy Renee

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA