CONTEMPORARY

CASE STUDIES IN CLINICAL MENTAL

HEALTH FOR CHILDREN AND
ADOLESCENTS
 CONTEMPORARY
CASE STUDIES IN CLINICAL MENTAL
HEALTH FOR CHILDREN AND
ADOLESCENTS

JENNIFER N. BAGGERLY
University of North Texas at Dallas

ATHENA A. DREWES
New York Association for Play Therapy

ROWMAN & LITTLEFIELD

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Names: Baggerly, Jennifer, editor. | Drewes, Athena A., 1948– editor.
Title: Contemporary case studies in clinical mental health for children and adolescents /
Jennifer N. Baggerly, University of North Texas at Dallas, Athena A. Drewes, New York
Association for Play Therapy.
Description: Lanham : Rowman & Littlefield, [2024] | Includes bibliographical references and
index.
Identifiers: LCCN 2023038904 (print) | LCCN 2023038905 (ebook) | ISBN 9781538173626
(hardback) | ISBN 9781538173633 (paperback) | ISBN 9781538173640 (epub)
Subjects: LCSH: Mental illness—Diagnosis. | Adolescent psychotherapy. | Psychology, Pathological.
Classification: LCC RJ503.5 .C66 2024 (print) | LCC RJ503.5 (ebook) | DDC
616.89/140835—dc23/eng/20231031
LC record available at https://lccn.loc.gov/2023038904
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I, Jennifer Baggerly, dedicate this book to my father and stepmother, Dr.
Leo Baggerly and Mrs. Carole Baggerly, for their lifetime of support and
inspiration to me and my daughter, Katelyn Jean Baggerly.

I, Athena Drewes, dedicate this book to my husband,

Dr. (Nelson) Keith Seibert, whose love and support
make my life full of wonderful adventures.
 Brief Contents

Foreword xxiii
Edward (Franc) Hudspeth

Preface xxv
Jennifer N. Baggerly and Athena A. Drewes

Acknowledgments xxxi

PART I: CHILDREN
1 Depression: Child-­Centered Play Therapy with a Biracial Child 3
    Peggy L. Ceballos and Marium Sadiq

2 Adjustment Difficulties: Child-­Centered Play Therapy and

Critical Race Theory with a Biracial Child 19
    Keith I. Raymond and Angela I. Sheely-­Moore

3 Domestic Violence: Trauma-­Informed Child-­Centered Play

Therapy with a White Child 31
   Jennifer N. Baggerly

4 Disruptive Behavior after January 6 Washington, DC, Uprising:

Cognitive Behavior Play Therapy with a White Child 43
   Athena A. Drewes

5 ADHD and COVID-19: Cognitive Behavioral Play Therapy

with an African American Child 61
   Lisa Remey

6 Anxiety and Asian Hate: Adlerian Play Therapy with

a Chinese American Child 77
   Kristin K. Meany-­ Walen

7 Autism and Neurodivergence: Group Play Therapy

with Children 95
   Robert Jason Grant

8 Grief after COVID-19 and Gun Violence: Sand Tray Therapy

with a Mexican American Child 109
    Clarissa L. Salinas and Jennifer N. Baggerly

9 Family Stress: Filial Therapy with an Indigenous

American Family 123
   Risë VanFleet

vii
viii Brief Contents

10 Divorced Parents: Child-­Parent Relationship Therapy with Parents

of a White Child 137
    Dalena Dillman Taylor and Caitlin Frawley

PART II: ADOLESCENTS

11 Depression: Cognitive Behavior Therapy and Expressive
Arts Therapy with a Chinese American Adolescent 157
    Yu-­Fen Lin and Chi-­Sing Li

12 Social Anxiety: Mindfulness-­Based Cognitive Behavior

Therapy with a Pakistani American Adolescent 169
    Yu-­Fen Lin and Samuel Bore

13 Divorce and Political Extremist Groups: Cognitive Behavior

Therapy and Expressive Arts with a White Adolescent 183
   Jennifer N. Baggerly

14 Sexual Abuse: Trauma-­Focused Cognitive Behavior Therapy

and Creative Approaches with a Biracial Adolescent 197
   Felicia R. Neubauer

15 Self-­Harm: Dialectical Behavior Therapy with an African

American Adolescent 211
    Anelie Etienne and Domonique Messing

16 Tourette Syndrome and Risk of Exploitation: Equine Assisted

Family Play Therapy with a White Adolescent 223
   Tracie Faa-­ Thompson

17 Eating Disorders: Enhanced Cognitive Behavior Therapy

with a Mexican American Adolescent 235
   Sara Cantu

18 Substance Use Disorder: Motivational Interviewing and

Creative Approaches with an African American Adolescent 247
    Allison Crowe and Jason O. Perry

19 LGBTQ: Gestalt Therapy and Liberatory Approaches with

a Dominican American Adolescent 259
    Ana Guadalupe Reyes

20 Gender: Narrative Therapy with Parents of a Nonbinary

Transgender Korean American Adolescent 273
   Brooks Bull

Index 287

About the Editors 295

About the Contributors 297

 Contents

Foreword xxiii
Edward (Franc) Hudspeth

Preface xxv
Jennifer N. Baggerly and Athena A. Drewes
Inspiration xxv
Book Chapter Authors xxvi
What the Book Is Not xxvi
What the Book Is xxvii
Structure for Book Chapters xxvii
Begin with Case Studies xxvii
Brief Overview of Issues and Treatment Approaches xxvii
Treatment Goals and Objectives xxviii
Session Description and Transcript Analysis xxviii
Ethical and Cultural Considerations xxix
Parent and Teacher Consultation xxix
Sample Case Notes xxix
Resources xxix
Discussion Questions xxx
Our Hope xxx

Acknowledgments xxxi

PART I: CHILDREN
1 Depression: Child-­Centered Play Therapy with a Biracial Child 3
    Peggy L. Ceballos and Marium Sadiq
Childhood Depression 3
Child-­Centered Play Therapy (CCPT) 5
CCPT with Childhood Depression 6
Case Study Application 7
Treatment Process 7
Ethical and Cultural Considerations 11
Parent and Teacher Consultations 12
Conclusion 12
Sample Case Notes 13
Session 1 13
Session 8 13

ix
x Contents

Resources 14
For Professionals 14
For Children 14
For Parents 14
Discussion Questions 14
References 15

2 Adjustment Difficulties: Child-­Centered Play Therapy

and Critical Race Theory with a Biracial Child 19
    Keith I. Raymond and Angela I. Sheely-­Moore
Racial Identity Development in Children 19
Child-­Centered Play Therapy 21
Critical Race Theory 21
Case Study Application 22
Session 1 22
Treatment Goals 23
Session 2 24
Ethical and Cultural Considerations 25
Parent Consultations 26
Conclusion 26
Sample Case Notes 27
Session 1 27
Session 2 27
Resources 28
For Mental Health Professionals 28
For Children 28
For Caregivers 28
Discussion Questions 28
References 28

3 Domestic Violence: Trauma-­Informed Child-­Centered

Play Therapy with a White Child 31
   Jennifer N. Baggerly
Impact of Domestic Violence on Young Children 31
Impact of COVID-19 Pandemic on Young Children 32
Trauma-­Informed Child-­Centered Play Therapy 32
Case Study Application 34
Session Overview 34
Ethical and Cultural Considerations 36
Parent Consultations 37
Conclusion 38
Sample Case Notes 38
Session 3 38
Session 10 38
 Contents  xi

Resources 39
For Professionals 39
For Children 39
For Parents 39
Discussion Questions 39
References 40

4 Disruptive Behavior after January 6 Washington, DC,

Uprising: Cognitive Behavior Play Therapy with a White Child 43
   Athena A. Drewes
Disruptive Behaviors in Children 44
Attention-­Deficit/Hyperactivity Disorder (ADHD) 44
Impact of Viewing Media Violence 45
Family Setting 46
Cognitive Behavioral Play Therapy 46
School-­Based Cognitive Behavioral Play Therapy 47
CBPT Techniques 47
Case Study Application 48
CBPT Strategies 49
Session 1 49
Session 2 50
Session 3 50
Session 4 51
Session 5 51
Session 6 52
Session 7 53
Session 8 53
Ethical and Cultural Considerations 53
Parent Consultations 54
Conclusion 55
Sample Case Notes 55
Session 4 55
Resources 56
For Professionals 56
For Children 56
For Parents 57
Discussion Questions 57
References 57

5 ADHD and COVID-19: Cognitive Behavioral Play Therapy

with an African American Child 61
   Lisa Remey
Attention-Deficit/Hyperactivity Disorder 61
Cognitive Behavioral Therapy 62
Cognitive Behavioral Play Therapy 63
xii Contents

Collaborative Session Structure 64

Strategies 64
Case Study Application 65
Session 1 65
Session 2 67
Session 3 69
Session 4 70
Ethical and Cultural Considerations 70
Parent Consultations 70
Conclusion 71
Sample Case Notes 71
Parent Consultation Session 71
Session 1 71
Session 2 72
Session 3 72
Session 4 72
Resources 73
For Professionals 73
For Parents 73
Discussion Questions 73
References 73

6 Anxiety and Asian Hate: Adlerian Play Therapy with

a Chinese American Child 77
   Kristin K. Meany-­ Walen
Chinese Culture and Virtues 77
Anxiety 78
Adlerian Play Therapy 78
View of Children 79
Four Phases of AdPT 80
Case Study Application 82
Client Conceptualization 82
Treatment Goals and Objectives 83
Treatment Process 84
Phase 1 85
Phase 2 86
Phase 3 87
Phase 4 89
Ethical and Cultural Considerations 90
Parent and Teacher Consultations 90
Conclusion 90
Session Notes 91
Huan, 1/26/2023, 4 p.m. 91
Hoops of Control 91
Security/Insecurity Blanket 92
 Contents  xiii

Discussion Questions 93
References 94

7 Autism and Neurodivergence: Group Play Therapy

with Children 95
   Robert Jason Grant
Autistic and Other Neurodivergent Children 96
Group Approach 96
Integrative Play Therapy 96
AutPlay Therapy 97
The Neurodiversity Paradigm 98
Case Study Application 99
Session 1 99
Later Sessions 101
Last Session 102
Ethical and Cultural Considerations 103
Parent Consultations 103
Conclusion 104
Sample Case Notes 104
Group Meeting 1 104
Group Meeting 5 104
Resources 105
For Professionals 105
For Children 105
For Parents 105
Discussion Questions 105
References 106

8 Grief after COVID-19 and Gun Violence: Sand Tray Therapy

with a Mexican American Child 109
    Clarissa L. Salinas and Jennifer N. Baggerly
Grief and Traumatic Grief 109
COVID-19 109
Grief 110
Community Violence 111
Traumatic Grief 111
Sand Tray Therapy 111
Case Study Application 114
Session 1 114
Session 2 116
Ethical and Cultural Considerations 117
Parent Consultations 117
Conclusion 118
Sample Case Notes 118
Session 1 118
xiv Contents

Session 4 119
Resources 119
For Professionals 119
For Children 119
For Parents 119
Discussion Questions 120
References 120

9 Family Stress: Filial Therapy with an Indigenous

American Family 123
   Risë VanFleet
Indigenous Cultural and Environmental Context 123
Filial Therapy 125
Case Study 127
Case Conceptualization 127
Treatment Goals 127
FT Treatment Process 128
Beginning Training Sessions 128
Office-­Based Parent-­Child Play Sessions 130
Home-­Based Parent-­Child Play Sessions 132
Ethical and Cultural Considerations 132
Conclusion 133
Sample Case Notes 133
Resources 134
For Professionals 134
For Parents 134
Discussion Questions 134
References 135

10 Divorced Parents: Child-­Parent Relationship Therapy with Parents

of a White Child 137
    Dalena Dillman Taylor and Caitlin Frawley
Impact of Divorce on Children 138
Child-­Parent Relationship Therapy 138
Case Study Application 140
Initial Intake Session 140
Treatment Objectives 141
Session 1 141
Session 2 142
Session 3 142
Session 4 143
Session 5 144
Session 6 144
Session 7 145
 Contents  xv

Session 8 146
Session 9 146
Session 10 146
Ethical and Cultural Considerations 146
Conclusion 148
Sample Case Note 149
Resources 150
For Professionals 150
For Parents 150
Discussion Questions 150
References 151

PART II: ADOLESCENTS

11. Depression: Cognitive Behavior Therapy and Expressive
Arts Therapy with a Chinese American Adolescent 157
    Yu-­Fen Lin and Chi-­Sing Li
Depression in Adolescents 158
COVID-19 and Adolescent Mental Health 159
Asian Culture and Mental Health Stigma 159
Cognitive Behavior Therapy and Expressive Arts Therapy 159
Case Study Application 161
Session 1 161
Sessions 2 and 3 162
Case Conceptualization and Treatment Goals 163
Later Sessions 163
Ethical and Cultural Considerations 164
Parent Consultations 164
Conclusion 164
Sample Case Notes 165
Session 1 165
Session 3 165
Resources 166
For Professionals 166
For Adolescents and Parents 166
Discussion Questions 166
References 167

12 Social Anxiety: Mindfulness-­Based Cognitive Behavior

Therapy with a Pakistani American Adolescent 169
    Yu-­fen Lin and Samuel Bore
South Asian Muslim Adolescents 170
Social Anxiety 170
Mindfulness-­Based Cognitive Behavior Therapy 170
xvi Contents

Case Application 171

Session 1 172
Session 2 174
Session 3 174
Ethical and Cultural Considerations 176
Parent and/or Teacher Consultations 176
Conclusion 177
Sample Case Notes 177
Session 1 177
Resources 178
For Clients 178
For Therapists 178
Discussion Questions 178
References 178

13 Divorce and Political Extremist Groups: Cognitive Behavior

Therapy and Expressive Arts with a White Adolescent 183
   Jennifer N. Baggerly
Impact of Divorce 183
Impact of Extremist Groups 184
Treatment Approach 186
Cognitive Behavior Therapy 186
Expressive Arts 187
Case Study Application 188
Treatment Goals 188
Initial Sessions 188
Middle Sessions 190
Ethical and Cultural Considerations 191
Parent Consultations 191
Conclusion 192
Sample Case Notes 192
Session 1 192
Session 4 193
Resources 193
For Professionals 193
For Adolescents 193
For Parents 193
Discussion Questions 194
References 194

14 Sexual Abuse: Trauma-­Focused Cognitive Behavior Therapy

and Creative Approaches with a Biracial Adolescent 197
   Felicia R. Neubauer
Child Sexual Abuse 197
CSA during COVID-19 198
 Contents  xvii

Description of TF-­CBT 198

Stabilization Phase 199
Trauma Narration Phase 200
Integration/Consolidation Phase 200
Case Study Application 201
Intake Assessment 201
Treatment Goals 202
Initial Phase of Treatment: Stabilization and Skill Building 202
Middle Phase of Treatment: Trauma Narration and
Cognitive Processing 204
Ending Treatment 206
Ethical and Cultural Considerations 206
Parent Consultations 207
Conclusion 207
Sample Case Notes 208
Session 1 208
Resources 208
For Professionals 208
For Children and Adolescents 208
For Parents 208
Discussion Questions 209
References 209

15 Self-­Harm: Dialectical Behavior Therapy with an

African American Adolescent 211
    Anelie Etienne and Domonique Messing
Hate Speech: A Form of Bullying 212
Non-­Suicidal Self-­Injury 213
Dialectical Behavioral Therapy 213
Case Study Application 215
Treatment Goals 215
Treatment Process 216
Ethical and Cultural Considerations 219
Parent Consultations 219
Conclusion 219
Sample Case Notes 220
Session 1 220
Resources 220
For Professionals 220
For Teens 220
For Parents 220
Discussion Questions 221
References 221
xviii Contents

16 Tourette Syndrome and Risk of Exploitation: Equine Assisted

Family Play Therapy with a White Adolescent 223
   Tracie Faa-­ Thompson
Tourette Syndrome 223
Risk of Sexual Exploitation 224
Needed Interventions 224
Animal-­Assisted Play Therapy 225
Case Study Application 226
Treatment Goals and Objective 226
The Treatment Process 227
Overview and Beginning Sessions 227
Sessions 5 through 7—Barriers Activity 228
Session 8 229
Ending Sessions and Learnings 230
Ethical and Cultural Considerations 231
Conclusion 231
Resources 232
Discussion Questions 232
References 232

17 Eating Disorders: Enhanced Cognitive Behavior Therapy

with a Mexican American Adolescent 235
   Sara Cantu
Eating Disorders 235
Enhanced Cognitive Behavioral Therapy 236
CBT-­E Overview and Stages 237
CBT-­E Stage 1 237
CBT-­E Stage 2 239
CBT-­E Stage 3 239
CBT-­E Stage 4 239
Case Study 239
Ethical and Cultural Considerations 242
Parent Consultations 243
Conclusion 243
Sample Case Notes 243
Session 1 243
Session 8 243
Resources 244
For Professionals 244
For Adolescents 244
For Parents 244
Discussion Questions 245
References 245
 Contents  xix

18 Substance Use Disorder: Motivational Interviewing and

Creative Approaches with an African American Adolescent 247
    Allison Crowe and Jason O. Perry
Depression 247
Substance Use Disorders 248
Motivational Interviewing 248
Four MI Principles 249
Case Study Application 250
Treatment Goals and Objectives 251
First Sessions 251
River of Life Activity 252
Case Discussion 253
Ethical and Cultural Considerations 254
Parent and Teacher Consultations 254
Conclusion 255
Sample Case Notes 255
Session 1 255
Session 3 256
Resources 256
For Professionals 256
For Adolescents 256
Discussion Questions 257
References 257
19 LGBTQ: Gestalt Therapy and Liberatory Approaches
with a Dominican American Adolescent 259
    Ana Guadalupe Reyes
LGBTQ People 259
Guiding Theory and Frameworks 261
Gestalt Therapy 261
Intersectionality Theory 262
Expressive Arts 262
Case Study Application 263
Intake Session 264
Session 1 264
Session 2 265
Later Sessions 266
Session 4 266
Ethical and Cultural Considerations 268
Parent Consultations 269
Conclusion 269
Sample Case Note 270
xx Contents

Resources 270
For Professionals 270
For Clients 270
For Parents 271
Discussion Questions 271
References 271

20 Gender: Narrative Therapy with Parents of a Nonbinary

Transgender Korean American Adolescent 273
   Brooks Bull
Transgender Environmental Context 274
Narrative Therapy 274
Re-­Storying as an Overall Goal 275
Dominant versus Alternative and Local Discourses 275
Remembering 276
Case Study Application 276
Treatment Process 277
Ethical and Cultural Considerations 281
Conclusion 282
Sample Case Notes 282
Session 3 282
Resources 283
For Adolescents 283
Current Resources for Therapists and Adult Clients
to Better Understand Gender Identity 283
Historical Resources for Therapists and Adult Clients
 to Learn the History of Transgender and
Gender-­Diverse People 283
Discussion Questions 283
References 284

Index 287

About the Editors 295

About the Contributors 297

 List of Figures, Tables, and Textboxes
Figures
5.1. Pause Button
14.1. “Before I Told”
15.1. Activity
19.1. La Tormenta Adentro

Tables
1.1. Roberto: Transcript/Analysis
1.2. Roberto: Transcript/Analysis
2.1. El: Session 1
2.2. El: Session 2
3.1. Carla: Session 3
3.2. Carla: Session 10
4.1. Jake: Session 1
4.2. Jake: Session 6
5.1. Benjamin: Session 1A
5.2. Benjamin, Session 1B
5.3. Benjamin: Session 2A
5.4. Benjamin: Session 2B
5.5. Benjamin: Session 2C
5.6. Benjamin: Session 3
6.1. Huan: Phase 1A
6.2. Huan: Phase 1B
6.3. Huan: Phase 2A
6.4. Huan: Phase 2B
6.5. Huan: Phase 3A
6.6. Huan: Phase 3B
7.1. AutPlay Group: Session 1
7.2. AutPlay Group: Session 5
7.3. AutPlay Group: Session 10
8.1. Salvador: Session 1
8.2. Salvador: Session 2
9.1. Kanani: Transcript/Analysis
10.1. Jessica and Edward: Session 4
10.2. Jessica and Edward: Session 7
11.1. Jade: Session 1
11.2. Jade: Session 3
12.1. Jasmin: Session 1
12.2. Jasmin: Session 2
12.3. Jasmin: Session 3

xxi
xxii 

13.1. David: Session 1

13.2. David: Session 4
14.1. Ava: Initial Phase
14.2. Ava: Middle Phase
15.1. Distress Tolerance Skills: Pros and Cons
15.2. Ashly: Session 1
15.3. Ashly: Session 2
16.1. Jenny: Session 8
17.1. Claudia: Transcript/Analysis
17.2. Claudia: Transcript/Analysis
17.3. Claudia: Transcript/Analysis
17.4. My Monitoring Record
18.1. Robby: Session 3
19.1. Jose Luis: Session 1
19.2. Jose Luis: Session 4
19.3. Case Note: Data/Assessment
20.1. Lisa: Session 1
20.2. Lisa and Charlie: Session 2
20.3. Lisa and Charlie: Session 3

Textboxes
10.1. CPRT Progress Notes: Session 1
 Foreword

I
n early 2002, while in an internship, I saw my first child and adolescent cli-
ents. I was a second-­year student completing a master’s degree in community
counseling. At that point, my training to work with child and adolescent cli-
ents consisted of two courses: introduction to play therapy and child and ado-
lescent counseling. What I had to offer was funneled through knowledge gained,
yet, I had little practical experience applying this knowledge. Running through
my head were many theories, skills, and techniques and a lot of fear. The fear was
centered on the fact that I was working with a vulnerable population who had
little choice in their outcomes. Surrounding all the information I had learned was
a statement that I had heard over and over: meet them where they are.
Though children and adolescents have always experienced difficulties, in the
20 years or so since my first clients, it seems that these difficulties are more fre-
quent and pervasive. As we find ourselves following several years of an unex-
pected and overwhelming pandemic, we are more aware than ever of the mental
health issues facing children and adolescents. Did the pandemic cause more men-
tal health issues? Yes, but it did much more. The pandemic removed many of the
avenues of support available to children and adolescents, leaving mental health
issues an unencumbered path in which issues thrive.
While reflecting on my abilities 20 years ago and the pandemic, I could con-
clude that had I started practicing during the pandemic, I might have been under-
prepared. Then again, maybe not, because so much of what I learned through
working with my first clients came from being present and attentive. It came from
a hypothesis (diagnosis) and a conceptualization and was guided by a theoretical
philosophy and a willingness to meet them where they were. So, whether in the
room with them or connected through a teleconferencing platform, I believe that
I would have relied on what had guided my facilitation in the past.
Now, after having been an educator for more than 15 years, I understand
what helped me become a competent practitioner and educator. I learned that all
clients are unique and present with varying circumstances, but our first few cli-
ents help us develop case conceptualization skills that can be applied to the next
clients. Case conceptualizations are not easy. They take practice and experience.
Our first case conceptualizations are akin to trial and error and hunches and are
only guided by the facts we have collected. Through practice, we learn to look
deeper.
I believe that had I had a text like Contemporary Case Studies in Clinical
Mental Health for Children and Adolescents, my journey into case conceptual-
ization and client work would have been easier. The text adds to our founda-
tion in child and adolescent therapy as it is full of robust case examples covering

xxiii
xxiv Foreword

numerous mental health issues. Across the child and adolescent cases, multiple
theoretical approaches are described and linked to treatment goals and objec-
tives. Adding to the practical nature of the text are realistic session descriptions
providing readers with a glimpse into how sessions might progress. Throughout
the 20 chapters, as one reads, I believe each reader will see themselves in the ther-
apist’s place. Seldom covered in most texts, but highlighted in this text, are the
sections, in each chapter, on parent and/or teacher consultation.
Contemporary Case Studies in Clinical Mental Health for Children and
Adolescents is not prescriptive, in that it does not attempt to assert that what
is described is the only way to work with a child or adolescent experiencing a
specific issue. The seasoned editors, Jennifer Baggerly and Athena Drewes, trans-
parently state that the text is not intended to be a step-­by-­step manual. Rather,
the extensive use of case illustrations along with questions for reflection make it
possible for practitioners to extrapolate beneficial principles that can be applied
to their clients.
As mental health practitioners, we are expected to conceptualize our clients
to develop the best course of action to help remediate their issues. The case con-
ceptualization process gives us a starting point to which we can connect empiri-
cally supported interventions. Through texts such as Contemporary Case Studies
in Clinical Mental Health for Children and Adolescents, we’re able to see the
linking of case conceptualization to empirically supported intervention. We can
see, through our clients’ worldview and circumstances, how one’s theoretical lens
can be applied.
As a counselor educator, I found Contemporary Case Studies in Clinical Men-
tal Health for Children and Adolescents to be an exceptional guide to help my
counseling students conceptualize and treat culturally diverse children and ado-
lescents. As a seasoned child and adolescent clinician, I found it to be a refreshing
reminder about applying key therapeutic principles and evidence-­based proce-
dures with each unique client. I also found it to be a challenging call to consider
expanding my clinical strategies. In summary, this text is valuable for beginning
and experienced clinicians working with children and adolescents post-­pandemic
and beyond.
Edward (Franc) Hudspeth, PhD, NCC,
LPC-­S, ACS, RPT-­S, RPh
Program Coordinator, EdS in Counselor
Education-­Play Therapy
University of Mississippi
 Preface
Jennifer N. Baggerly and Athena A. Drewes

Inspiration
The inspiration for Contemporary Case Studies in Clinical Mental Health for
Children and Adolescents came during the world’s life-­altering COVID-19 pan-
demic during 2020, referred to as “the year from hell” (Wikipedia). In January
of 2020, I (JB) heard a medical professional say on television, “Life as you know
it will change because of this coronavirus.” I thought to myself, well, that seems
a little extreme. I wish I were wrong, but as we now know, millions of lives were
impacted for at least two years and some for even more.
Children’s and adolescents’ mental health plummeted. The pandemic trig-
gered some children to experience anxiety, depression, abuse, and grief. Children
who already had ADHD became more symptomatic during the COVID quar-
antine. Then the death of George Floyd ignited a social fire, in which some peo-
ple protested for justice while others balked. Hate crimes and political extremist
groups increased. This anger and tension in the community at large seemed to
reflect anger and tension within families.
Early in the pandemic, many mental health professionals (MHP) experienced
financial anxiety from not having as many clients and trying to figure out tele-
health. Then the surge hit with parents, educators, and medical professionals
inundating mental health professionals with referrals of children and adolescents
desperate for relief. Indeed, mental health became the second wave of the COVID-
19 crisis, cresting only after the medical outlook stabilized. It was all hands on
deck. As a counselor educator, I (JB) was teaching classes, providing counseling to
as many children and adolescents as possible, and supervising new professionals
who were trying to keep up. One new counselor said to me, “I don’t feel ready
but so many children need me. I need more than weekly supervision because there
are so many different problems that it seems I forgot how to counsel. I wish there
was a book that gave me concrete examples of what to do and say and how to
conceptualize treatment for lots of different children and adolescents.”
Like many MHP, this new professional experienced the pressing urgency of
numerous children struggling with contemporary challenges. Constant requests
to serve more and more children resulted in some MHP feeling so overwhelmed
that they worried that they had forgotten how to do things properly and forgot
about self-­care. A physical book with concrete examples as well as case concep-
tualization analysis was needed to remind us of all of the key theoretical concepts
and strategies that lead to therapeutic change. We need to be reminded of how
to counsel lots of different types of children and adolescents struggling with lots

xxv
xxvi Preface

of different recent realities. We need contemporary case studies that reflect this
changing world. We need Contemporary Case Studies in Clinical Mental Health
for Children and Adolescents.

Book Chapter Authors

Along with Athena Drewes, we contacted experts in specific counseling
approaches for specific presenting problems. We developed “the dream team”
of passionate, seasoned therapists to share case studies of diverse children and
adolescents including Caucasian, Black, Latinx, Asian, indigenous, LGBTQ, and
neurodivergent. We divided the sections into children and adolescents with com-
mon presenting problems such as depression, anxiety, ADHD, divorce, domestic
violence, sexual abuse, self-­harm, eating disorders, and substance abuse. For chil-
dren, theoretical approaches include Child-­Centered Play Therapy (CCPT) and
variants such as Trauma-­Informed CCPT and Critical Race Theory with CCPT;
Adlerian Play Therapy; Cognitive Behavioral Play Therapy; AutPlay; sand tray;
Filial Therapy; and Child-­Parent Relationship Therapy. For adolescents, theoret-
ical approaches include Cognitive Behavior Therapy (CBT) with expressive arts,
Mindfulness CBT, Trauma-­Focused CBT, equine therapy, motivational interview-
ing, queer and liberatory approaches, and narrative therapy. In summary, our
book is unique in describing how to treat numerous presenting problems with
various theoretical approaches for uniquely diverse clients.

What the Book Is Not

This book is not a one-­size-­fits-­all approach to counseling. We recognize that the
intersectionality of gender, age, racial and ethnic identity, language, religion, fam-
ily status, personality, presenting problems, and so forth impact the type of treat-
ment approach for each client. We recognize that clients tend to have overlapping
concerns beyond one diagnosis. We recognize that children and adolescents are
people first and are more than just their problems. Some need a child-­centered
approach, others need a cognitive behavioral approach, others need an integra-
tive approach. Yet most importantly, each needs an authentic relationship with a
caring and trained mental health professional who provides genuineness, empa-
thy, and unconditional positive regard.
This book is not a step-­by-­step approach for clients with a particular diag-
nosis. Not only do we see each child and adolescent as an individual who is very
complex, but we see each MHP as very complex with various training and profes-
sional experiences. We honor MHPs’ therapeutic judgment to prescriptively select
a treatment approach for a particular client and encourage flexibility within the
limits of MHP training. Some MHP are not trained in play therapy, beyond a
day or two workshop, and should not state that they are providing play therapy.
Likewise, others are not trained in equine therapy and should not provide it. For-
tunately, we do provide resources where you can seek training.
 Preface  xxvii

What the Book Is

In this book, we offer a guide in how to conceptualize specific presenting problems
and operationalize specific theoretical treatment strategies with a particular child
or adolescent. We provide concrete illustrations through a sample transcript anal-
ysis. I (JB) learned this technique from the late great Nancy Boyd Webb. I realized
it was important when one of my supervisees said, “Your suggested responses to
my videos seem to come so easily to you. I wish there was a book that gave me
examples of what to say in difficult cases.” The therapeutic responses provided
are examples of how to start or reminders of what is helpful.
This book does address controversial issues, especially Critical Race Theory
(CRT), transgender youth, undocumented immigrants, and gun violence. The
legislators in our states (Texas and Florida) have banned Critical Race Theory,
which helps to conceptualize racism, from being taught in K–12 and have pro-
posed legislation to ban CRT in higher education. The legislators in our states
have also denied access to gender-­affirming care for trans children; denied access
to immigrants and rights to undocumented people; and protected access to semi-
automatic guns. Yet, as mental health professionals, our clients face these issues,
and we are called to provide ethical care for them. Our chapter authors are men-
tal health experts who guide us in doing so.

Structure for Book Chapters

Our book chapter structures have several unique features that differ from other
books.

Begin with Case Studies

We start with the case scenario to pique your interest and draw you into con-
templation of a specific client’s gender, age, race/ethnicity, culture, family context,
and presenting problems. Starting with this holistic case study overview, which
reflects actual case consultations, the reader gets to see how counselors make clin-
ical decisions based on aspects of a particular client’s needs and how it leads to
tentative goals and then therapeutic approaches.
All case studies are composites, representing common characteristics and
experiences of clients with specific diagnoses. Each case uses pseudonyms to pro-
tect the privacy of any client who may resemble the description.

Brief Overview of Issues and Treatment Approaches

Next, we provide a brief literature review to promote understanding of the com-
plexity of presenting problems and cultural issues that may apply. Frequently,
counselors brush past this and rely on past knowledge, which can lead to simplis-
tic assumptions. Our up-­to-­date literature reviews bring to attention nuances and
connections that even seasoned counselors may take for granted.
xxviii Preface

Descriptions of treatment approaches highlight key principles and procedures

in a way that motivates commitment to them. Too frequently we lose the awe-­
inspiring holding and integration of theoretical tenets. Yet, these are the key to
therapeutic success. Therefore, we encourage a fresh reading of the theoretical
approach.

Treatment Goals and Objectives

Often treatment goals and objectives are written in an almost “cut and paste”
obligatory manner. Prior to electronic records, many counselors kept treatment
goals in the back of the file without regular review. This approach would be like
driving from Florida to Washington state without looking at the GPS. You have a
general direction but are bound to get lost and not know when you have reached
your goal, resulting in inefficient progress toward agreed-upon goals. Regular
review of treatment goals and objectives, with the client and family, helps to rein-
force progress, strengthen collaboration, assess where treatment is in relationship
to termination, and whether the approach needs to be adjusted. Reviews also
help to ensure counselor accountability and that the treatment is in the best inter-
est of the client.
Further, many counselors may feel at a loss as to what the treatment goals
and objectives should be. This is partly because, in typical practice, counselors
seldom discuss them with colleagues who hold a like theoretical perspective. See-
ing how specific treatment goals and objectives for a specific client and situation
are written will help clinicians create better treatment plans for their own cases.

Session Description and Transcript Analysis

To make session descriptions more personable and accessible, we had the authors
use the first person, “I,” to explain what they did. We wanted to approach the
description as if a colleague asked, “What did you do with this client and how did
it turn out?” The “I” approach is intended to be less academic and more friendly.
After all, counselors are people, too. The “I” creates a vulnerability rather than a
disconnected abstract idea of “the counselor.”
Our session transcripts and analysis provide a glimpse into how a counselor
implements theory, what she might say, and why she says it. This is the nuts-­and-­
bolts approach. It is not a treatment manual of specific things you should or must
say. Rather, it is an example of what session content can look like for this partic-
ular client in this particular context with this particular theory. Many times, you
may think, I say the same thing, or Oh, that is an interesting way to demonstrate
that concept, or I would have said it differently. All of these thoughts are fine. The
transcript may confirm what you do or improve what you do. More importantly,
the transcript analysis helps you to consider the “why” of what you do. I tell my
counseling students, “I will stop your video at any random moment and ask you
 Preface  xxix

to provide a theoretical rationale for why you said what you did or did what you
did.” I always love seeing the look of panic on my students’ faces when I say this
because then I can help them realize they know or need to know the theoretical
rationale. Then their faces turn to a look of contemplation and commitment to be
the best counselor they can be in each session.

Ethical and Cultural Considerations

Ethics are so important that most state licensing boards and clinical associa-
tions require numerous hours in ethical training each renewal cycle. Our chapter
authors remind us of both common and specific ethical considerations for each
case study. They explain how they work toward aspirational ethics of evaluat-
ing their actions and ethical code to ensure that their clients receive services that
exceed the expected standard of care, often through social justice advocacy.
For cultural considerations, our chapter authors discuss the client’s intersec-
tionality of gender, age, race, ethnicity, culture, religion, socioeconomic status,
family context, school context, local community environment, broader societal
events, political environment, and oppressive forces such as racism that they may
have experienced. They provide guidance in honoring clients’ culture through
practical suggestions.

Parent and Teacher Consultation

Parent and teacher consultations are not often discussed in books. However, they
are crucial for success because parents and teachers influence for better or worse
the immediate environment of children and adolescents. MHP have wisdom to
guide parents and teachers in new attitudes, skills, and directions to improve their
children’s lives. Our authors share their approach to enhance parents’ and teach-
ers’ supports for children and adolescents.

Sample Case Notes

MHP seldom share case notes. Although MHP are required to write case notes
after every session, these notes seem to be a mystery. What is amazing about our
authors’ case notes is that they are all different. Some use forms whereas others
use SOAP (subjective, objective, assessment, plan) and others free write. It was
validating to see that case notes can be so different and so on target.

Resources
Our chapter authors share their go-­to resources for professional training, chil-
dren, and parents. If you are new to a subject and don’t know where to start, our
chapter authors will point you in a helpful direction. If you are well versed in an
approach, you may find something new.
xxx Preface

Discussion Questions
Each chapter asks you specific questions to extend your thinking and learning,
either on your own or in a group discussion. These questions are a helpful way
to engage colleagues in professional development, for personal growth by jour-
naling individually, and for use in academic settings to engage students in prob-
lem solving. Whichever way, we encourage you to think about and answer these
questions.

Our Hope
Our hope for you, the reader, is to experience new learning and renewal as you
work with contemporary issues and challenges with your clients. Honestly, we as
editors have learned so much from each chapter author, which in turn has helped
to improve our treatment approaches with some of our own clients. We believe
you will find this volume clinically useful as well.
 Acknowledgments

W
e also wish to thank the reviewers whose thoughtful comments and
expertise guided our writing and revisions for the development of this
book. As always, any errors and omissions are our own:
Carleton Brown, University of Texas at El Paso
Celeste Fiori, University of Wyoming
Kenisha Gordon, Mississippi College
Sueann Kenney-­Noziska, Play Therapy Corner
Donna Kreskey, California State University, Chico
Craig LeCroy, Arizona State University
Misti Lindquist, Azusa Pacific University
Jack Peltz, Daemen College
Richard Ruth, The George Washington University
Sean Scanlan, Chaminade University of Honolulu
Anne Stewart, James Madison University
Hayley Stulmaker, HLS Counseling PLLC
Daniel Sweeney, George Fox University
Gabriel Young, Pacific Oaks College

xxxi
PA RT I
Children
 CHAPT E R 1

Depression
Child-­Centered Play Therapy with a Biracial Child
Peggy L. Ceballos and Marium Sadiq

Roberto is a 7-year-­old biracial male (mom identifies as African American and

father as Puerto Rican Latino) who was referred to counseling by the school. His
parents are divorcing after 9 years of marriage and according to Roberto’s par-
ents, the divorce is causing a lot of problems between the two of them, which
Roberto has witnessed. A more in-­depth family history revealed that Roberto’s
mom has been diagnosed with major depressive disorder and currently takes
medication for it. Roberto’s teacher describes him as a child who is very “hyper-
active” and extremely anxious. Recent incidents at school include Roberto crying
uncontrollably when he could not perform an academic task, being very anxious
in social situations, and tending to keep to himself in social situations. The teacher
adds that Roberto is hyper and that she needs to call him out constantly for not
following school rules. At home, Roberto is described as having angry outbursts.
Roberto’s parents also stated that Roberto tends to become anxious and that
lately he has lost his appetite and refuses to eat during mealtimes. They have
observed Roberto’s anxiety coming up at times when he is afraid of a new situa-
tion or around new people. His mom explains he has always tended to want to do
everything perfectly, and when he cannot accomplish a task, he feels very disap-
pointed in himself. In general, his parents describe him as having a lot of negative
self-­thoughts such as “I am bad,” “I cannot do things right,” and “I am stupid.” He
has expressed to his mom feeling sad sometimes and wanting her and dad to get
back together. The father stated that he thinks Roberto feels guilty about them
separating and thinks it is his fault for misbehaving and for feeling sad. Roberto’s
parents clarified that they had noticed this sense of sadness and negative self-­
image in Roberto since he was about 4 years old.

Childhood Depression
According to the Centers for Disease Control and Prevention (CDC, 2023),
approximately 2.7 million children, ages 3–17, were diagnosed with depression
between 2016 and 2019. Symptoms of childhood depression can present in a
variety of ways. Children experiencing depression may exhibit impairment across
cognitive, affective, physiological, and social domains (Burgin & Ray, 2022;

3
4 Chapter 1

Korczak, Madigan, & Colasanto, 2017). These symptoms can negatively impact
children’s level of functioning by impeding their school performance and impact-
ing their ability to participate in interpersonal relationships (Garber, 2006).
Researchers associate childhood depression with exposure to early life stress-
ors. LeMoult et al. (2020) conducted a meta-­analysis and found that exposure
to early life stressors such as physical abuse, emotional abuse, sexual abuse,
the passing of a loved one, or domestic violence were linked to greater risk of
being diagnosed with major depressive disorder before the age of 18 years. Other
researchers have corroborated the significant link that exists between adverse
childhood experiences and depression (Satinsky et al., 2021). In addition, family
history of mental health problems such as depression (Maughan, Collishaw, &
Stringaris, 2013; Mills & Baker, 2016) and lack of social support (Rueger, Mal-
ecki, Pyun, Aycock, & Coyle, 2016) are factors linked to childhood depression. It
is important to note that childhood depression may leave the child prone to the
development of other mental health conditions (Weisz et al., 2006; Avenevoli,
Stolar, Li, Dierker, & Ries Merikangas, 2001).
According to Delaney and Smith (2012), the negative effects of early onset
of depression continue into adulthood. When depression appears in childhood,
there are more risks of developing comorbidity of mental health problems and
major depressive disorder later in life (Zisook et al. 2007). This is concerning
as statistics show that about 25% of children are diagnosed with major depres-
sive disorder by adolescence (Abela & Hankin, 2008). Maughan et al. (2013)
explained that depression in adolescents is preceded by anxiety, addictions, and
disruptive behaviors. The authors concluded that a combination of environ-
mental and genetic factors play a role in the development of depression during
childhood, affecting more girls than boys. According to Maughan et al. (2013),
diagnosing depression in childhood is difficult due to developmental concerns
and how depression often presents itself in comorbidity with other disorders.
The criteria to diagnose depression center on symptoms of continued sadness,
significant loss of interest in enjoyable activities, changes in appetite, fatigue or
diminished physical activity, feeling a sense of worthlessness or guilt, inability to
think concretely, and suicide ideation (American Psychiatric Association [APA],
2022). However, Allgaier et al. (2014) cautioned of the difficulties most men-
tal health providers face when trying to diagnose depression during childhood.
The authors explained several factors that contribute to this difficulty, including
developmental factors that cause symptoms to present in an atypical manner, the
presence of other disorders such as anxiety, and the struggle children face when
trying to express verbally what is happening to them. According to Sánchez Rus,
Solis, Rodriguez, & Suárez-­Gómez (2021), because depressive symptoms in chil-
dren may present as irritability, lack of attention, and hyperactivity, the diagnosis
can be confused with ADHD. The authors also warned that both diagnoses can
coexist, making it hard for mental health providers to determine the best treat-
ment. Thus, Sánchez Rus et al. (2021) urged providers to closely monitor early
diagnosis to lower chances for later complications.
 Depression 5

When diagnosing depression, it is also important to have an in-­depth under-

standing of the cultural background of the client. Research conducted in coun-
tries outside the United States have found that clients are more likely to show
symptoms of depression through physical rather than psychological symptoms
(Bibi, Masroor, & Iqbal, 2013; Mumford, Devereux, Maddy, & Johnston, 1991).
In addition, studies have found that exposure to adverse childhood experiences
(ACEs) such as living in unsafe, violent neighborhoods or lack of access to basic
resources contribute to the onset of depression during childhood (Satinsky et al.,
2021). Girls are more prompt to show depression symptoms than boys and to
carry a major depressive diagnosis once they get to puberty (Maughan et al.,
2013). These factors make it imperative for clinicians to properly consider cul-
tural factors that may be affecting a child’s depression symptoms. Thus, it is
important to conduct a thorough family interview that includes attention to
cultural factors such as how a family conceptualizes depression, understanding
the client’s intersectionality of identities (e.g., religion, language, disability, race/
ethnicity) and the lived experiences these identities bring into the child’s daily
life (Strand & Bäärnhielm, 2022). Similarly, Bibi, Lin, Zhang, & Margraf (2020)
remind clinicians to use culturally appropriate diagnostic measurements that
account for cultural differences in symptomatology.

Child-­Centered Play Therapy (CCPT)

Given Roberto’s developmental stage and presenting problem, we believe that
CCPT can be beneficial to help him deal with his presenting issues and symptoms
of depression and ADHD. CCPT is a developmentally appropriate approach to
therapy with children ages 3–10 (Landreth, 2012). CCPT was adapted from Carl
Rogers’s person-­centered theory, and it expands on the nondirective tenants pre-
sented by Virginia Axline (1947). Landreth (2012) presents CCPT as an approach
in which “play is the child’s language” (p. 12). Within CCPT, the child attends
therapy in a room with carefully curated toys so that the child can express their
internal self through using these toys as their words. The therapist provides a
culturally appropriate space in which the child experiences empathy, genuine-
ness, and unconditional positive regard from the therapist. In addition, because
in CCPT the therapist believes in the child’s inner capacity for self-­actualization,
the therapist offers a structured yet nondirective space where the child is free to
express himself freely (Landreth, 2012).
Responses used in play therapy, such as tracking, reflection of feelings,
reflection of content, esteem building, reflection of meaning, facilitating deci-
sion making, facilitating creativity, facilitating relationship, and reflecting larger
meanings (Ray, 2011), are used to communicate understanding and acceptance
of the child (Landreth, 2012). These skills combined with the therapist’s attitu-
dinal conditions outlined by Carl Rogers (1957; i.e., genuineness, empathy, and
unconditional positive regard) provide a psychologically safe environment for the
child. Within the relationship, the child needs to experience the play therapist’s
6 Chapter 1

attitudinal conditions to begin to integrate a more positive self-­structure (Haas &

Ray, 2020; Jayne & Ray, 2015).

CCPT with Childhood Depression

Lin and Bratton’s (2015) meta-­analysis found that CCPT showed a statistically
significant effect on reducing symptoms for internalizing behavioral problems.
This finding is corroborated by a meta-­analysis conducted by Ray, Armstrong,
Balkin, and Jayne (2015) that examined interventions conducted in school set-
tings and found CCPT to be effective in reducing internalizing problems among
other problem behaviors while increasing academic achievement. It is import-
ant to note that most studies used in these meta-­analyses looked at internal-
izing behaviors in general, which include depression; however, these studies
did not look at depression as a diagnosis by itself. To date, two studies have
looked at CCPT and depression (Baggerly, 2004; Burgin & Ray, 2022). Baggerly
(2004) conducted a nonrandomized study and concluded that homeless children
improved in their symptomatology of depression after 12 sessions of CCPT as
measured by the Children’s Depression Inventory (Kovacs, 1978). In a more
recent study, Burgin and Ray (2022) conducted a randomized clinical study with
71 children in five Title I schools. The experimental group received between 14
and 16 biweekly 30-minute individual CCPT sessions to be compared with the
wait-­list control group. Results showed a statistically significant improvement in
depressive symptoms with a large effect size among children who participated in
CCPT.
From a CCPT perspective, mental health problems arise when children start
to form conditions of worth; external messages interfere with one’s self-­concept
(Rogers, 1957). Conditions of worth create an ideal self as the child starts to
live to external expectations. For example, in the case of Robert he may have
created conditions of worth around having to be perfect to be worthy of being
accepted, which has led to his negative self-­image when he is not able to accom-
plish tasks. Conditions of worth create a dissonance between who Roberto truly
is and who he internalizes he should be according to how he has experienced his
world (Rogers, 1957). It is the tension created by this incongruence that has led
him to the formation of psychological maladjustments. Thus, the healing process
occurs when he can feel unconditionally accepted, which can lead him to reject
previously internalized conditions of worth (Landreth, 2012). As he starts to
achieve a sense of congruence between his two selves, he can decrease symptom-
atology (Landreth, 2012).
In CCPT, children can express their symptomatology of depression in a devel-
opmentally appropriate way as they are not required to verbalize their inner
experience; instead, they use toys to play out their feelings and perceptions. The
child-­centered play therapist can provide a safe environment characterized by
the core conditions (Landreth, 2012) using CCPT skills (Ray, 2011). This type
of environment allows children to feel free to express themselves holistically
 Depression 7

(feelings, thoughts, behaviors) and to try new ways of being that allow them to
experience more congruence with their real self. The child-­centered play therapist
believes in the child’s self-­actualizing force and therefore does not need to use
activities or interventions (Landreth, 2012). Burgin and Ray (2022) stated that
in CCPT the safe environment characterized by the core conditions and created
by the application of CCPT skills “provide the child with the freedom to express
their experiences of depression, naturally moving towards confronting their per-
ceptions of inadequacy, and beginning to experience themselves as capable as they
build coping skills, resulting in positive integrations to self-­concept” (Ray, 2018).

Case Study Application

Roberto presents with signs of major depression disorder as specified by the
DSM-­V-TR (APA, 2022). He reports feeling negative about himself, withdrawn
from social interactions in a way that is not expected at his age, and feeling sad.
In addition, as expected in childhood depression, Roberto is expressing symptom-
atology that aligns with comorbidity of presenting issues (Burgin & Ray, 2022).
The teacher describes him as hyperactive, which is characteristic of children expe-
riencing depression (Sánchez Rus et al., 2021), and he is exhibiting anxiety and
other behavioral problems such as anger outbursts also associated with the onset
of depression in childhood (Allgaier et al., 2014).
From a child-­centered theoretical approach, Roberto has been exposed to
experiences that have created conditions of worth for him. These conditions of
worth led him to experience incongruence between his true self and ideal self.
For example, although his organismic experience is of a human being who learns
through mistakes, he has learned through his interactions growing up that he
is only worthy when he is perfect. This condition of worth led him to inter-
nalize negative messages about himself such as “I am not good at anything”
and “I won’t learn how to do things.” This incongruence between his ideal self
and true self creates feelings of sadness, anxiety, and anger, which externalize
in behaviors such as hyperactivity, withdrawnness, anger outbursts, and crying
uncontrollably.

Treatment Process
The CCPT treatment plan consisted of seeing Roberto once a week for 50 min-
utes. Prior to starting sessions, I (first author) completed an intake session with
Roberto’s parents to discuss presenting issues and administered the Children’s
Depression Inventory (Kovacs, 1978) with Roberto, which measures depressive
symptoms in children over the age of 6. Roberto scored in the significant range
for multiple subscales on the assessment. Based on the intake and assessment
results, the parents and I collaborated to create the following therapeutic goals:
• increase Roberto’s awareness of his own feelings and how he could express
these feelings in socially acceptable ways,
8 Chapter 1

• decrease the number of instances in which Roberto engaged in negative self-­

talk, and
• increase Roberto’s ability to stay on task and follow directions in class and at
home.
Throughout treatment, I conducted parent consultations every four weeks to
assess for progress and changes in Roberto’s disposition. I also conducted two
teacher consultations to provide tools that would be helpful in supporting Rober-
to’s educational success.
During sessions, I focused on providing the therapeutic conditions outlined
by Axline & Carmichael (1947) for Roberto to feel safe enough to experience
his true self in the playroom without fear of not being accepted. To this end,
I provided Roberto with a level of unconditional acceptance, empathy, and
congruence that he needed in the therapeutic relationship to feel safe to make
mistakes and to express himself freely about his parents’ divorce. The child-­
centered play therapist used the skills (reflection of feelings, tracking, reflection
of meaning) to let Roberto know that I understood what he was expressing.
In addition, I worked to return responsibility to Roberto to empower him and
encourage him in social situations.
I used advanced skills such as setting limits to help Roberto develop an inner
sense of self-­control and learn alternative more appropriate ways to express feel-
ings such as anger. In addition, due to his negative self-­talk and beliefs about
himself, I used skills such as encouragement to help him experience a new sense
of self in the playroom. This new sense of self allowed him to perceive himself as
someone who could try new tasks and value the process rather than the product.
As Roberto was able to have these new experiences in the playroom, he was able
to gain a new sense of self more aligned with his self-­actualizing force and true
self, thus reducing his need for symptomatology associated with depression. I saw
these behaviors and skills play out over the next few sessions.
TABLE 1.1. ROBERTO: TRANSCRIPT/ANALYSIS
Transcript Analysis
T: “Hello, Roberto, we are going to have our Introduction of the playroom and invitation to play
special playtime. In here, you can play with all the with the toys. This informed the child that he gets
toys you want in many of the ways you want.” to take the lead in the playroom.
R: “Can I play with that?” Children often feel unsure and uneasy in a new
situation. In addition, Roberto specifically tended
to be anxious in new social situations.
T: “You’re feeling nervous. You’re not sure if you Reflection of feeling and meaning. Here, the
can play with what you want.” therapist acknowledged Roberto’s nerves.
R: “So, can I?” Children are often unsure initially how to respond
to reflections of feeling. Roberto was persistent
in his questioning, still unsure of what he was
allowed to do.
T: “Well, Roberto, in here that’s something that I returned responsibility to Roberto. This both
you can decide.” helped set the structure of play therapy and
reminded Roberto that he was in charge of his
own choices.
R: [Roberto quietly walks over to the dollhouse Roberto began playing with the toys. He remained
and removes half the family from the house. He hesitant around me, but he was drawn to the toys
begins arranging the figures in different positions.] that allow him to express his reality.
T: “You’re moving those around. It seems like you I began tracking. This communicated interest and
know where everybody goes.” understanding to Roberto without imposing or
leading the play.
R: [Roberto solemnly stares at the family and While occupied with his play, Roberto expressed
quietly responds to the therapist without making his sadness and experience through his voice,
eye contact.] “Yeah.” body language, and play.
T: “You feel sad [tone and body language should Reflection of feeling was used to bring Roberto’s
match the reflection].” sadness to his awareness while continuing
to provide a safe and supportive space to
experience this sadness.
R: “Um, a little, but it’s fine! Ooh, look, there are It is not uncommon for children to appear
dinosaurs in here!” uncomfortable with their difficult emotions. In
addition, I began to see how Roberto’s depressive
symptoms appeared as difficulty staying on task.
TABLE 1.2. ROBERTO: TRANSCRIPT/ANALYSIS
Transcript Analysis
R: [Roberto spends his eighth session hitting the Roberto was much more comfortable in the
bop bag with a sword. Meanwhile‚ he is shouting counseling room and felt safe to express his anger
angrily at the bop bag.] to me.
T: “You are so mad! You want to show how angry I reflected Roberto’s feelings and tracked what
you are.” he is trying to do. I used a tone to communicate
understanding and not judgment.
R: “DON’T SAY THAT! I DON’T WANT YOU TO Roberto did not like his anger being seen as he
TALK!” [Roberto hits the therapist on the leg with had received the message that his anger was not
the sword.] allowed. This triggered his condition of worth that
he must be “good” to be worthy.
T: “Roberto, I know you are very angry‚ but I am I used limit setting here to express to him that
not for hitting. You can choose to hit the bop bag hitting people was not the appropriate way to
or you can choose to hit the dolls.” express anger. By offering choices to express
his feelings, I did not shut down his feelings but‚
rather‚ shared a way that he can express them.
R: [Roberto immediately shut down‚ embarrassed Roberto was expressing his guilt. He began his
and concerned about his relationship with the negative self-­talk.
therapist.] “I’m sorry; I didn’t mean to hurt you.
Please don’t be mad; my teacher says I make bad
choices.”
T: “You’re worried about how I feel about you. You I stayed with reflecting feelings here. It was not my
were just trying to show me how mad you are.” goal to rescue the client but‚ rather‚ to express
empathy and unconditional positive regard.
R: “Yeah.” [Roberto begins to hit the bop bag Roberto felt understood by me and was able to
again.] continue his play.
T: “You chose to hit that instead. You knew just I used encouragement to reflect that Roberto was
what to do!” able to make choices on his own that helped him
express his anger.
 Depression 11

Ethical and Cultural Considerations

Ceballos et al. (2021) presented cultural considerations for the use of CCPT.
These authors highlighted the need for play therapists to understand and apply
the tenets of the theory within the cultural bounds of the client. For example,
while self-­actualization in individualistic cultures is understood as clients’ tak-
ing decisions that promote independence, in collectivistic cultures, self-­actualizing
tendency can be viewed as an interdependence process. In the case of Roberto,
both of his parents come from cultures known for being collectivistic (Sue &
Sue, 2016). Taking this into account, I needed to understand that Roberto’s self-­
actualization process may be understood within the context of what was in the
best interest of the whole family and not only of him.
Ceballos, Post, and Rodríguez (2021) highlighted the need to account for the
effects of oppressive factors on clients’ self-­actualizing force as oppression can
play a role in children’s ability to self-­actualize. When working with Roberto, it
was important to look at his experiences in school as a biracial child and whether
these experiences had been negative or discriminatory, as exposure to discrimi-
nation could be an ongoing external stressor that negatively affected Roberto’s
self-­actualizing force. In this case, engaging in advocacy actions on behalf of the
client or with the client’s parents was a way to intervene at the school. In addi-
tion, Cornelius-­White (2016) cautioned about the importance of person-­centered
therapists acknowledging their intersectionality of identities in relation to their
privileges. This awareness is critical to form genuine relationships with clients
characterized by respect and empathy (Cornelius-­White, 2016). While working
with Roberto, it was important for me to engage in self-­reflection about my own
identity as an upper-­ middle-­class Venezuelan woman who immigrated to the
United States as a young adult and to consider any unconscious biases I may
have.
Similarly, play therapists must be aware of how oppression affects the cli-
ent’s presenting problem and to what extent internalized oppression exists and
contributes to the formation of conditions of worth. For example, in the case of
Roberto, I had to conceptualize whether Roberto had internalized microaggres-
sions about his racial identity or microaggressions he had witnessed his mother
or father experience. If it was determined that he had internalized these messages
received through his lived experiences with oppression, I had to conceptualize
what, if any, conditions of worth Roberto had formed around these experiences.
For example, later during the treatment, his father reported Roberto witnessed
him experiencing discrimination for having an accent. This could have contrib-
uted to Roberto’s sense of feeling that he was not good enough to belong in his
school or with a group of friends.
Ethically, I had to be careful with confidentiality. Although Roberto was a
minor and the parents had a legal right to access the therapeutic information,
the play therapist had to consider Roberto’s right to privacy and confidential-
ity (ACA, 2014). Thus, when talking to parents, I reported overall impressions
12 Chapter 1

and talked about emerging play therapy themes but never disclosed specific play
behaviors or verbal disclosures that Roberto made unless it became necessary
(e.g., disclosing wanting to harm himself). There is also an ethical obligation to
attend to Roberto’s cultural background (ACA, 2014) by delivering culturally
responsive CCPT, which was done by following best practices provided in the
literature (Ceballos et al., 2021). In addition, it was important for me to imple-
ment culturally and age-­appropriate assessments with Roberto to ensure that
results were valid and applicable to him. Finally, it was important for me to seek
supervision and relevant information regarding the client’s presenting issue (ACA,
2014). I made sure to have knowledge of depression in childhood and to seek
peer supervision as needed throughout the case to maintain objectivity.

Parent and Teacher Consultations

I met with parents about once a month to discuss progress and with the teacher
once at the beginning of treatment and once toward the middle of treatment (at
about 12 sessions). When working with Roberto’s parents and teachers, I had spe-
cific goals in mind that guided the consultation. First, I worked to help Roberto’s
parents and teacher differentiate between ADHD and depressive symptomatol-
ogy. I did this by helping the parents and teachers notice the difference between
Roberto’s behaviors related to his inattention and behaviors related to his feelings
of sadness. For example, through talking to his teacher, it was noted that Roberto
tended to start talking about dinosaurs and become agitated when he no longer
could sit in his sadness. When not looking for depression, it can be easy to mis-
take this type of behavior as a symptom of ADHD rather than depression.
In addition, I worked with Roberto’s family and teachers to know how
to respond to Roberto’s feelings. Many of the skills used (reflection of feeling,
returning responsibility, encouragement, and limit setting) were especially helpful
to Roberto to create space for his feelings without perpetuating his conditions of
worth (i.e., I must be happy to be worthy). Later during the treatment, Rober-
to’s mother was able to participate in Child-­Parent Relationship Therapy, which
allowed her to gain a deeper understanding of these skills. I also provided psy-
choeducation about child development and childhood depression to increase the
caregivers’ empathy and ability to respond to Roberto in a more developmentally
appropriate manner.

Conclusion
Throughout Roberto’s time in therapy, he was able to make significant prog-
ress in identifying his feelings and noticing when they were coming up for him.
Through his growth, he found ways to express his anger and sadness, which
in turn reduced the angry outbursts that his teachers and parents reported. As
he worked through these feelings, Roberto’s parents and teacher also noticed a
decrease in his anxiety and his willingness to participate more in social activities,
 Depression 13

although he still showed signs of anxiety when faced with new tasks and was shy
when engaged with new people. I was able to effectively use CCPT with Roberto
to create a space in which he was able to explore his feelings in a nonpunitive
way and learn how to process and experience the symptoms of his depression.
Through play therapy and my attitudinal conditions, Roberto felt accepted and
was able to become more congruent without feeling further isolated. In addition
to validating Roberto’s feelings, I was able to validate his experience as a biracial
child. Roberto’s entire identity was considered in understanding him. Throughout
therapy, I found out there had been experiences of bullying related to his and his
parents’ racial identity. I perceived these as factors contributing to his conditions
of worth and perfectionistic themes. Through parent and teacher consultations,
Roberto’s parents and teachers increased insight into Roberto’s experience, which
in turn impacted their level of empathy for him. Overall, this case example shows
ways that CCPT can be used in treating childhood depression.

Sample Case Notes

Session 1
Diagnosis/Presenting Problem: The child’s parents brought the child to counsel-
ing to address angry outbursts, feelings of anxiety, and difficulty in school.
Intervention: Child-­Centered Play Therapy
Description of Play: The child worked to explore the playroom and become
familiar with the counselor. The client maintained a sad affect while playing with
the dolls as evidenced by speaking low and body language. The client appeared
uncomfortable with his sadness as evidenced by quickly changing the subject
when the counselor brought attention to his feelings.
Assessment: The child engaged primarily in exploratory play while he familiar-
ized himself with the playroom. It appeared important to the client that he was
able to explore and be in charge of himself as evidenced by confirming that he
was able to make his own choices in the playroom.

Session 8
Diagnosis/Presenting Problem: The child’s parents brought the child to counsel-
ing to address angry outbursts, feelings of anxiety, and difficulty in school.
Intervention: Child-­Centered Play Therapy
Limits Set: Counselor set limits to protect counselor safety and provided choices
around how the client can express his anger.
Description of Play: The child worked to express his anger and, at the same time,
to maintain his relationship with the counselor. The client demonstrated guilt
when he was unsure of the appropriate way to express his anger as evidenced by
negative self-­talk.
14 Chapter 1

Assessment: The child engaged in relationship and abandonment themes through-

out the session as evidenced by wanting to repair his relationship with the thera-
pist after the limit was set. The client experienced conditions of worth that made
him believe that he had to control his emotions to be considered worthy.

Resources

For Professionals
Child-­Centered Play Therapy Treatment Manual found in Advanced Play Ther-
apy: Essential Conditions, Knowledge, and Skills for Child Practice by Dee C.
Ray (2011).
Children’s Depression Inventory Assessment by Maria Kovacs (1978).
Dibs in Search of Self: The Renowned, Deeply Moving Story of an Emotionally
Lost Child Who Found His Way Back by Virginia Axline (1986).

For Children
A Terrible Thing Happened: A Story for Children Who Have Witnessed Violence
or Trauma by Margaret M. Holmes (2000).
Was It the Chocolate Pudding?: A Story for Little Kids about Divorce by Sandra
Levins & Bryan Langdo (2006).
When Sadness Is at Your Door by Eva Eland (2019).

For Parents
How to Talk So Teens Will Listen and Listen So Teens Will Talk by Adele Faber
& Elaine Mazlish (2006).
The Whole-­Brain Child: 12 Revolutionary Strategies to Nurture Your Child’s
Developing Mind by Daniel J. Siegel & Tina P. Bryson (2011).
Parents may also benefit from participating in a Child-­Parent Relationship Ther-
apy group to practice strategies that help them engage relationally with their
child.

Discussion Questions
1. How do Roberto’s experiences as a biracial child impact his conditions of
worth?
2. How would you discuss Roberto’s potential depression diagnosis with his
parents and teachers?
3. What are different cultural views about depression that need to be consid-
ered. How would this knowledge be helpful in explaining Roberto’s diagnosis
to his family?
4. How did you see CCPT address Roberto’s symptoms of depression? Please
give specific examples.
 Depression 15

5. Is there other information and/or resources that you believe would be helpful
for parents and teachers to support Roberto?

References
Abela, J. R. Z., & Hankin, B. L. (2008). Cognitive vulnerability to depression in
children and adolescents: A developmental psychopathology perspective. In J.
R. Z. Abela & B. L. Hankin (Eds.), Handbook of depression in children and
adolescents (pp. 35–78). Guilford Press.
Allgaier, A. K., Krick, K., Opitz, A., Saravo, B., Romanos, M., & Schulte-­Körne,
G. (2014). Improving early detection of childhood depression in mental health
care: The children’s depression screener (ChilD-­ S). Psychiatry Research,
217(3), 248–252. https://doi​​.org/10.1016/j​​.psychres.2014.03.037
American Counseling Association. (2014). 2014 ACA code of ethics. https://www​​
.counseling​​.org/docs/default-­source/default-­document-­library/2014-code-­of​
-­ethics-­finaladdress​​.pdf
American Psychiatric Association. (2022). Diagnostic and statistical man-
ual of mental disorders (5th ed., text rev.). https://doi​​ .org/10.1176/appi​​
.books.9780890425787
Avenevoli, S., Stolar, M., Li, J., Dierker, L., & Ries Merikangas, K. (2001). Comor-
bidity of depression in children and adolescents: Models and evidence from a
prospective high-­risk family study. Biological Psychiatry, 49(12), 1071–1081.
https://doi​​.org/​10.1016/s0006-3223(01)01142-8
Axline, V. M. (1986). Dibs in search of self. Ballantine Books.
Axline, V. M., & Carmichael, L. (1947). Play therapy: The inner dynamics of
childhood. Houghton Mifflin.
Baggerly, J. (2004). The effects of child-­centered group play therapy on self-­
concept, depression, and anxiety of children who are homeless. International
Journal of Play Therapy, 13(2), 31–51. https://doi-­org​​.libproxy​​.library​​.unt​​
.edu/10.1037/h0088889
Bibi, A., Lin, M., Zhang, X. C., & Margraf, J. (2020). Psychometric properties and
measurement invariance of depression, anxiety and stress scales (DASS‐21)
across cultures. International Journal of Psychology, 55(6), 916–925. https://
doi-­org​​.libproxy​​​.library​​​.unt​​.edu/10.1002/ijop.12671
Bibi, A., Masroor, U., & Iqbal, N. (2013). Dysfunctional attitudes and demo-
graphic correlates of patients with conversion disorder; an exploratory study.
Journal of Pakistan Psychiatric Society, 10(1), 25–29.
Burgin, E. E., & Ray, D. C. (2022). Child-­centered play therapy and childhood
depression: An effectiveness study in schools. Journal of Child and Family
Studies, 31(1), 293–307. https://doi​​.org/​10.1007/s10826-021-02198-6
Ceballos, P. L., Post, P., & Rodríguez, M. (2021). Practicing child-­centered play
therapy from a multicultural and social justice framework. In E. Gil & A. A.
Drewes (Eds.), Cultural issues in play therapy (pp. 13–31). Guilford Press.
16 Chapter 1

Centers for Disease Control and Prevention. (2023, March 8). Data and statistics
of children’s mental health. https://www​​.cdc​​.gov/childrensmentalhealth/data​​
.html#print
Cornelius-­White, J. (2016). Person-­centered approaches for counselors. Sage Pub-
lications. https://doi​​.org/10.4135/9781506302621
Delaney, L., & Smith, J. P. (2012). Childhood health: Trends and consequences
over the life course. The Future of Children, 22(1), 43–63. https://doi​​
.org/10.1353/foc.2012.0003
Eland, E. (2019). When sadness is at your door. Random House Children’s Books.
Faber, A., Mazlish, E., & Coe, K. A. (2016). How to talk so teens will listen &
listen so teens will talk. Collins, an imprint of HarperCollins.
Garber, J. (2006). Depression in children and adolescents: Linking risk research
and prevention. American Journal of Preventive Medicine, 31(6 Suppl 1),
S104–S125. https://doi​​.org/10.1016/j​​​.amepre.2006.07.007
Haas, S. C., & Ray, D. C. (2020). Child-­centered play therapy with children
affected by adverse childhood experiences: A single-­case design. International
Journal of Play Therapy, 29(4), 223–236. https://doi​​.org/10.1037/pla0000135
Holmes, M. M. (2000). A terrible thing happened. Magination Press.
Jayne, K. M., & Ray, D. C. (2015). Therapist‐provided conditions in child‐­
centered play therapy. Journal of Humanistic Counseling, 54(2), 86–103.
Korczak, D. J., Madigan, S., & Colasanto, M. (2017). Children’s physical activity
and depression: A meta-­analysis. Pediatrics, 139(4), e20162266. https://doi​​
.org/​10.1542/peds.2016-2266
Kovacs, M. (1978). Children’s depression inventory (CDI) [Database record]. APA
PsycTests. https://doi​​.org/10.1037/t00​788​-000
Landreth, G. L. (2012). Play therapy: The art of relationship (3rd ed.). Routledge/
Taylor & Francis Group.
LeMoult, J., Humphreys, K. L., Tracy, A., Hoffmesiter, J., Ip, E., & Gotlib, I. H.
(2020). Meta-­analysis: Exposure to early life stress and risk for depression
in childhood and adolescence. Journal of the American Academy of Child &
Adolescent Psychiatry, 59(7), 942–855.
Levins, S., & Langdo, B. (2006). Was it the chocolate pudding? A story for little
kids about divorce. Magination Press.
Lin, Y.-W., & Bratton, S. C. (2015). A meta-­analytic review of child-­centered
play therapy approaches. Journal of Counseling & Development, 93, 45–58.
https://doi​​.org/10​.1002/j​.1556​-6676​.2015.00180.x
Maughan, B., Collishaw, S., & Stringaris, A. (2013). Depression in childhood and
adolescence. Journal of the Canadian Academy of Child and Adolescent Psy-
chiatry = Journal de l’Academie Canadienne de Psychiatrie de l’enfant et de
l’adolescent, 22(1), 35–40.
Mills, S. E. E., & Baker, L. D. (2016). Childhood depression. InnovAiT, 9(9),
524–530.
Mumford, D. B., Devereux, T. A., Maddy, P. J., & Johnston, J. V. (1991). Factors
leading to the reporting of “functional” somatic symptoms by general practice
 Depression 17

attenders. British Journal of General Practice: The Journal of the Royal Col-
lege of General Practitioners, 41(352), 454–458.
Ray, D. (2011). Advanced play therapy: Essential conditions, knowledge, and skills
for child practice (1st ed.). Routledge. https://doi​​.org/10.4324/9780203837269
Ray, D. C. (2018, October). Advanced play therapy. Doctoral counseling course,
Denton, TX.
Ray, D. C., Armstrong, S. A., Balkin, R. S., & Jayne, K. M. (2015). Child-­centered
play therapy in the schools: Review and meta-­analysis. Psychology in the
Schools, 52, 107–123. https://doi​​​.org/10.1002/pits.21798
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic per-
sonality change. Journal of Consulting Psychology, 21(2), 95–103. https://doi​​
.org/​10.1037/h0045357
Rueger, S. Y., Malecki, C. K., Pyun, Y., Aycock, C., & Coyle, S. (2016). A meta-­
analytic review of the association between perceived social support and
depression in childhood and adolescence. Psychological Bulletin, 142(10),
1017–1067. https://doi​​​.org/​10.1037/bul0000058
Sánchez Rus, S. S., Solis, M. O., Rodriguez, L. S., & Suárez-­Gómez, M. (2021).
Depressive disorder in childhood: The importance of an early diagnosis for
a functional recovery. Specific symptoms and treatment in an 8-years old
patient with depression. European Psychiatry, 64(Suppl 1), S332. https://doi​​
.org/10.1192/j​​​.eurpsy.2021.891
Satinsky, E. N., Kakuhikire, B., Baguma, C., Rasmussen, J. D., Ashaba, S.,
Cooper-­Vince, C. E., Perkins, J. M., Kiconco, A., Namara, E. B., Bangsberg,
D. R., & Tsai, A. C. (2021). Adverse childhood experiences, adult depression,
and suicidal ideation in rural Uganda: A cross-­sectional, population-­based
study. PLOS Medicine, 18(5), e1003642. https://doi​​.org/10.1371/journal​​​
.pmed.1003642
Siegel, D. J., & Bryson, T. P. (2016). The whole-­brain child: 12 revolutionary strat-
egies to nurture your child’s developing mind. Langara College.
Strand, M., & Bäärnhielm, S. (2022). Could the DSM-5 cultural formulation
interview hold therapeutic potential? Suggestions for further exploration and
adaptation within a framework of therapeutic assessment. Culture, Medicine
and Psychiatry, 46(4), 846–863. https://doi​​.org/10.1007/s11013-021-09761-2
Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: Theory and prac-
tice (7th ed.). John Wiley & Sons.
Weisz, J. R., McCarty, C. A., & Valeri, S. M. (2006). Effects of psychotherapy for
depression in children and adolescents: A meta-­analysis. Psychological Bulle-
tin, 132(1), 132–149. https://doi​​.org/10.1037/0033-2909.132.1.132
Zisook, S., Lesser, I., Stewart, J. W., Wisniewski, S. R., Balasubramani, G. K.,
Fava, M., Gilmer, W. S., Dresselhaus, T. R., Thase, M. E., Nierenberg, A. A.,
Trivedi, M. H., & Rush, A. J. (2007). Effect of age at onset on the course of
major depressive disorder. American Journal of Psychiatry, 164(10), 1539–
1546. https://doi​​.org/10.1176/appi​​.ajp.2007.06101757
 CHAPT E R 2

Adjustment Difficulties
Child-­Centered Play Therapy and Critical Race Theory
with a Biracial Child
Keith I. Raymond and Angela I. Sheely-­Moore

Laenor “El” is an 8-year-­old biracial, cis male who racially identifies as “pinkish.”
During the intake, El’s Black American father, Daemon, and White mother, Laena,
reported changes in El’s demeanor since relocating to a new town the previous
summer due to Laena’s job promotion. Both parents expressed concerns about
El’s emotional and physical outbursts toward Laena when she attempts to disci-
pline him when house rules are broken. Both parents noticed how El has with-
drawn from expressing himself openly, with the exception of showing his anger
and frustration. Both parents acknowledged that similar to their old neighbor-
hood, their new town is predominantly White. However, with the recent move,
they reported El having difficulty adjusting to their new home and community.
Instead of meeting new friends, El prefers to stay home, gaming all day.

For this case study, consider the following questions:

1. How does history inform El’s biracial identity development?
2. What is the rationale for using Child-­Centered Play Therapy and Critical
Race Theory with El?
3. What strengths, grounded in the Black American and other minoritized popu-
lations, can support El and his family?

Racial Identity Development in Children

It is essential to understand and support racial identity development for youth of
color. In the case of El, we need to unpack how he navigates his biracial identity
development to better understand his view of self, others, and the world (Gathier
et al., 2014) within the context of a White-­dominant culture in the United States.
Before diving into El’s world as a young biracial male, we need to understand the
implications of the historical, legal racial classification of the “one drop rule” that
continues to impact individuals of Black ancestry.

19
20 Chapter 2

Black-­categorization bias of bi- and multiracial people originated in 1702

with the “one drop rule” in the state of Virginia (Goodyer & Okitikpi, 2007;
Roberts & Gelman, 2017). These authors explained how individuals with traces
of African/Black ancestry were categorized as Black or more Black than White
with the sole intention of distinguishing between and the division of Black and
White people. Despite the US Census abandoning this policy in 2000, these
authors indicated that White and monoracial people continue to maintain similar
presumptions that bi- and multiracial people are more Black than White. Exam-
ining El’s social and structural perspective of his biracial identity could serve as
a catalyst to self-­acceptance and pride in adopting a positive, healthy biracial
identity. Hence, to prepare El for how US society will perceive him not as a young
biracial male, but as a young Black male, El’s father sought out a Black American
play therapist (the first author of this book chapter) to provide representation
and to increase El’s comfort with his biracial identity status.
Although El’s father encourages El to embrace his Black heritage, developing
a firm biracial identity is a process in which El would need additional space to
explore his Whiteness. Researchers (Gathier et al., 2014; Morrison & Bordere,
2001) proposed developmental stages for biracial children, which in some ways
parallel the historical “one drop rule” by centering Whiteness as a critical aspect
of this model. The first proposed stage occurs by the age of 2 when children begin
to notice racial differences. During the second stage, which happens by the age
of 3, children begin to recognize their own racial identity in a concrete manner,
categorize people by race, and communicate a racial preference. For the third
stage, children at the age of 4 start to recognize the social effects of skin color,
show a pro-­White bias, or feel a sense of pressure to choose between their bira-
cial or multiracial identities. During stage four, 5-year-­old children develop more
favorable stereotypes of the dominant White racial group and more unfavorable
stereotypes of marginalized racial groups. The remaining two stages involve chil-
dren understanding the depth of racial identity, including being bi- or multiracial.
Although the aforementioned biracial identity development reflects a linear
process with corresponding age ranges, El appears to fall within the second and
third stages. Various internal and external factors (e.g., individual perception,
personality, ethnicity, gender, family, society, political climate, and racist events
such as George Floyd’s murder) influence biracial children’s identity development
(Morrison & Bordere, 2001). For example, El’s father identifies his son as Black,
whereas his mother wants El to self-­identify in a way that also honors her White
ancestry. Many biracial children may struggle to form their racial identities due
to feeling the need to compromise (Morrison & Bordere, 2001). Based on what
El witnesses in his family unit and his surrounding White community, he chooses
to label himself as “pinkish,” possibly in hopes of finding a middle ground.
Clearly, El is processing his physical and social features associated with race,
including his skin tone and his transition to a new home and community (Mor-
rison & Bordere, 2001). As play therapists, it is essential to address El’s racial
 Adjustment Difficulties 21

identity while mitigating the potential conflict of choosing between his racial
identities based on influences from his parents, the environment, and other social
factors. El can form a strong biracial identity and choose how he self-­identifies by
providing a safe space to explore his identity through play.

Child-­Centered Play Therapy

Given El’s developmental level and environmental factors shared by his parents
related to El’s struggle in adjusting into his new and predominantly White com-
munity, Child-­Centered Play Therapy (Axline, 1981; Landreth, 2012) and Criti-
cal Race Theory (Delgado & Stefancic, 2017) would benefit El for a few reasons.
First, the innate propensity for self-­understanding and self-­acceptance is the cor-
nerstone of the child-­centered framework. Trusting in El’s inner capacity to set
his own pace to explore himself, others, and the world will not only enhance
his self-­esteem, but will also affirm his own personhood—including how he self-­
identifies racially. Promoting self-­agency for El will also set the tone for him to
process emotional and physical outbursts in a socially constructive and acceptable
manner. Providing toys that can be used in “aggressive” ways (while keeping El,
myself, and the toys clear of intentional physical harm) will enhance El’s capacity
to engage in self-­control and, ultimately, self-­responsibility for his actions. Last,
race can be taxing and at times traumatic for persons of color who experience
power over, lack of privileges, and oppression on a daily basis. Within the con-
text of therapy, it is critical for play therapists to understand that play is cultur-
ally contextualized (Sheely-­Moore, Ceballos, Lin, & Ogawa, 2020). To ignore the
issue of race and racism would communicate disconnection and invalidation to
El’s experience as a biracial youth living in a predominantly White community.
Child-­Centered Play Therapy (CCPT; Axline, 1981; Landreth, 2012) is based
on the premise that children have the innate capacity to move in a forward, con-
structive manner. In essence, the core of human nature is good. My role as El’s
therapist using a CCPT framework is to promote his natural tendency to develop
in a positive, healthy manner by communicating three key ways of being: uncon-
ditional positive regard, genuineness, and empathy (Landreth, 2012). Ultimately,
my goal with El is to provide toys and other materials to give him a platform to
communicate his perception of the world and how the world sees him. Doing
so will enhance El’s capacity to express a wide range of thoughts, feelings, and
behaviors—while accepting all parts of himself, as I continuously demonstrate
my acceptance of him.

Critical Race Theory

According to DiAngelo (2021) and Kendi (2019), racially colorblind ideology
leads to support for racist policies and procedures. Play therapists practicing
from a colorblind framework may thereby engage in and perpetuate racist prac-
tices. This colorblind framework can be reflected in counseling research that
22 Chapter 2

highlighted the negative impact of racism on Black, Brown, and indigenous cli-
ents through their underuse of mental health services when compared to their
White counterparts (Kilmer et al., 2019) and experienced racial microaggressions
in counseling (Sue et al., 2007).
Although play has been described as the universal language for all children
(Landreth, 2012), the nuances of play remain culturally contextualized. Hence,
it is important to include a theory that centers on the social and institutional
embeddedness of race and the impact of race on disenfranchised members of
society. Hence, it behooves play therapists to challenge and disrupt colorblind
ideologies by acknowledging the impact of race and racism. Critical Race The-
ory (CRT) provides the grounding to engage in such actions. There are five main
tenets of CRT, all of which centralize White people and their sociopolitical power
to maintain this supremacy over others for their benefit (Delgado & Stefancic,
2017). Using a CRT framework, my role with El is to invite the conversation of
race into the playroom by validating El’s experience of racism, racial microag-
gressions, and racist events such as George Floyd’s murder. Narrative storytell-
ing (Trahan & Lemberger, 2014), one of CRT’s tenets, honors the experiences
shared by people of color. Within the US society, embedded in White privilege and
power, the history of people of color is ignored and misrepresented—with min-
imal perspectives taken outside of a White person’s lens (Delgado & Stefancic,
2017). Providing space for El to explore and articulate his experience of a biracial
male living in a predominantly White community can affirm his experiences as
real and not imagined or taken out of context. My goal with El is to affirm his
biracial identity with equal value and worthiness for both racial backgrounds.

Case Study Application

Understanding El within a historical context of being Black in America, along
with a nascent biracial identity developmental model and theoretical underpin-
nings for CCPT and CRT, we can return to El and explore how these concepts
and tenets come to fruition in therapy. From a CCPT perspective, I conceptual-
ize El as capable of uncovering and resolving challenges that he has faced, both
past and present, within a therapeutic relationship that is based on the three core
conditions (Axline, 1981; Landreth, 2012). Infusing a CRT lens within my work
with El will provide opportunities to broach and unpack race and racism in an
open, validating, and healing manner.

Session 1
The goals for my first session with El were twofold: to build rapport with El and
to empower El by having him decide if he wants to continue play therapy sessions
with me. After I introduced him to the playroom, El began to explore the area by
pointing, hitting, and eventually punching the bop bag with more force when he
learned that no video games were available in the playroom. He then proceeded
to share his plan to draw a picture.
 Adjustment Difficulties 23

TABLE 2.1. EL: SESSION 1

Transcript Analysis
El: [Starts to look through crayons available in the El appeared frustrated while looking in the crayon
box] “Ugh . . . [sigh].” box.
T: “You are looking really hard for something you I communicated understanding of El’s search for a
can’t find.” specific crayon.
El: “I can’t find the crayon that looks like me El was clearly upset for not locating a particular
[makes grunting noise].” shade of his skin tone.
T: “You are frustrated that you can’t find the color I validated El’s emotions and communicated
that matches your skin color.” acceptance by exploring and acknowledging his
racial identity in a developmentally appropriate
manner.
El: “Which crayon do I use?” El looked to an external locus of control to decide
which crayon matched his skin color rather
than depending upon himself to develop his
self-­concept.
T: “You can decide which color crayon to use.” I encouraged El to take the lead by trusting
himself to form his own racial identity.
El: “I don’t want to use these crayons. These El began to explore his racial identification instead
crayons don’t look like me.” of relying on me to determine his racial identity.
T: “You put a lot of thought into deciding you don’t I highlighted the strength it took for El to recognize
want to use these crayons because they don’t that the selection of crayons did not match his
match your skin.” skin color.
El: [Gets up from the table, walks over to the bop El demonstrated a play disruption here when his
bag and punches it hard.] feelings were challenging to process.

Treatment Goals
Upon receiving parental confirmation that El wanted to continue with therapy,
we agreed to the following treatment plan: (1) reduce emotional and physical
outbursts and aggressive behaviors and (2) increase the ability to communicate
feelings more assertively and constructively. The treatment objectives were as
follows:
1. Identify and express thoughts and feelings associated with emotional and
physical outbursts.
2. Explore and create meaning for El’s racial identity and develop a positive
self-­concept.
3. Conduct parent consultations to discuss treatment goals, progress, and
recommendations.
During this same parent consultation, I shared the multicultural theme that
emerged from his play. I knew El’s play was interrupted because he could not
locate a crayon that matched his skin tone. Therefore, I asked his parents for
24 Chapter 2

recommendations on toys that would be racially and ethnically appropriate to

include in his play while avoiding making assumptions on my behalf.

Session 2
My objective for the second session was to incorporate additional toys and mate-
rials his parents suggested to better represent El’s world. I also wanted El to take
the lead by providing him opportunities to explore his biracial identity, which he
did by beginning the second session excitedly locating a marker that represented
his skin tone.
El experienced a significant breakthrough toward the end of the second ses-
sion as he courageously recounted his painful experiences with covert racism and
racial discrimination at school. El disclosed that his classmates made derogatory
racial remarks about his skin tone and implied that his mother could not be his
mother because she was White. From a CRT lens, it was my responsibility to
dismantle the colorblind rhetoric that maintains racism and White supremacy in
America. At that moment, I made it a priority to honor our racial identities and

TABLE 2.2. EL: SESSION 2

Transcript Analysis
El: [Starts dancing and singing in the chair as he El’s self-­esteem increased when he identified the
draws himself] marker that resembled his skin color.
T: “You are working really hard drawing yourself.” I highlighted El’s effort in creating a self-­portrait.
El: [Looks at me several times] “You are darker El explored various shades of brown and black
than me, so I am going to use this marker.” before selecting a marker that best matched my
skin tone.
T: “You noticed the differences in our skin color I broached and highlighted El’s observations about
and want to make sure you pick the right color.” our differences in skin tone.
El: [Pause and slight smile] “You look like my El’s comfort level seemed to have increased as
favorite cousin.” this time was the first where he self-­disclosed.
T: “I remind you of your cousin who is Black, just Often therapists avoid discussing race to avoid
like me.” offending clients. However, I found it essential
to share my Black racial identity to enhance our
relationship and to increase El’s comfort level to
discuss race.
El: [Pause] “Yeah, but I don’t see him anymore or Positive racial representation for youth of color
anyone that looks like you.” can help ensure that they are validated, heard,
and understood.
T: “You seem sad that you don’t get to see your El expressed sadness for the first time, so it was
cousin or Black people often.” important that I acknowledged his feelings.
El: “Yeah.” [gets up from the table, walks over to El demonstrated play disruption as he expressed
the bop bag, and starts punching it] sadness about his disconnection with his cousin
and other people of color.
 Adjustment Difficulties 25

empower El to narrate his own story to form his own racial identity. I facilitated
this by fostering a space for El to engage in counter-­storytelling through his draw-
ings in opposition to the prevalent White dominant narratives told and upheld in
El’s occupied environments. I facilitated El’s counter-­stories by encouraging and
empowering him to help him feel comfortable and confident in using his voice to
share his counter-­stories to combat racist and discriminatory narratives and to
construct narratives that defined his experiences and worldview. I employed min-
imal tracking and paraphrasing responses to allow him to take the lead in telling
his story. By leaning forward, matching my tone and attitude to his effect, and
reflecting on El’s feelings, I conveyed that I was with him, heard him, understood
him, and acknowledged that his story mattered.
In the following sessions, El experienced intense emotions due to conflicting
issues related to his biracial identity and experiences of racial prejudice, which
required ordering a new bop bag to continue processing his feelings in a healthy
manner. During the working stage of El’s therapeutic process, he remained in
stage three of the biracial identity development model. Specifically, El understood
that he did not have the same privileges as his White peers. El began to articu-
late observed racial differences between himself and others, to express feelings
of anger toward his mother, and to share how he often felt betrayed by his mom
for scheduling play dates with the White parents of the students who made rac-
ist comments about him. Eventually, El demonstrated anxiety themes within his
play as he attempted to determine his racial identity. In subsequent sessions the
theme of anxiety dissipated with El’s increased comfort when he began to share
additional instances of racial prejudice within his social environments, which
prompted me to schedule frequent phone calls with his parents.

Ethical and Cultural Considerations

Counselors are ethically bound to provide culturally and developmentally appro-
priate treatment to their clients. Hence, it is critical to examine my own cultural
knowledge, biases, attitudes, and beliefs (Holcomb-­McCoy, 2009) to avoid per-
petuating colorblind ideology and racial microaggressions. The implementation
of CCPT and CRT served to empower El by deconstructing race on his own terms
and in his own time frame. Using these strength-­based theoretical frameworks
also prevented me from labeling El as defiant or misdiagnosing his exhibited
emotions as having anger problems before understanding his worldview. With
El’s minor legal status, it was also imperative to engage his parents on a con-
sistent basis while maintaining confidentiality and fidelity with El. Maintaining
transparency with El’s caregivers regarding what can and cannot be shared about
El’s session promoted agency within El to take the sessions where he needed them
to go while keeping his parents informed on as-­needed basis.
26 Chapter 2

Parent Consultations
With El’s presenting issue centered on race, including discrimination, I conducted
regularly scheduled parent consultations to gain more insight into El’s home,
neighborhood, and school environment that seemed to impact El’s daily function-
ing and views about himself. During these consultations I also had to consider
the cultural impact of race on El’s parents by exploring their family dynamics
and cultural values (Holcomb-­McCoy, 2009). Daemon and Laena had different
views about how to parent their child racially and ethnically. Although they both
identify El as Black, Laena did not want to disregard her White ancestry and was
unsure how to share her thoughts related to this issue with the family.
Based on El’s needs, I encouraged his parents to have conversations with El
about their own cultural background, to share information about Black and bira-
cial identity, and to encourage El to explore his racial identity freely. Using a CRT
perspective, I discussed with his parents the potential benefits of imparting cultural
knowledge and fostering a community that reflects both of his cultural identities
by adopting a cultural relativistic paradigm (i.e., a person’s behaviors, attitudes,
beliefs, values, practices, and worldviews understood in light of their own culture
and not judged by the standards of the White dominant group relative to the US
societal context) to dismantle the universalistic paradigm that devalues people of
color, such as El, and his position in predominantly White spaces.

Conclusion
El made significant progress in processing his racial identity issues and his experi-
ences of racism, discrimination, and racial microaggressions. Prior to termination,
El was able to communicate his thoughts, feelings, and experiences effectively
without getting easily angered as evidenced by a decrease in aggressive play and
the elimination of emotional and physical outbursts toward his mom. At the end
of therapy, El reached the final stages of the biracial identity development model
by gaining awareness of his biracial heritage and understanding that he can be
both Black and White and still identify as a Black male. As a result, El developed
a sense of pride in his biracial identity and gained self-­confidence.
As a culturally competent therapist, I am aware that CCPT is a framework
based on Eurocentric thought. Based on El’s complex issues of racial identity, rac-
ism, racial microaggressions, and oppression, I knew I could not solely draw from
a White ideological approach that would unjustly reflect and devalue his racial
identity and discriminatory experiences. Integrating CRT, a social justice frame-
work, alongside CCPT served to deconstruct Western colonist beliefs that nega-
tively impacted El’s daily life and impeded his racial identity development. Using
both CCPT and CRT allowed me to help dismantle systems of White dominance
and oppression experienced in El’s occupied environments while demonstrating
 Adjustment Difficulties 27

empathic understanding, genuineness, and acceptance. As a therapist, I learned

the importance of cultivating an inclusive and nurturing environment where
youth from different racial and ethnic backgrounds can freely form and learn to
embrace their racial identities on their own.

Sample Case Notes

Session 1
Subjective: Client expressed frustration when he could not locate a crayon that
matched his skin tone. Client stated, “I don’t want to use any of these crayons”
before hitting the bop bag.
Objective: Client’s general appearance and dress were appropriate. Client’s
behavior shifted from calm to aggressive, releasing built-­up tension. Throughout
the session, client’s mood fluctuated from happy, frustrated, and angry with con-
gruent affect. Client spoke minimally but talked clearly at an average rate and
volume.
Assessment: From a CCPT perspective, El demonstrated difficulty making deci-
sions independently due to relying on others to develop his self-­concept. El tended
to communicate his thoughts and feelings by punching the bop bag rather than
verbally articulating his experience.
Plan: Client will continue with weekly counseling sessions. Counselor will incor-
porate additional culturally and developmentally appropriate toys and materials
in the playroom.

Session 2
Subjective: Client stated his feelings about the therapist: “I really like playing with
you.” Client explored self-­racial identity and in relation to others when he stated,
“You are darker than me, so I am going to use this marker” and “You look like
my favorite cousin.”
Objective: Client’s speech was energetic while he drew a self-­portrait and main-
tained direct eye contact with the therapist while selecting a marker. Client’s eye
contact decreased when he inquired about race and racial experiences. Client
articulated his feelings verbally, nonverbally, and physically. Client’s mood was a
mixture of happy, angry, and sad with congruent affect.
Assessment: From a CCPT perspective, El was vulnerable when describing his
disconnection with people of color and his experience of racial discrimination at
school. The therapeutic connection deepened as the therapist demonstrated the
three core conditions of CCPT. El felt more at ease disclosing personal infor-
mation along with his feelings. From a CRT perspective, El was provided the
28 Chapter 2

opportunity to explore his own racial identity and dismantle White ideologies
that did not accurately reflect his biracial identity.
Plan: Client will continue with weekly counseling sessions. The therapist will
schedule a parent consultation to discuss possible strategies for broaching topics
about racial identity.

Resources

For Mental Health Professionals

Atkin, A. L., & Yoo, H. C. (2019). Familial Racial-­Ethnic Socialization of Multi-
racial American Youth: A Systematic Review of the Literature with MultiCrit.
Developmental Review, 53, 1–28.

For Children
Beauvais, G., & Jones, S. A. (2015). I Am Mixed. Stranger Comics.
Tyler, M., & Csicsko, D. L. (2005). The Skin You Live In. Chicago Children’s
Museum.

For Caregivers
The Conscious Kid. (2023). The Conscious Kid: Definitions of Words and Phrases
That Can Be Helpful to Understand When Discussing Race and Identity.
https://www​​.theconsciouskid​​.org/racial-­literacy-­key-­terms
Parents. (2023). Six Things to Stop Saying to Kids of Different Races and Ethnic
Groups. https://www​​.parents​​.com/parenting/better-­parenting/things-­to​-­stop​
-­saying​-­to-­kids-­of-­different-­races-­and-­ethnic-­groups/

Discussion Questions
1. Describe key considerations of El’s biracial experience and how it relates to
the historical structuring of race in America.
2. How did using CCPT and CRT in tandem work to help meet El’s treatment
goals? Provide examples.
3. As a therapist, what are some strategies that you would embody to avoid
the perpetuation of a colorblind ideology and racial microaggressions when
working with El and his family?

References
Axline, V. (1981). Play therapy. Ballantine Books.
Delgado, R., & Stefancic, J. (2017). Critical race theory: An introduction (3rd
ed.). New York University Press.
DiAngelo, R. (2021). Nice racism: How progressive White people perpetuate
racial harm. Beacon Press.
 Adjustment Difficulties 29

Gaither, S. E., Chen, E. E., Corriveau, K. H., Harris, P. L., Ambady, N., & Som-
mers, S. R. (2014). Monoracial and biracial children: Effects of racial identity
saliency on social learning and social preferences. Child Development, 85(6),
2299–2316.
Goodyer, A., & Okitikpi, T. (2007). “. . . But . . . But I am Brown.” The ascribed
categories of identity: Children and young people of mixed parentage. Child
Care in Practice, 13(2), 83–94.
Holcomb-­McCoy, C. C. (2009). Cultural considerations in parent consultation.
American Counseling Association.
Kendi, I. X. (2019). How to be an antiracist. One World.
Kilmer, E. D., Villarreal, C., Janis, B. M., Callahan, J. L., Ruggero, C. J., Kilmer, J.
N., Love, P. K., & Cox, R. J. (2019). Differential early termination is tied to
client race/ethnicity status. Practice Innovations, 4(2), 88–98. https://doi​​.org/​
10.1037/pri0000085
King, K., & Summers, L. (2020). Predictors of broaching: Multicultural com-
petence, racial color blindness, and interpersonal communication. Coun-
selor Education & Supervision, 59(1), 216–230. https://doi​​.org/10.1002.
ceas.12185
Landreth, G. (2012). Play therapy: The art of the relationship (3rd ed.).
Brunner-­Routledge.
Morrison, J. W., & Bordere, T. (2001). Supporting biracial children’s identity
development. Childhood Education, 77(3), 134–138.
Ray, D. C. (2011). Advanced play therapy: Essential conditions, knowledge, and
skills for child practice. Routledge/Taylor & Francis Group.
Roberts, S. O., & Gelman, S. A. (2017). Multiracial children’s and adults’ catego-
rizations of multiracial individuals. Journal of Cognition and Development,
18(1), 1–15.
Sheely-­Moore, A., Ceballos, P., Lin, Y. W., & Ogawa, Y. (2020). Culturally respon-
sive child parent relationship therapy. In Landreth, G., & Bratton, S. (Eds.),
Child parent relationship therapy (2nd ed.), 431–443. Routledge.
Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B.,
Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life:
Implications for clinical practice. American Psychologist, 62(4), 271–286.
Trahan, D., & Lemberger, M. (2014). Critical race theory as a decisional frame-
work for the ethical counseling of African American clients. Counseling and
Values, 59(1), 112–124. https://doi​​.org/10.1002/j.2161-007X.2014.00045.x
 CHAPT E R 3

Domestic Violence
Trauma-­Informed Child-­Centered
Play Therapy with a White Child
Jennifer N. Baggerly

Carla is a White 5-year-­old girl living with her mother and 3-year-­old brother in
a small apartment after her mother left her father due to domestic violence. Her
mother, Sara, presents as anxious and timid. Sara quietly explained that Carla
witnessed her father, Tim, yelling and slapping her (Sara) on a weekly basis for
more than a year during the COVID-19 pandemic. Prior to this domestic violence,
Tim lost his job due to pandemic layoffs and began drinking excessively. Sara
escaped with her children and moved in with her parents until she was able to
find an apartment. Sara obtained a restraining order so that her husband is not
allowed near their new home. Sara is concerned that Carla has become very
hyper and bossy toward her but cries excessively when Sara leaves her with any-
one other than her grandparents.

For this case study, consider:

1. What is the physiological, emotional, and behavioral impact of domestic vio-
lence on Carla? How did the COVID-19 pandemic complicate these matters?
2. What is the rationale for using Trauma-­Informed Child-­Centered Play Ther-
apy with Carla? Which strategies in each TI CCPT stage seemed to help
Carla?
3. What unique ethical guidelines need to be considered? What does Carla’s
mother need to help Carla?

Impact of Domestic Violence on Young Children

The Centers for Disease Control and Prevention (n.d.) defines domestic violence,
also known as intimate partner violence (IPV), as a current or former partner’s
physical violence such as hitting, kicking, or other types of physical force; sex-
ual violence of forcing a partner to take part in a sex act; stalking or repeated
unwanted contact that causes fear; and psychological aggression of verbal and
nonverbal communication with the intent to harm mentally or emotionally.

31
32 Chapter 3

Surveillance data shows that more than 10 million women and men experience
IPV each year (Breiding, Basile, Smith, Black, & Mahendra, 2015).
Numerous studies reveal the short- and long-­term impact of domestic violence
on young children such as pervasive feelings of fear, powerlessness, and sadness
(Noble, Moore, & McArthur, 2020); anxiety and depression (Chen & Lee, 2021);
posttraumatic symptoms (Paul, 2019); disruptive behavior (Juan, Washington,
& Kurlychek, 2020); and physical and psychological barriers to learning (Lloyd,
2018). This impact of domestic violence on young children is often revealed in
their play during play therapy sessions (Tyndall-­Lind, 2010; Weinreb & Groves,
2007). Kot & Tyndall-­Lind (2005) found children exposed to IPV had play themes
of aggression, killing, death, and escape. For example, they described a boy who
engaged in aggressive play of shooting, hitting, and killing a Bobo blow-­up doll
until he collapsed in exhaustion. Another girl used scary animals (i.e., spiders,
snakes, alligator, and other wild animals) to reenact the escape from her home
after a violent episode.

Impact of COVID-19 Pandemic on Young Children

The World Health Organization (2020) and other studies (Cappa & Jijon, 2021)
reported that IPV increased during the COVID-19 pandemic. Kelly and Mor-
gan (2020) reported a 25% increase in calls to the domestic abuse hotline in the
United Kingdom. This increased violence was triggered by financial stress from
losing jobs, isolation due to quarantine, frequent volatile interactions because
work and school were no longer an escape, and fewer checks and balances from
outside family members, friends, and teachers (Ragavan, Garcia, Berger, & Miller,
2020). Parental burnout and child maltreatment also increased during the pan-
demic (Griffith, 2020; Russell, Hutchison, Tambling, Tomkunas, & Horton,
2020). Donagh (2020) stated, “The impact of COVID‐19 has meant children and
young people experiencing abuse have gone from being unnoticed to invisible”
(p. 388).
Young children such as Carla who witnessed IPV during COVID-19 des-
perately needed treatment interventions (Donagh, 2020). Because Carla’s devel-
opmental level at 5 years old limits her cognitive ability to understand abstract
concepts, she needed a developmentally appropriate treatment intervention that
allows for movement. Play therapy allows young children to express their experi-
ences, feelings, and perceptions through their natural language of play (Landreth,
2012). When working with children who witnessed IPV, the play therapy needs to
be trauma informed and promote coping strategies (Gil, 2017).

Trauma-­Informed Child-­Centered Play Therapy

Trauma-­Informed Child-­Centered Play Therapy (TI CCPT) (Baggerly, 2013) is
a comprehensive treatment approach that combines knowledge of trauma and
trauma-­specific strategies with Landreth’s (2012) Child-­Centered Play Therapy.
 Domestic Violence 33

The format of TI CCPT is 30 minutes of CCPT as described by Landreth (2012)

followed by 15 to 20 minutes of psychoeducation based on neurophysiology
and core components of children’s trauma interventions (National Children’s
Traumatic Stress Network, n.d.). TI CCPT follows three fundamental stages of
trauma recovery, identified in Judith Herman’s (1992) seminal work: (1) estab-
lishing safety, (2) restorative retelling of the trauma story, and (3) restoring the
connection between survivors and their community.
In stage one, safety in the setting is established by creating a warm and inviting
playroom with toys from each category as described by Landreth (2012). Safety
in the relationship is developed through implementing Axline’s eight principles.
In the second part of the session, safety is facilitated through play-­based psycho-
education. Play therapists educate children and parents on basic neurophysiology
through illustrations such as Daniel Siegel’s hand model of the brain, found on
YouTube. Then play therapists use playful games and children’s books to teach
physiological regulation strategies including deep breathing, progressive muscle
relaxation, playful exercises, and mindful movements. Next, they help children
develop a safety plan of where to hide and who to call for help. Finally, they teach
positive cognitive strategies such as positive self-­talk (e.g., “I am smart, and I am
strong”), looking for clues that a place is safe, and thinking of the most likely
thing that will happen rather than the worst thing that could happen. Resources
for other coping strategies can be found in COVID-19 Interventions (O’Conner
& Picard, 2021) accessible on the APT website; Caroline Conquers Her Corona
Fears (Camelford et al., 2020); First Aid Arts (FirstAidArts​​.org, 2020); and Help-
ing Children with Traumatic Separation or Traumatic Grief Related to COVID-19
(NCTSN, 2020).
In stage two, when children reenact their trauma experience during their non-
directed play, play therapists facilitate understanding and enlarge the meaning.
For example, “you like to be the one with the power to decide if I am stuck here
or if I can go free” and “you know how scary it can be when there is no escape
from danger.” During psychoeducation, play therapists read children’s books
explaining trauma and domestic violence. Then they can guide children in mak-
ing a book about their own experience. For example, “The happy things I remem-
ber about my family are when . . . ,” “A scary thing that happened in my family
was when . . . ,” and “A hopeful thing about my future is . . .” Play therapists use
other creative approaches such as puppet shows, sand tray, and art to facilitate a
restorative retelling of children’s trauma stories.
In stage three, play therapists help restore connection between children and
their families, peers, and community members by reflecting or proposing effective
interpersonal skills during nondirective play. For example, if the child is reenacting
a scene of her dad yelling at her, then the play therapist could say, “The daddy
doll yelled at the girl doll, who felt scared. The girl doll may be wishing daddy
would just calmly say, ‘Please pick up your toys.’” During psychoeducation, play
therapists teach effective interpersonal skills such as “I” messages; compromising,
34 Chapter 3

encouraging words; and safe responses to harsh words. Children learn to say to
angry siblings or peers, “I know you are angry. You look like you need time to
calm down. I’ll go do something else for now.” In addition, play therapists invite
parents who are safe and can regulate their own emotions into play sessions. Play
therapists facilitate positive parent-­child connections through strategies such as “I
love you rituals” (Bailey, 2000), Theraplay activities (Booth & Jernberg, 2009), or
Child-­Parent Relationship Therapy (Landreth & Bratton, 2019).
Implementing TI CCPT with children who have experienced IPV during
COVID-19 provides a safe space for children to develop an accurate emotional
understanding of their experiences. Children can adjust their self-­concept from
“this is my fault, and I am helpless” to “even in scary situations, I am strong,
and I know ways to help myself be safe and calm.” Although it is difficult to
witness the harsh impact of IPV in the pandemic, play therapists can take self-­
compassion breaks (Neff, n.d.) throughout the week and find inspiration in chil-
dren’s resilience.

Case Study Application

With this deeper understanding of the impact of domestic violence, the COVID-
19 pandemic, and TI CCPT, we can now apply them to Carla. From a TI CCPT
perspective, I conceptualize Carla as experiencing incongruence between her ideal
self as a safe and emotionally regulated girl and her current self as experienc-
ing trauma symptoms (e.g., permanent alert) with a desperate need to control to
regain a sense of safety. Carla has inaccurately symbolized her experience as “the
world is always unsafe so I must control people.” She has denied to her aware-
ness that her mother is growing stronger and is able to protect her. My treatment
goals and objectives for Carla are as follows:
Treatment Goal: Decrease trauma symptoms of hypervigilance, separation
anxiety, and controlling “bossy” behavior and increase effective emotional and
behavioral regulation.
Objectives:
1. Express her feelings, experiences, and perceptions through play to gain an
emotional understanding, mastery, and self-­empowerment.
2. Identify and connect physiology, emotions, perceptions, and behavior related
to trauma.
3. Develop effective safety and coping skills.

Session Overview
In the first play therapy session, Carla was intrigued enough about the playroom
that she set aside her anxiety to investigate the toys. As in a typical first session,
she explored all the toys, playing with them for a few minutes and then going
on to the next toy. After 30 minutes of CCPT, I read Don’t Pop Your Cork on
 Domestic Violence 35

Mondays: Children’s Anti-­Stress Book (Moser, 1988) to help Carla develop basic
calming strategies of deep breathing, progressive muscle relaxation, and so forth.
By the third play session, Carla began to play out her feelings and perceptions
related to IPV and COVID-19.
As shown in the Session 3 transcript below, Carla’s play themes were aggres-
sion, power/control, nurturing, and protection. Through her play, she developed
an emotional understanding of the danger she experienced and a sense of hope
that she would be protected.
In the next sessions, I continued TI CCPT and stage one of psychoeducation
for safety planning and anxiety management. Then I began stage two of restor-
ative retelling of her trauma narrative by introducing books such as A Terrible
Thing Happened (Holmes, 2000) and The Strongest Thing: When Home Feels
Hard (Adelman, 2022). I facilitated a sand tray for Carla to show how she per-
ceived the time living with dad. She depicted dad as “the Beast” from the Disney
Movie Beauty and the Beast; her mom as “Belle,” who was imprisoned by “the
Beast”; her brother as a dog; and herself as a lioness. When asked what is differ-
ent since they moved, Carla said, “The Beast is in a cage.” Later she added that
she hopes the Beast turns back into a prince.

TABLE 3.1. CARLA: SESSION 3

Transcript Analysis
C: “Close your eyes.” [Child put toy spiders on my This appeared to be her concrete explanation of
shoulders.] “There are bugs all over you, and they COVID-19, which is sometimes explained as a
are trying to crawl up your nose.” “bug” to children.
T: “Something strange and scary is happening to Reflection of feeling and enlarging the meaning.
me.”
C: [Child used a rope to tie me to my chair], saying, This appeared to be her perception of danger
“You can’t escape these bugs. Now I have you within her family with limited protection due to
trapped, and no one is going to come over to see.” the quarantine. Note: The child looped the rope
[She used a toy knife to pretend to stab me.] loosely. Otherwise, I would have set a limit via “I
know you would like to tie the rope behind me,
but the rope is not for tying in the back. You can
choose to tie it in the front.”
T: “It is super scary because there is danger all Reflection of feeling and enlarging the meaning.
around me, and I can’t seem to escape.”
C: “No you can’t escape. I won’t let you,” she said Play theme was power and control, possibly
in a taunting voice with a smile. representing her perception of dad controlling
mom.
T: “You enjoy keeping me trapped. I feel powerless Reflection of the power dynamic she is playing
and need someone to help me.” out. In my assigned role as “victim,” I voice my
need for help.
C: “No one will help you.” [Walks around me] “But Child creates an escape to get help from the
since you have bugs all over you, I will take you to doctor. Medical personnel were often the only
the doctor because they bit you.” professionals a child would see during COVID.
Because many children call me “Dr. Jennifer,” she
may see me as a rescuer.
T: “I feel relieved that I can get help from the doctor Reflection of feeling and enlarging the meaning.
who can help take care of me and protect me.”
36 Chapter 3

TABLE 3.2. CARLA: SESSION 10

Transcript Analysis
C: “I’m the cop now, and I’m going to arrest you Play theme was still control but was serving a
for being bad.” social purpose of being a helper.
T: “You are an important and powerful cop, and Facilitated understanding of her strengths as an
you know how to stop me from being bad.” important and powerful person who no longer is
out of control, watching bad things, but has the
power to protect herself.
C: “Yes. Now, stay in there (behind the puppet She created a safe space for her by jailing “the
stand) for 100 years. I’m going to make dinner. I bad,” which could represent IPV and/or her own
get pizza, strawberries, and ice cream. You only misbehavior. She has enough power to nurture
get bread.” herself and show compassion to “the bad” by at
least giving bread.
T: “You are making a safe place for yourself by Reflection of her agency in self-­protection to the
making sure I won’t get out for a really long time. point of no longer being in constant state of alert
You know how to get good things to eat for but calm and confident enough to nurture herself
yourself. You’re giving me bread, even though I’ve while showing compassion.
been bad.”
C: “Now pretend to escape from jail.” [Therapist Establishes control over the fear of danger from
pretends to sneak away] “Hey, I see you! Get back tricky people. Demonstrates self-­protection.
here. You’re not going to trick me. Back in jail,”
she said with authority.
T: “You are strong and in charge even when I try to Encourages her confidence to protect herself.
trick you. You have the power to protect yourself.”

By session 10, Carla had integrated a sense of safety and self-­empowerment

so that she could transform her role from being perpetrator to being the police.
In later play sessions, Carla was able to balance her need for control with
cooperation as she engaged me in creative activities such as painting a rainbow
forest. During stage three, I facilitated playful engagement between Carla and her
mother, who had become much more confident and enjoyed Carla with smiles
and laughs.

Ethical and Cultural Considerations

Ethical considerations in Carla’s case began with her ongoing safety. Sara, her
mother, had already obtained a restraining order so the father would not come
to their new home. However, as is the case with many people, Carla’s mother
would occasionally visit her husband after being sweet-­talked. Although I kept
the information confidential, I still had a duty to protect Carla. I recommended
that Sara not take Carla on these visits as they could turn violent. I followed the
ethical principle of autonomy in respecting Sara’s right to make her own deci-
sions regarding her relationship.
Another ethical consideration was the likelihood of being subpoenaed for
criminal charges against the father or custody battles. At the initial intake session,
I reviewed our office policies that court appearances are charged at twice the usual
session hourly fee. I clarified that I can only report what I directly witness, and
I will not state an opinion on custody. I am careful not to overinterpret Carla’s
 Domestic Violence 37

play in my documentation or possible testimony. For example, I can not say that
Carla’s play proves violence by the father or that he is a dangerous person. I can
say, “In my professional opinion, Carla is processing perceptions of danger and
feelings of fear.” I can share assessment results from the Trauma Symptom Check-
list for Children that indicate she is in the clinical range for trauma symptoms.
I can also say that Carla needs to be in an environment in which she perceives
safety and has consistently calm parenting.
A cultural consideration for Carla was related to her parents’ religious belief
that the husband is the head of the household, and the wife must submit to him.
Because this belief is different from mine, I bracketed my beliefs and respected
their freedom of choice. During a parent consultation, I briefly explained that
spiritual faith often grows through different stages. Many adults are at a con-
ventional stage of conforming to traditional beliefs while other adults grow into
a more individual, reflective stage of analyzing their own values and becoming
more flexible in some beliefs (Fowler, 1995). I asked Sara what changes, if any,
she had noticed in her faith over the past few years. This prompted a discussion
of how her faith grew to a different stage than her husband’s. As a result, Sara felt
proud of her growth and less judgmental toward her husband.

Parent Consultations
Given these ethical issues, it was crucial for me to have regular parent consul-
tations with Carla’s mom. Prior to seeing Carla, I conducted a parent consul-
tation with Sara, her mother. Using Daniel Siegel’s hand model of the brain, I
explained strategies to calm the lower regions of Carla’s brain through deep
breathing, rocking, and soft voice rather than trying to reason with her prefrontal
cortex, which was “offline” during her anxious times. To reinforce these concepts,
I asked Sara to watch a parenting video by Tina Payne Bryson, 10 Brain-­Based
Strategies: Help Children Handle Their Emotions and to read Siegel and Payne
Bryson’s (2016) No-Drama Discipline. These two resources helped Sara calm her
own anxieties so she could provide co-­regulation to help Carla calm down. After
each play therapy session, I spent a few minutes informing Sara about what Carla
had learned in psychoeducation so that Sara could encourage, not demand, the
new skill at home.
To demonstrate my due diligence in my communication with Carla’s dad, I
emailed Tim to introduce myself and invited him to schedule a parent consul-
tation with me. After a few weeks, he scheduled an online parent consultation.
I reviewed with Tim the same information as with Carla’s mother. Much of the
session was spent with Tim explaining that there was a lot of misunderstanding,
Sara had blown things out of proportion, and Carla was much better off with the
family back together. I reflected his feelings and perceptions while also presenting
him with facts. “You’re very frustrated because, from your perspective, this was
a misunderstanding. You just want things back the way they were. [Brief pause]
And Sara sees it very differently; the judge granted a restraining order; and we all
38 Chapter 3

need to help Carla be less scared. This will be a much slower process than what
you want, but the most important concern is Carla being calmer and confident. I
know you want that for Carla. For now, I encourage you to focus on reading and
viewing the resources I gave you.”

Conclusion
Carla made remarkable progress over 20 sessions of TI CCPT. She transformed
from being a perpetrator who put bugs on me while I was tied up to a calm, con-
fident, and cooperative child. Her mother also became more confident, gave her
choices, and set limits as needed. Her father chose not to engage with me past the
parent consultation but continued to pressure Sara to reunite. Fortunately, Sara
chose a calmer life for herself and Carla.

Sample Case Notes

Session 3
Subjective: Child expressed feelings of satisfaction, confidence, meanness, and
projected fear and distrust.
Objective: During CCPT, child put toy spiders on Play Therapist’s (PT) shoulders
and said, “There are bugs all over you”; “You can’t escape these bugs; you’re
trapped.” Child used rope to pretend to tie PT to chair and pretended to stab
me. During psychoeducation, the counselor read Listening to My Body (Garcia,
2017) to help the child understand physiological sensations, feelings, needs, and
calming strategies.
Assessment: From a TI CCPT perspective, child is experiencing incongruence
between her ideal self as a safe and emotionally regulated girl and her current self
as experiencing fear with a desperate need to control to regain a sense of safety.
Carla has inaccurately symbolized her experience as “the world is always unsafe
so I must control people.” Play themes were power and control, nurturing, and
protection. She is developing an emotional understanding of the danger she expe-
rienced and a sense of hope that she will be protected.
Plan: Continue TI CCPT and psychoeducation book of I Am Stronger Than Anx-
iety (Cole, 2021) for stage one of establishing safety.

Session 10
Subjective: Child expressed feelings of confidence, determination, satisfaction,
and annoyance.
Objective: Child put on police vest, held handcuffs and gun. She said, “I’m the
cop now, and I’m going to arrest you for being bad.” She used the kitchen food
to make herself dinner and give the prisoner bread. Child caught prisoner from
breaking out of jail and said, “You’re not going to trick me.”
 Domestic Violence 39

Assessment: From a TI CCPT perspective, child is making progress as indicated

by shifting her role from perpetrator to police. She is aware of safety strategies
such as protecting herself from being tricked. She is integrating a helper and nur-
turer identity into her self-­concept. Through this self-­empowerment, she is mas-
tering her trauma experience.
Plan: Continue TI CCPT and facilitate sand tray for stage two of restorative
retelling of trauma narrative.

Resources

For Professionals
Mindful Self-­Compassion Breaks (audio) as described by Kristin Neff at https://
self-­compassion​​.org/category/exercises/​#​exercises.
Posttraumatic Play in Children: What Clinicians Need to Know by Eliana Gil
(2017).

For Children
A Terrible Thing Happened: A Story for Children Who Have Witnessed Violence
or Trauma by Margaret Holmes (2000).
Don’t Pop Your Cork on Mondays!: The Children’s Anti-­Stress Book by Adolph
Moser (1988).
I Am Stronger Than Anxiety: Children’s Book about Overcoming Worries, Stress
and Fear by Elizabeth Cole (2021)
Listening to My Body by Gabi Garcia (2017)
The Strongest Thing: When Home Feels Hard by Hallee Adelman (2022).

For Parents
NCTSN, “Helping Children with Traumatic Separation or Traumatic Grief
Related to COVID-19” (2020). https://www.nctsn.org/resources/helping-chil-
dren-with-traumatic-separation-or-traumatic-grief-related-to-covid-19
No-­Drama Discipline: The Whole Brain Way to Calm the Chaos and Nurture
Your Child’s Developing Mind by Daniel Siegel and Tina Payne Bryson
(2016).
Recover and Rebuild: Moving on from Partner Abuse. Domestic Violence Work-
book by Stacie Freudenberg (2020).

Discussion Questions
1. How did IPV and COVID-19 uniquely impact Carla’s feelings, experiences,
perceptions, and behavior?
2. How did TI CCPT facilitate the achievement of Carla’s treatment goals? Give
specific examples.
40 Chapter 3

3. As a therapist, what beliefs, biases, and/or emotions would you need to

bracket to effectively work with Carla and her family?
4. What steps would you take to manage ethical and legal issues related to Car-
la’s case and family? How would you respond if you received a subpoena for
a custody dispute?

References
Adelman, H. (2022). The strongest thing: When home feels hard. Albert Whitman
& Company.
Baggerly, J. (2013). Trauma informed child centered play therapy [video]. Micro-
training Associates and Alexander Street Press.
Baggerly, J. (2021, April 9). Play therapy heroes for the corona­virus pandemic
and national crises. Texas Association for Play Therapy Conference. Virtual.
Bailey, B. (2000). I love you rituals. Harper.
Booth, P. B., & Jernberg, A. M. (2009). Theraplay: Helping parents and children
build better relationships through attachment-­based play. Jossey-­Bass.
Breiding, M. J., Basile, K. C., Smith, S. G., Black, M. C., & Mahendra, R. (2015).
Intimate partner violence surveillance: Uniform definitions and recommended
data elements. Centers for Disease Control and Prevention. https://www​​.cdc​​
.gov/violenceprevention/pdf/ipv/intimatepartnerviolence​​.pdf
Brown, S. M., Doom, J. R., Lechuga-­Peña, S., Watamura, S. E., & Koppels, T.
(2020). Stress and parenting during the global COVID-19 pandemic. Child
Abuse & Neglect, 110, 104699. https://doi​​.org/10.1016/j​​.chiabu​.2020​
104699
Camelford, K., Vaughn, K., & Dugan, E. (2020). Caroline conquers her Corona
fears. LSU Health Sciences Center.
Cappa, C., & Jijon, I. (2021). COVID-19 and violence against children: A
review of early studies. Child Abuse & Neglect, 116 (Part 2). https://doi​​.org/​
10.1016/j​​.chiabu.2021.105053
Centers for Disease Control and Prevention. (n.d.). What is intimate partner vio-
lence? https://www​​.cdc​​.gov/violenceprevention/​intimate​partnerviolence/index​​
.html
Chen, W., & Lee, Y. (2021). Mother’s exposure to domestic and community vio-
lence and its association with child’s behavioral outcomes. Journal of Com-
munity Psychology, 49, 2623–2638. https://doi​​.org/10.1002/jcop.22508
Donagh, B. (2020). From unnoticed to invisible: The impact of COVID‐19 on
children and young people experiencing domestic violence and abuse. Child
Abuse Review, 29(4), 387–391. https://doi​​.org/10.1002/car.2649
First Aid Arts (2020). First Aid Arts Mini Toolkit: Tools for Mental & Emotional
First Aid. Seattle, WA. Available at https://www.firstaidarts.org/minitoolkit
Fowler, J. W. (1995). Stages of faith: The psychology of human development and
the quest for meaning. HarperCollins.
 Domestic Violence 41

Gil, E. (2017). Posttraumatic play in children: What clinicians need to know.

Guilford Press.
Griffith, A. K. (2020). Parental burnout and child maltreatment during the
COVID-19 pandemic. Journal of Family Violence, 37, 725–731. https://doi​​
.org/10.1007/s10896-020-00172-2
Herman, J. (1992). Trauma and recovery: The aftermath of violence—From
domestic abuse to political terror. Basic Books.
Juan, S.-C., Washington, H. M., & Kurlychek, M. C. (2020). Breaking the inter-
generational cycle: Partner violence, child–parent attachment, and children’s
aggressive behaviors. Journal of Interpersonal Violence, 35(5–6), 1158–1181.
https://doi​​.org/​10.1177/0886260517692996
Kelly, J. & Morgan, T. (2020, April 6). Coronavirus: Domestic abuse calls up
25% since lockdown, charity says. BBC News. https://www​​.bbc​​.co​​.uk/news/
uk-52157620
Kot, S., & Tyndall-­Lind, A. (2005). Intensive play therapy with child witnesses of
domestic violence. In L. A. Reddy, T. M. Files-­Hall, & C. E. Schaefer (Eds.),
Empirically based play interventions for children (pp. 31–49). American Psy-
chological Association. https://doi​​.org/10.1037/11086-003
Landreth, G. (2012). Child centered play therapy: The art of the relationship.
Routledge.
Landreth, G. L., & Bratton, S. C. (2019). Child-­ parent relationship ther-
apy (CPRT): An evidence-­based 10-session filial therapy model (2nd ed.).
Routledge.
Lloyd, M. (2018). Domestic violence and education: Examining the impact of
domestic violence on young children, children, and young people and the
potential role of schools. Frontiers in Psychology, 9. https://doi​​.org/10.3389/
fpsyg.2018.02094
National Children’s Traumatic Stress Network. (n.d.). Core components of inter-
ventions. https://www​​.nctsn​​.org/treatments​-­and​-­practices/trauma-­treatments/
overview
Noble, C. D., Moore, T., & McArthur, M. (2020). Children’s experiences
and needs in relation to domestic and family violence: Findings from a
meta‐­synthesis. Child & Family Social Work, 25(1), 182–191. https://doi​​
.org/10.1111/cfs.12645
O’Conner, K., & Picard, S. (2021). COVID-19 interventions. Association for Play
Therapy.
Paul, O. (2019). Perceptions of family relationships and post-­traumatic stress
symptoms of children exposed to domestic violence. Journal of Family Vio-
lence, 34(4), 331–343. https://doi​​.org/​10.1007/s10896-018-00033-z
Ragavan, M. I., Garcia, R., Berger, R. P., & Miller, E. (2020). Supporting intimate
partner violence survivors and their children during the COVID-19 pandemic.
Pediatrics, 146(3). https://doi​​​.org/10.1542/peds.2020-1276
42 Chapter 3

Russell, B. S., Hutchison, M., Tambling, R., Tomkunas, A. J., & Horton, A. L.
(2020). Initial challenges of caregiving during COVID-19: Caregiver burden,
mental health, and the parent–child relationship. Child Psychiatry & Human
Development, 51(5), 671–682. https://doi​​.org/10.1007/s10578-020-01037-x
Siegel, D., & Payne Bryson, T. (2016). No-drama discipline: The whole-­brain way
to calm the chaos and nurture your child’s developing mind. Mind Your Brain.
Tyndall-­Lind, A. (2010). Intensive sibling group play therapy with child witnesses
of domestic violence. In J. N. Baggerly, D. C. Ray, & S. C. Bratton (Eds.),
Child-­centered play therapy research: The evidence base for effective practice
(pp. 69–83). John Wiley & Sons.
Weinreb, M., & Groves, B. M. (2007). Child exposure to parental violence: Case
of Amanda, age 4. In N. B. Webb (Ed.), Play therapy with children in crisis:
Individual, group, and family treatment (3rd ed., pp. 73–90). Guilford Press.
World Health Organization. (2020, March 26). COVID-19 and violence against
women: What the health sector/system can do. https://www​​.who​​.int/repro​
ductivehealth/publications/​emergencies/​COVID-19-VAW-­full-­text​​.pdf
 CHAPT E R 4

Disruptive Behavior after January 6

Washington, DC, Uprising
Cognitive Behavior Play Therapy
with a White Child
Athena A. Drewes

Jake, a White 6-year-­old boy in elementary school, who repeatedly witnessed the
January 6 Washington, DC, uprising on television with his parents, started acting
out at home and school. His parents, who were in favor of the uprising and very
vocal about it while watching daily televised live reports and repeated showing of
the events, used negative discipline on Jake’s disruptive behaviors through harsh
name calling, yelling, and periodic swats on Jake’s bottom. Although Jake, his
parents, and his older brother and sister did not directly have anyone they knew
attend or die in the uprising, Jake began to experience nightmares, had anger
management problems, became more oppositional at home, and had major
behavioral problems in school. More specifically, his impulsivity resulted in rarely
attempting his academic assignments, frequent disagreements with peers, whin-
ing and tattling on peers, temper tantrums and name-­calling when he did not get
his way on the playground, aggressive behavior by pushing and shoving peers,
and pacing in class. Jake’s parents noted increased negative behaviors at home
that included physical aggression with siblings and neighborhood children, and
frequent breaking of household rules. Jake was referred to the school psycholo-
gist for assessment and counseling.

For this case study, consider the following questions:

1. What were the main factors that contributed to Jake’s disruptive behavior? Is
Jake only responding to his environment, or is there an underlying diagnosis?
2. What is the rationale for using Cognitive Behavior Play Therapy with Jake?
What specific strategies seemed to be helpful with Jake?

43
44 Chapter 4

3. How would you manage your political views if they are different from the
parents’ views? Describe ethical considerations and consultation strategies
you would use when working with the parents.

Disruptive Behaviors in Children

Disruptive or externalizing behaviors are an increasing concern in school-­age
children, with kindergarten teachers rating approximately 20% of students expe-
riencing elevated behaviors (Murray, 2015). Externalizing behaviors are those
characterized by aggressive, disruptive, oppositional, noncompliant, or antiso-
cial behaviors (Murray, 2015). They include behaviors related to impulsivity and
hyperactivity.
Various factors can trigger the emergence of disruptive behavior symptoms
in children. Disruptive behaviors can be triggered by genetic/biological factors;
emotional factors that include temperamental personality, frustration, fear, over-
stimulation, need for attention, or anxiety; family factors such as stress caused
by parenting, parental marital dysfunction, or sibling conflicts; community envi-
ronmental factors such as exposure to violence; and school environment factors
(Afdal, Zikra, Sakmawati, Syapitri, & Fikeri, 2022). Further disruptive behav-
ior can be triggered by physiological factors that include poor nutrition, hun-
ger, fatigue, disease, and allergies as well as socioeconomic factors such as food
insecurity or homelessness (Afdal et al., 2022). Fortunately, Hirshfeld-­Becker and
Bierderman (2002) found younger children to be more plastic in terms of behav-
ior and their neurodevelopment. This plasticity continues throughout the life-
time, and brains can be rewired at any age (Siegel & Bryson, 2012); consequently,
treatment interventions can have a positive impact. Considering Jake’s disruptive
behavior, I will focus on a few of these triggering factors, mainly ADHD, expo-
sure to media violence, and family factors.

Attention-­Deficit/Hyperactivity Disorder (ADHD)

Attention-­Deficit/Hyperactivity Disorder (ADHD) is a complex neurodevelop-
mental disorder that is the most frequently diagnosed emotional/behavioral health
disorder in children referred to school and mental health professionals. The preva-
lence in 2020 was 9.3% of children receiving an ADHD diagnosis (NSCH, 2021).
This translates into 5.64 million children between the ages of 3 and 17 years.
This prevalence has shown an increase over time. It is estimated that 5–10% of
all school-­age children have the disorder, resulting in approximately two to three
children with ADHD in an average classroom (Kasiati, Naruvita, Harti, Yulia, &
Yunitsari, 2022). Of children diagnosed with ADHD, 64%, or two in three chil-
dren, suffer from at least one other psychiatric disorder, and 52% have comorbid
behavioral or conduct problems (NSCH, 2021).
ADHD is associated with abnormalities in cognitive, psychomotor, and affec-
tive aspects and characterized by impulsive and hyperactive behavior. Factors that
 Disruptive Behavior after January 6 Washington, DC, Uprising 45

cause ADHD include heredity/genetic factors, brain damage during fetal develop-
ment/after birth, smoking/alcohol during pregnancy, and babies born with low
body weight resulting in delays in the prefrontal cortex. Neurological correlates
of aggression in childhood, often comorbid with ADHD, were associated with
smaller amygdala volume and decreased cortical thickness in the brain (Thijssen
et al., 2015).
ADHD manifests in poor executive deficits in planning, attention, organiza-
tion, monitoring, and self-­control. Common behaviors seen include always being
on the move, tapping fingers, shaking feet, pushing other children for no apparent
reason, talking incessantly, and fidgeting. These children also find it difficult to
concentrate on tasks with low task completion in a reasonable amount of time,
show difficulty doing assignments at school or at home, difficulty listening, day-
dreaming, not having a lot of patience, often making noise, interrupting others,
and difficulty calming down (Kasiati et al., 2022). Parents of children with ADHD
often complain about disobedience, defiance, and rebelliousness with aggression at
home (Jafari, Mohammadi, Khanbani, Farid, & Chiti, 2011).
As a result of these behaviors, many children with ADHD exhibit severe and
chronic academic symptoms in school. Prevalence rates indicate that children with
ADHD experience specific learning disabilities (SLD), which affects about 31% of
the ADHD population across studies (Reddy, 2010). A child’s high rate of exter-
nalizing behaviors can have a deleterious impact on classmates, teachers, and par-
ents. Children’s ADHD impulsivity can result in disagreements with peers, temper
tantrums when the child does not get her way, aggressive behavior, whining, and
tattling on peers.

Impact of Viewing Media Violence

The effect of violence in the media, especially television, on children is a well-­known
subject of research (Anderson et al., 2003; Husemann, Moise-­Titus, Podolski, &
Eron, 2003). Findings have demonstrated that exposure to high levels of violence
in the media, television and computer or video games can lead to higher levels and
increased probability of aggression in children. Because of their inability to distin-
guish fantasy from reality, preschool children and young schoolchildren, especially,
are more likely to imitate the violence and aggression they see on television. As
they watch more television, they become increasingly likely to resort to hostile and
aggressive ways to solve problems (Berk, 2003). Seeing violence and aggression on
television may spark hostile and aggressive thoughts and behavior in aggressive as
well as nonaggressive children. Seeing violence can also make children more toler-
ant of aggression in others and in their environment. Research further shows that
children will imitate what is seen on television or demonstrated by adults, even
as young as the age of three (Calvert, 2006), and they become desensitized to its
impact on others (Browne & Hamilton Giachritsis, 2005).
46 Chapter 4

Family Setting
The family setting in which a child is raised plays an important role and can
explain why some children are more aggressive than others. Research has shown
that parents who are rejecting, use physical punishment in an inconsistent and
erratic manner, and permit their children to express aggressive impulses are likely
to raise aggressive and hostile children (Patterson, 2002). By ignoring their child’s
aggressive behavior, they are legitimizing it and failing to teach the child how
to control their aggressive behaviors. Patterson compared families of aggressive
children to families of the same socioeconomic status and size without aggres-
sive children and found aggressive children often live in a setting where approval
and affection are not expressed and where family members are constantly in
conflict (e.g., arguing, threatening, fighting, and annoying each other). Patterson
contended that these coercive homes with negative reinforcement maintain these
coercive interactions.

Cognitive Behavioral Play Therapy

Cognitive Behavioral Play Therapy (CBPT) is a helpful treatment option for chil-
dren with disruptive and aggressive behaviors as well as ADHD (Drewes, 2009).
Cognitive behavioral play therapy interventions help ADHD children develop self-­
control and problem-­solving skills by examining and correcting the thoughts that
lead to actions. They can be used in both individual and group formats for treating
a broad range of behaviors including impulsivity, social skills deficits, intrusiveness
of thoughts, and anger management.
Cognitive behavioral therapy (CBT) (Beck, 1976) is a structured, goal-­oriented
therapy with a focus on deficits or distortions in thinking that interfere with appro-
priate social skills and behavior. CBT also increases the ability to express feelings,
increases adaptive and realistic assessment of relationships, increases positive self-­
talk, and increases appropriate use of problem-­solving skills. CBT is based on the
work of theorists Ellis (1971), Beck (1976), and Bandura (1977). Behavioral ther-
apy uses the concepts of antecedents, reinforcers, contingencies, and social learn-
ing therapy; cognitive therapy helps children learn to change their own behavior,
change cognitions, and become part of their own treatment. The therapist and
child develop goals for treatment. The therapist selects play materials and activ-
ities that will facilitate meeting the therapy goals. Modeling, role-­playing, and
behavioral techniques are used, mainly with children ages 10 and over who have
abstraction skills.
Cognitive Behavioral Play Therapy (CBPT) (Drewes, 2009) is a theoretical
framework based on cognitive behavioral principles and integrates these principles
in a developmentally appropriate manner within a play therapy paradigm using
empirically demonstrated techniques such as modeling and role-­playing (Knell,
2009). It is usually used with children 10 and under who are concrete thinkers but
can be used with older children and even teens. Play activities and verbal and non-
verbal forms of communication are used to resolve problems. CBPT has several
 Disruptive Behavior after January 6 Washington, DC, Uprising 47

stages and components including forming a therapeutic relationship/alliance, iden-

tifying the problem of the child (through formal and informal assessments and
observation), creating an individually tailored collaborative treatment plan (with
child and parent), as well as teaching coping skills, social skills, and regulatory
skills to increase behavioral tolerance and competence. In some cases, psychophar-
macological therapy (medication) is added to help in regulating behavioral dysreg-
ulation and diminished attention/concentration (Perryman, 2016). Interventions
might include use of games, bibliotherapy, role-­playing, storytelling, modeling,
desensitization, shaping, and positive reinforcement, as well as confronting any
irrational beliefs that may be contributing to the child’s difficulties (Knell, 2009;
Perryman, 2016).
Play therapy with Cognitive Behavioral Therapy (CBPT) is effective for
increasing the attention of children with ADHD, lessening impulsivity, and
increasing self-­control. Even on a short-­term basis, positive gains are reported in
building self-­esteem, on-­task behavior, self-­control, channeling aggression appro-
priately, expression of anger through play, and practicing patience and problem
solving (Jafari et al., 2011; Lochman, Powell, Boxmeyer, & Jimenez-­Camargo,
2011; Murray, 2015; Sukhodolsky, Kassimnove, & Gorman, 2004). In their sin-
gle case study, Chen and Chang (2014) found that CBPT had immediate and
maintenance effects on increasing appropriate talking and playing with others
and decreasing interrupting and loud responding. Agus, Bali, and Maula (2022)
found that the use of role-­playing in the classroom with the teacher had positive
effects in increasing vocabulary, focus, peer interaction, and social relatedness in
hyperactive schoolchildren.

School-­Based Cognitive Behavioral Play Therapy

Schools are increasingly looked at as a viable service delivery system for pri-
mary mental health services, especially due to the prevalence of mental health
issues involving anger management (Rones & Hoagwood, 2009). Play therapy is
needed in the school setting to provide more developmentally appropriate inter-
ventions at an early age (Perryman, 2016). CBPT within schools is a time-­efficient
approach, with most behavioral interventions taking about 30 days (Perryman,
2016).

CBPT Techniques
Play therapy techniques such as role-­ playing, feelings identification, problem
solving, developing social skills, and learning coping strategies are used. The par-
ent component involves stress management, establishing rules and expectations,
appropriate discipline to avoid punishing, improving parent-­child relationship,
giving effective instructions to children, academic support, family problem solv-
ing, family communication, family cohesion, and long-­term planning.
During role-­play, children can imitate or pretend to be someone by using
objects around them and practice appropriate behavioral responses. This
48 Chapter 4

approach supports and enhances child development by promoting acquisition

of cognitive, social, emotional, and language knowledge and skills (Viranda &
Istiningtyas, 2019). By playing a role, children increase their ability to deal with
experiences and interactions with friends and their social environment, develop
empathy, add new feelings vocabulary, and anticipate future situations (Agus et
al., 2022). Role-­playing uses the therapeutic powers of play through accelerating
knowledge acquisition, improving skills and attitudes, increasing self-­confidence,
and improving communication.
Additional techniques are chosen to cover six different modalities: affective,
behavioral, cognitive, developmental, educational, and social. These activities
may include storytelling, turtle technique, self-­calming techniques, substituting
behaviors when angry, and catharsis.

Case Study Application

As described above, CBPT will be a helpful treatment for Jake to treat his disrup-
tive behavior, which seems to be triggered by ADHD, viewing violence on media,
and his family environment. I began with a classroom observation of Jake, created
a behavioral log to establish a baseline and monitoring mechanism, administered
a formal assessment using the Child Behavior Checklist (Achenbach & Rescorla,
2001) completed by his teacher and parent, and conducted a play session with
Jake. Based on this holistic information, I formulated a play-­based treatment plan
with Jake and his parents.
We agreed that the goals of treatment were to build self-­esteem, teach on-­task
behavior, teach self-­control, channel aggression appropriately, allow expression
of anger through play, practice patience, and help problem solve through play.
We also agreed that homework would be assigned after each counseling session
for Jake to rehearse and practice his calming and coping skills at home and in the
community. Finally, I taught his parents play skills and encouraged each parent
to conduct special play sessions with Jake daily. I also taught his parents age-­
appropriate discipline techniques to counter harsh physical punishment.
Treatment Goals: Decrease disruptive and aggressive behaviors in school and
increase affective and behavioral regulation, problem-­solving skills, on-­task aca-
demic behavior, and positive peer interactions.
Objectives were as follows:
1. Jake will learn the value of cooperating and supporting peers in the class-
room through an increase in empathy skills.
2. Jake will decrease tattling on peers to zero per week.
3. Jake will gain experience in social problem solving so that tantrums and
oppositional behavior incidents will be reduced to zero per week.
4. Jake will be able to modulate shifting between active and calm state and use
his coping and calming skills at least once per day.
5. Jake will show an increased focus on academic tasks by remaining on task
and completing assignments daily.
 Disruptive Behavior after January 6 Washington, DC, Uprising 49

6. Parents will report a decrease in disruptive and negative behaviors at home to

a minimum of once per week.

CBPT Strategies
I scheduled to see Jake for weekly 30-minute individual CBPT sessions for 8
weeks at his school. Throughout the sessions, I conducted numerous play-­based
activities such as feelings identification and expression (e.g., what is behind the
anger; catharsis in expressing anger); self-­calming techniques (e.g., the turtle tech-
nique, deep breathing); role-­play (using puppets), a feelings thermometer and
drawing and using clay.

Session 1
In the first play therapy session, the goal was to help Jake feel comfortable in
the therapy room, know what the sessions would be like, and review the reason
Jake was in counseling and his treatment goals. I read the bibliotherapy book A
Child’s First Book about Play Therapy. Jake engaged in child-­directed play for
15 minutes, during which time he reenacted the uprising by having his characters
scream and yell at the “grown-­up” figures, bang and hit the block door and wall
he created, push in to get the “grown-­ups,” and build up and smash down block
buildings. This playtime gave Jake an opportunity to reenact the disaster, have

TABLE 4.1. JAKE: SESSION 1

Transcript Analysis
J: [Uses male doll to knock on the door he Jake reenacts what he saw on television of
created] Yells, “Let me in. I’m going to stop you people pushing into the US Capitol. He does
from doing that stuff!” not understand what was being stopped, but he
understood the anger.
T: “That guy is super angry and trying to force Reflection of anger, force, and content.
others to stop what he doesn’t like.”
J: “Yeah, me and my buddies are going to take Jake observed the power of a group mob that
over, and no one can stop us.” loses self-­control, defusing responsibility onto the
group.
T: “They want to all be the boss but have lost Highlights the responsibility of self-­control.
self-­control.”
J: “Well, watch this!” [Knocks down the wall he Jake is proud of his power. He wants to be seen
built] as a powerful boy, perhaps to feel safe.
T: “You want to show me how powerful you are, Brings to Jake’s awareness that misused power
even if it means someone or something might get has consequences, and to introduce empathy.
hurt.”
J: “Well, I don’t want to hurt anyone. I just want to Jake adjusts his intentions. He starts to become
show them my friends and I are in charge.” aware that his underlying desire is to belong with
strong people.
T: “You know it is important not to hurt others. Reflected his value of not hurting others and his
What you really want is to be part of a group that desire to belong. Provided some psychoeducation
is strong. There are lots of different ways to do that he can do so without aggression.
that without causing destruction.”
50 Chapter 4

cathartic emotional release, and allowed for discussion of feelings associated with
it. I used reflective comments and modeled feelings associated with his actions,
which helped to reduce his anger.
In the final three minutes, I taught Jake and practiced the hills and valley
finger breathing calming technique. For this activity, Jake used his nondomi-
nant hand and with pointer finger on his dominant hand he traces to the top of
his thumb while breathing in and then traces down the thumb while breathing
out. He repeats this breathing in and out while tracing each finger with a pause
between fingers. Jake’s homework was to keep practicing finger tracing, teach it
to his parents and siblings, and use it as often as possible.
Earlier that day, I saw Jake’s parents at the beginning of the school day for
a 30-minute session to teach them reflective statements and how to implement
natural consequences at home. (See Parent section for more details and additional
meetings.)

Session 2
At the beginning of the session, I reviewed the previous week, checked on
rehearsal use of the finger breathing, and did a quick practice of finger breathing.
I focused on identifying feelings and explained the “What’s under the Anger”
poster, which shows multiple feelings underneath anger. I encouraged Jake to
throw a bean bag at the different feelings and mention a time he felt that way. I
provided a handheld mirror for him to see how his face looked while showing
the feeling and to check if it was congruent with the chart. We played this for
five minutes and the Talking, Feeling & Doing board game for 10 minutes. Jake
was then able to have child-­led play, which resulted in another abreaction of the
uprising using puppets. I used puppets to express empathy and role-­modeled
appropriate responses and feelings identification. The last few minutes were
spent blowing on a pinwheel and taking deep breaths as a coping and calming
technique before returning to class. I encouraged Jake to try using his finger
breathing at home as homework.

Session 3
After reviewing the previous week, I shared the positive teacher comments that
Jake is showing some progress. Jake smiled. We discussed Jake’s report about his
breathing practice at home, when he used it, and the results. We practiced “I feel”
statements. I used a three-­headed dragon puppet to show Jake how his thoughts,
feelings, and behaviors are related. I explained that the goal was to get the angry,
scared thoughts and feelings to lessen, and thereby not get the negative behaviors
to come out. We made a feelings thermometer with increasingly larger smiley
faces, which Jake colored accordingly. He agreed to use this at home and counsel-
ing to show how he was feeling.
 Disruptive Behavior after January 6 Washington, DC, Uprising 51

Then Jake had 10–15 minutes for self-­directed play. Jake decided he wanted
to put on a puppet show about being on the playground and a problem he was
having with another classmate. I provided empathic responses and role-­played
problem solving when disagreements and frustration were getting in his way. Jake
alternated with me in taking the role of classmate versus himself. The last three
minutes were spent on deep breathing using the pinwheel before returning to
class. His homework was to practice using “I” statements when needing some-
thing or in expressing feelings and using his feelings thermometer at home to
show his feelings.

Session 4
Week in review; checked in on trying “I” statements at home and practiced again
in session using “I” statements to express his anger. Read How to Take the Grr
out of Anger and played one round of the Angry Monster Machine board game.
Jake had the last 10 minutes for self-­directed play. During this play, Jake’s play
was starting to change. He would build buildings, put miniatures on them, and
knock it down, but his aggression was noticeably less. He started to verbalize
more empathic feelings toward the figures inside the building, stating, “I feel
scared. There are angry people outside. I hope they don’t hurt us” as he played
out the reenactment. The last few minutes before returning to class were spent
with the hills and valley finger breathing, which Jake was also to use at home as
homework.

Session 5
Week in review with Jake stating that he liked using his feelings thermometer to
show his parents how angry he was feeling. I had Jake trace his left shoe on a
large piece of paper, and then his right shoe on it. He was encouraged to stomp
on the paper and say the things that make him angry. He was encouraged to let
out his angry feelings about school, classmates, parents, and siblings. After about
five minutes, Jake was encouraged to say positive things about himself. I led with
statements about how great a smile he had and how magical it was in being able
to make others smile back. Jake was able to come up with three positives: being
a fast runner, able to build things with blocks, and having a loud voice. Jake then
spent the next 15 minutes playing with the puppets and putting on a puppet show.
He had his puppets talk about being friends, and he and I role-­played on making
friends and being able to share and not always win. The last five minutes were
spent having a cotton ball race. Using two cotton balls, one for Jake and one for
me and a straw for each, we took turns in slowly blowing the cotton ball across
the table; and then seeing how fast they could roll after taking deep breaths and
blowing hard. We repeated this a few times to help teach Jake control and patience.
Jake was encouraged to continue working on “I” statements at home and use of
his feelings thermometer.
52 Chapter 4

Session 6
Week in review; taught the turtle technique (Feindler, 2009). Jake was told the
story using a turtle puppet, of a boy turtle who had problems in school with his
classmates with name calling, tattling, and not listening to his teacher. A wise old
tortoise shared with the little turtle the secret of being able to calm down. The
turtle could pull his head in and count to 10, pretending a red light is shining.
Then as he counted down, the turtle would slowly breathe in and out, and the
light would change to yellow, and when the turtle felt calm, it would turn to
green. Then he could avoid getting himself in trouble. Jake was then encouraged
to wrap his arms around himself, put his head down and slowly breathe until he
felt calm (green light). This was practiced several times.
During child-­led playtime, Jake shifted his play, deciding to use army figures
to set up a battle in the sand tray with figures having magical powers to build
force fields around themselves to protect themselves from the oncoming army.
His battle ended with all parties deciding not to fight.

TABLE 4.2. JAKE: SESSION 6

Transcript Analysis
T: “Today I will teach you the turtle technique The goal is to add to the repertoire of techniques
to help with calming down and thinking before Jake can use for affect regulation. By modeling
acting. Watch how I do it, as though I am pulling and role-­play, Jake will be able to imitate the
my head into my shell and slowly breathing.” therapist and try out the technique.
J: “I am a turtle! I can wrap my arms around me Role-­play allows Jake to experience relaxation
and pull my head in. Now I will breathe in and out while trying the technique. Repetition allows for
until I can relax!” practice in session and mastery to then generalize
its use and apply it in other settings.
T: “Now you can use this time to use the toys in Child-­led therapy time allows Jake to access
the way you would like to play.” unconscious feelings, feel mastery and control
while using catharsis to release affect.
J: “I am going to set up my army, and they are Power and mastery through use of magic and
going to fight the other guys. But this time my force field. A shift in the play allowing his army to
army has a force field to protect them. They have show strength and have protection.
magic.”
T: “Your army has magic. They can protect Empowering Jake and joining in the metaphor
themselves and be safe with their force field.” of magic and increased sense of protection and
safety.
J: “YES! They are safe. No one can hurt them.” Realization that there is safety and that outside
forces cannot hurt them. A shift in his cognitive
distortions that the world is a dangerous place to
feeling that there is safety, and he doesn’t have to
fear getting hurt.
T: “No one can hurt them. They feel safe.” Reaffirming his realization that there is safety and
protection.
J: “The other army cannot win, and they know it. Shift in outcome with the armies deciding not to
They are deciding not to fight. My army doesn’t fight, and his side not needing to be aggressive.
need to attack them.” Jake realizes that aggression and fighting does
not have to be the first response and that there
are choices and options.
 Disruptive Behavior after January 6 Washington, DC, Uprising 53

Homework was to practice the turtle technique at home and teach it to his
parents. Session ended with Jake using the turtle technique.

Session 7
Week in review. I reviewed progress to date and discussed Jake’s upcoming treat-
ment termination with just one session left. We read the book The Very Angry
Day Amy Didn’t Have. I helped Jake with problem-­solving skills and taught him
the sequence and mantra STAR—
1. STOP: What is the problem?
2. THINK: What can I do? Brainstorm solutions; look at all the possibilities.
3. ACT: Try it out and check your answer.
4. REACT: Did it work? Tell yourself, “I did a good job!”
During child-­led play, Jake set up the dollhouse and showed what things make
him angry at home and how he manages his anger at home. Before ending, Jake
picked the turtle technique to practice. Parents were called to check on the prog-
ress and remind that next week was the last session.

Session 8
Review of the week; read about termination in A Child’s First Book about Play
Therapy. Coping cards were made, writing the name of each coping and calm-
ing technique on separate index cards with Jake drawing pictures on the cards
to help remind him what to do. The instructions were written on the back of
the card, a hole punched, and a ring attached to them. Jake and I went through
each card and practiced each technique twice, reinforcing them, and reviewing
his overall progress. I reviewed the problem-­solving steps, STAR, with a situation
Jake picked about not liking to lose. Jake was given the cards to take home and
use whenever he started to feel upset or angry to help him calm down.

Ethical and Cultural Considerations

Ethically, part of informed consent is explaining the limits to confidentiality,
which includes serious and foreseeable harm to self or others. To be clear, what
a child plays out in a play session does not necessarily indicate that the child will
act that out in the community. Clearly, Jake’s reenactment of the Capitol violence
did not indicate that he would do that or enact that at his school. A play ther-
apy guideline is to “allow in fantasy what they cannot do in reality” (Landreth,
2012). His parents and teachers were told that the risks of Jake harming himself
or others were minimal at this time but would continue to be monitored through-
out treatment. And his parents were made aware of the need to keep any weap-
ons, should they be in the household, safely locked in a gun safe and inaccessible
to Jake.
54 Chapter 4

Cultural considerations included ongoing sensitivity and exploration of the

parents’ conservative religious beliefs and culture of violence that they espoused.
Throughout consultation sessions I worked toward being open and accepting of
their differing points of view and offered the parents literature on different par-
enting styles and the impact of viewing violence on television by Jake so that they
could better understand how to help Jake regulate his emotions and behaviors.

Parent Consultations
As described above, I met with Jake’s parents on a regular basis. The goal was
to teach positive parenting skills, help the parents use alternative and more pos-
itive means of modifying Jake’s behaviors and lessen the negative and aggressive
atmosphere in the home that was contributing to Jake’s behavioral dysregulation.
The parents were receptive and open in working with me and made significant
progress over the span of treatment in modifying their interactions with Jake and
using suggested techniques.
At the beginning of treatment, the parents were encouraged to “catch Jake
being good” by putting a sticker on their watch, and every time they looked at
their watch, give positive verbal praise for even the slightest positive behavior at
that moment (e.g., “I like how you are sitting so quietly”; “I see how hard you
are working on playing nicely with your sister”). I encouraged them to keep a
behavioral log and be specific in verbal reprimands, such as “Stop banging the
toy in the living room. You can bang it in your bedroom,” rather than just saying
“stop it” over and over with escalating anger resulting in swatting Jake’s bottom.
I also taught them natural consequences and encouraged appropriately set limits
by stating, “If you continue to bang the toy in the living room, and not play in
your room, then you choose to no longer play with that toy for the rest of today.”
The parents were very receptive to this guidance and willing to implement the
suggestions at home.
I also asked Jake’s teacher to keep a behavioral log and “catch Jake being
good” using the same intermittent reinforcement of randomly focusing on Jake’s
positive behaviors, which would subsequently increase over responding to nega-
tive attention-­seeking behaviors.
After the third session, I contacted Jake’s parents to share the various self-­
calming techniques, explain the feelings thermometer, and inquire about the
status of behaviors at home. Jake’s parents noted that there was progress with
Jake listening to them and responding without aggression when they set limits.
His interactions with his siblings showed improvement with fewer conflicts, and
Jake’s nightmares were diminishing. I reviewed with the parents their reflective
comments, frequency in “catching Jake being good,” and natural consequences
used.
In the fifth session Jake’s parents came in and reviewed their behavioral log,
how they were doing with limit setting and “catching Jake being good.” Parents
reported positive results in Jake’s lessening of behavioral problems, staying more
 Disruptive Behavior after January 6 Washington, DC, Uprising 55

focused, and absence of any nightmares. They stated that he still had occasional
temper outbursts when he got frustrated or did not get his way with his sib-
lings, but Jake was responding to using the self-­calming techniques. Parents were
encouraged to continue their work with Jake, especially giving spontaneous pos-
itive reinforcement. Each parent was encouraged to pick a separate night that
was designated as Jake’s to spend a few minutes before bedtime to read a book,
rub his back, and help him settle into sleep. Parents were to keep those desig-
nated evenings with Jake regardless of how Jake behaved during the day. The
parents wondered how jealous the other children might become in reaction to
Jake’s exclusive time with a parent. I encouraged the parents to have designated
evening times for each of the children, as they, too, could benefit from the positive
attention.
In the seventh session, the parents reported Jake’s negative behaviors at home
were manageable, and interactions were much more positive than negative; all
sleep difficulties had ceased, and his interactions with siblings were significantly
better. We also discussed termination and my availability in the future should any
issues reemerge.
Jake’s teacher was contacted periodically regarding progress, and the teacher
reported steady positive change. By the seventh session, the teacher reported that
Jake’s disruptive behaviors had ceased in the classroom and his peer interactions
were significantly better. I let the teacher know that the next session would be
Jake’s last one but that she could contact me in the future should the need arise
regarding Jake.

Conclusion
Jake made significant progress in being able to be supportive and cooperative
with peers in the classroom, decreased tattling on peers, stayed focused on tasks
and completed assignments, and decreased to zero oppositional behaviors in
school and at home. He learned coping and calming skills, which he used regu-
larly, and was able to use empathy as well as alter his negative cognitive distor-
tions. Consequently, Jake’s relationships with his parents significantly improved,
aided by their use of positive feedback and decrease of negative punishment and
by altering their lifestyle by lessening TV viewing of violence.

Sample Case Notes

Session 4
Subjective: The previous week was reviewed regarding anger levels and the use
of “I” statements at home by Jake. Jake stated that he was using “I” statements
when he could remember to use them and that it seemed to help him to slow
down and be able to express his feelings with his parents and not become so
56 Chapter 4

explosive. Jake’s free playtime showed noticeable shifts in not being as aggressive
and showing more empathy.
Objective: Read bibliotherapy book How to Take the Grr out of Anger and
played the Angry Monster Machine board game to help increase understanding
about feelings, problem solve, and allow for catharsis.
Assessment: Jake’s play is starting to change with noticeably less aggression, with
increased verbalization of empathic feelings toward the figures. He was able to
express his own scared feelings about potential anger and danger in his world. He
is showing more coping strategies and less reactivity.
Plan: Goal is to increase self-­soothing and calming resources for Jake to use when
upset or angry. Hills and valley deep breathing was taught and homework given
to practice this at home.

Resources

For Professionals
The Angry Monster Machine board game—Childswork/Childsplay.
The Talking, Feeling & Doing game—Childswork/Childsplay.
CBT Workbook for Kids: 40+ Fun Exercises and Activities to Help Children
Overcome Anxiety & Face Their Fears at Home, at School, and Out in the
World by Heather Davidson, PsyD, BCN (2019).
The Mindfulness Workbook for ADHD: Effective Strategies to Increase Focus,
Build Patience, and Find Balance by Beata Lewis and Nicole Foubister (2022).
Thriving with ADHD Workbook for Kids: 60 Fun Activities to Help Children
Self-­Regulate, Focus, and Succeed by Kelli Miller, LCSW, MSW (2018).
Understanding ADHD: A Neurodiversity Affirming Guidebook for Children and
Teens by Robert Jason Grant (2022).

For Children
A Child’s First Book about Play Therapy by Marc Nemiroff and Jane Annunziata
(1990).
How to Take the Grr out of Anger by Elizabeth Verdick and Marjorie Lisovskis
(2015).
I Am Stronger Than Anger: Picture Book about Anger Management and Dealing
with Kids Emotions and Feelings by Elizabeth Cole (2020).
My Whirling Twirling Motor by Merriam Sarcia Saunders and Tammie Lyon
(2019).
The Very Angry Day Amy Didn’t Have by Lawrence Shapiro and Charles Brenna
(1994).
 Disruptive Behavior after January 6 Washington, DC, Uprising 57

For Parents
The ADHD Parenting Guide for Boys: From Toddlers to Teens Discover How to
Respond Appropriately to Different Behavioral Situations by Richard Bass
(2023).
Explosive Children with ADHD: A New Approach to Managing Attention Defi-
cit Disorder in Children to Discipline and Empower Your Super Hero to
Achieve Success and Accomplishment by Pansy Bradley (2023).
What Your ADHD Child Wishes You Knew: Working Together to Empower Kids
for Success in School and Life by Sharon Saline (2018).

Discussion Questions
1. What contributing factors exacerbated Jake’s aggressive behaviors?
2. How would you work in an integrative manner on a short-­term basis to
address Jake’s behavioral issues and ADHD? Would you consider referral for
medication?
3. What additional techniques or approaches would you use with Jake going
forward if you had more sessions to continue building self-­regulation and
coping skills?
4. As a mental health professional, how would you talk with the parents about
potential possession of guns in the home and personal views about use of
violence?

References
Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-­
age forms & profiles. University of Vermont, Research Center for Children,
Youth, & Families.
Afdal, A., Zikra, Z., Sakmawati, I., Syapitri, D., & Fikeri, M. (2022). Psychoedu-
cational intervention in early childhood education: Analysis for children with
disruptive behavior. Advances in Social Science, Education and Humanities
Research, 668, 2–8.
Agus, A. H., Mushfi El Iq Bali, M., & Maula, I. (2022). Role-­playing therapy in
handling hyperactive children. Al-­Hayati Journal of Islamic Education, 6(1),
34–42.
Anderson, C. A., Berkowitz, L., Donnerstein, E., Huesmann, L. R., Johnson, J. D.,
Linz, D., Malamuth, N. M., & Wartella, E. (2003). The influence of media
violence on youth. Psychological Science in the Public Interest, 4(3), 81–110.
Bandura, A. (1977). Social learning theory. Prentice Hall.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International
Universities Press.
Berk, L. E. (2003). Child development (6th ed.). Allyn & Bacon.
Browne, K. D., & Hamilton-­Giachritsis, C. (2005). The influence of violent media
on children and adolescents: A public health approach. Lancet, 365, 702–710.
58 Chapter 4

Calvert, S. L. (2006). Media & early development. In K. Mc­Cartney & D. Phillips

(Eds.), The Blackwell handbook of early childhood development (pp. 508–
529). Blackwell.
Chen, M., & Chang, K. (2014). A study of the effects of cognitive-­behavioral play
therapy for ADHD child with disruptive behaviors. https://www​​.airitilibrary​​
.com/Publication/Detail​Print​?Doc​ID​=1992
Drewes, A. A. (2009). Blending play therapy with cognitive behavioral therapy:
Evidence-­based and other effective treatments and techniques. Wiley & Sons.
Ellis, A. E. (1971). Growth through reason: Verbatim cases in rational-­emotive
therapy. Science and Behavior Books.
Feindler, E. (2009). Playful strategies to manage frustration: The turtle technique
and beyond. In A. A. Drewes (Ed.), Blending play therapy with cognitive
behavioral therapy: Evidence-­based and other effective treatments and tech-
niques (pp. 401–422). Wiley & Sons.
Hirshfeld-­Becker, D. R., & Bierderman, J. (2002). Rationale and principles for
early intervention with young children at risk for anxiety disorders. Clinical
Child and Family Psychology Review, 5, 161–172.
Huesmann, L. R., Moise-­Titus, J., Podolski, C., & Eron, L. D. (2003). Longitudi-
nal relations between children’s exposure to TV violence and their aggressive
and violent behavior in young adulthood: 1977–1992. Developmental Psy-
chology, 39(2), 210–221.
Jafari, N., Mohammadi, M. R., Khanbani, M., Farid, S., & Chiti, P. (2011). Effect
of play therapy on behavioral problems of maladjusted preschool children.
Iranian Journal of Psychiatry, 6(1), 37–42.
Kasiati, S., Naruvita, S. R., Harti, U., Yulia, I., & Yunitsari, S. E. (2022). Play cog-
nitive behavioral therapy improves the concentration of children with ADHD.
Journal Scientia, 11(2), 439–443.
Knell, S. M. (2009). CBT: Cognitive behavioral play therapy: Theory and applica-
tions. In A. A. Drewes (Ed.), Blending play therapy with cognitive behavioral
therapy: Evidence-­based and other effective treatments and techniques. Wiley
& Sons.
Landreth, G. L. (2012). Play therapy and the art of the relationship (3rd ed.).
Routledge/Taylor & Francis Group.
Lochman, J. E., Powell, N. P., Boxmeyer, C. L., & Jimenez-­Camargo, L. (2011).
Cognitive behavioral therapy for externalizing disorders in children and
adolescents. Child and Adolescent Psychiatric Clinics of North America, 20,
305–318.
Murray, A. E. (2015). Evaluating CBPT intervention for kindergarten students
with externalizing behaviors [Unpublished doctoral dissertation, Pennsylva-
nia State University].
National Survey of Children’s Health (NSCH) Report. (2021). Cfah​​.org/adhd​
statistics/2020.
 Disruptive Behavior after January 6 Washington, DC, Uprising 59

Patterson, G. R. (2002). The early development of coercive family process. In J.

B. Reid, G. R. Patterson, & J. Snyder (Eds.), Antisocial behavior in children
and adolescents: A developmental analysis and model for intervention (pp.
25–44). American Psychological Association.
Perryman, K. (2016). Play therapy in schools. In K. J. O’Connor, C. E. Schaefer,
& L. D. Braverman (Eds.), Handbook of play therapy (2nd ed., pp. 485–503).
Wiley.
Reddy, L. A. (2010). Group play interventions for children with attention deficit/
hyperactivity disorder. In A. A. Drewes & C. E. Schaefer (Eds.) School-­based
play therapy (2nd ed., pp. 307–329). Wiley & Sons.
Rones, M., & Hoagwood, K. (2009). School-­based mental health services: A
research review. Clinical Child and Family Psychology, 3, 223–241.
Siegel, D., & Bryson, T. P. (2012). The whole-­brain child: 12 revolutionary strate-
gies to nurture your child’s developing mind. Bantam Books.
Sukhodolsky, D. G., Kassimnove, H., & Gorman, B. S. (2004). Cognitive-­
behavioral therapy for anger in children and adolescents: A meta-­analysis.
Aggression and Violent Behavior, 9, 247–269.
Thijssen, S., Ringoot, A., Wildeboer, A., Bakermans-­Kranenburg, M., El Marroun,
H., Hofman, A., Jaddoe, V., Verhulst, F. C., Tiemeier, H., van IJzendoorn, M.
H., & White, T. (2015). Brain morphology of childhood aggressive behav-
ior: A multi-­informant study in school-­age children. Cognitive, Affective, &
Behavioral Neuroscience, 15(3), 564–577.
Viranda, C., & Istiningtyas, L. (2019). Bermain Peran (role play) dan Peningkatan
Keterampilan Sosial Anak Usia Dini. Psikostudia: Jurnal Psikologi, 8(1), 1.
 CHAPT E R 5

ADHD and COVID-19

Cognitive Behavioral Play Therapy with
an African American Child
Lisa Remey

Benjamin is a 6-year-­old African American boy living with his mother and father
and is a first grader attending public school. Both parents have full-­time jobs out-
side the home. Benjamin has a 4-year-­old brother. His parents sought counseling
services due to daily teacher reports of incomplete tasks, class disruptions, non-
compliance to teacher requests, and classroom outbursts resulting in referrals to
the principal’s office. An intake session was held with both parents, who shared
a history of concerns beginning in kindergarten with some disruptions at home.
When asked about day care and/or preschool attendance, parents shared that
Benjamin attended day care at 1 year of age; however, when COVID-19 occurred
at age 3 and day care closed, he remained at home. During that time, both par-
ents worked from home, navigating parenting and work responsibilities.

For this case study, consider the following:

1. How did the COVID-19 quarantine impact young children with symptoms
of Attention-­Deficit/Hyperactivity Disorder (ADHD)?
2. What is the rationale for using Cognitive Behavior Play Therapy (CBPT)
with Benjamin?
3. Which directive and nondirective strategies seemed to support Benjamin
within sessions?

Attention-­Deficit/Hyperactivity Disorder
Current research shows that ADHD is the most common childhood neurode-
velopmental disorder, which affects 3–9% of school-­age children and often per-
sists into adulthood (Ogundele & Ayyash, 2023). The core symptoms of ADHD
include pervasive inattention and/or overactivity/impulsiveness and impaired
functioning across multiple settings (American Psychiatric Association, 2022).

61
62 Chapter 5

Additional indicators of ADHD are a short attention span with difficulty sustain-
ing attention due to distraction from extraneous stimuli and internal thoughts.
Consequently, it then appears as if children with ADHD are not listening. When
children have difficulty focusing their attention, they also have difficulty with
follow-­through on instructions and completing tasks in a timely manner. Some
children with ADHD may have components of hyperactivity as evidenced by high
energy levels, difficulty sitting still, impulsivity resulting in disruptive behaviors,
difficulty waiting for a turn, and/or interrupting others with questions/comments.
Due to these behavioral challenges, children with ADHD tend to have poor social
skills and low self-­esteem (Ogundele & Ayyash, 2023). They also have decreased
working memory, which affects their ability to temporarily store, manipulate,
and retrieve information while completing tasks (Wiest, Rosales, Looney, Wong,
& Wiest, 2022).
Since the onset of COVID-19, children with ADHD had increases in emo-
tional symptoms (i.e., sadness/depressed mood, loneliness, conduct problems, and
sleep problems) compared to before COVID (Segenreich, 2022). Other researchers
found that during the COVID-19 quarantine, children with ADHD had increases
in anxiety and home learning difficulties (Jackson et al., 2022); deterioration of
functional impairment in home life, friendships, learning, and leisure activities
compared to children without ADHD (Hall, Partlett, Valentine, Pearcey, & Sayal,
2023); and hyperfocus on the internet with 28% of children with ADHD meeting
diagnostic criteria for internet addiction (Kuygun Karci & Arici Gurbuz, 2021).
ADHD symptoms can result in education problems that are predictive of
student underachievement and an increased risk of delinquency (Strelow, Dort,
Schwinger, & Christiansen, 2021). Because student success requires the ability to
attend to tasks, recall teacher instructions, and regulate behavior throughout the
school day, children with ADHD need effective treatment.

Cognitive Behavioral Therapy

Cognitive behavior therapy (CBT) has been identified as an approach to support
clinical goals associated with treatment for ADHD (Khatoon, Iqbal, & Masroor,
2020). CBT is set in the foundational work of Aaron Beck (2021) and examines
how underlying maladaptive beliefs affect emotions and behaviors. Within the
CBT framework, change occurs when clients learn to evaluate and shift think-
ing into more realistic and adaptive patterns, which then increases both positive
emotions and behaviors (Beck, 2021). CBT is an empirically researched approach
and has been found to be effective in treating children with ADHD (Drewes &
Cavett, 2019; Doyle & Terjesen, 2020). Research by von Brachel et al. (2019, as
cited in Beck, 2021) showed lasting effects from CBT sessions ranging from 5 to
20 years beyond receiving counseling services.
CBT interventions and approaches are effective for clients from diverse socio-
economic backgrounds, cultures, and ages (Halder & Mahato, 2019). Despite
 ADHD and COVID-19 63

well-­defined research, Halder and Mahato (2019) identify clinicians who some-
times hesitate to use CBT with children due to minimal levels of young children’s
language, communication, self-­awareness of cognitions, and emotional compe-
tencies. However, Halder and Mahato (2019) explain that when working with
young children, the focus of CBT is on neutralizing behaviors rather than identi-
fying core cognitive errors.

Cognitive Behavioral Play Therapy

Cognitive Behavioral Play Therapy (CBPT) (Knell, 1993) merges CBT’s theoret-
ical foundation with the foundational aspects of play therapy to meet children’s
developmental level in communication and awareness. When CBT is blended
with the therapeutic powers of play, children can communicate without verbaliz-
ing thoughts explicitly (Kaduson, Cangelosi, & Schaefer, 2019). Through thera-
peutic play and concrete examples, CBPT builds social-­emotional understanding
and positive self-­talk before negative patterns take root (Drewes, 2009; Knell &
Dasari, 2010). It also supports CBT essentials of building client awareness of
emotions and the ability to discriminate thoughts, behaviors, and feelings. CBPT
uses the CBT framework of reinforcement techniques to achieve the desired
change in the client’s behavior (Halder & Mahato, 2019).
Knell (1993) outlines six aspects of CBPT:
1. treatment that involves play;
2. a focus on the client environment, fantasy, thinking, and feeling;
3. strategies to develop adjusted behaviors and thinking;
4. structured and goal-­oriented sessions;
5. using a combination of empirically demonstrated techniques; and
6. allowing collaborative control of treatment.
Razak, Johari, Mahmud, Zubir, and Johan (2018) explained that CBPT addresses
problematic behaviors arising from maladaptive thinking by using play activities
and engaging children in verbal and nonverbal communication. This play-­based
approach positively affects children’s feelings and behaviors. CBPT uses both
directive and nondirective approaches to address treatment goals. It involves
structured and unstructured activities to support the child in generalizing and
learning adaptive behaviors (Friedberg & McClure, 2018; Knell, 2015).
In both traditional nondirective play therapy (e.g., Child-­ Centered Play
Therapy) and CBPT, therapists establish a positive therapeutic relationship
with children by having a play therapy room that is a safe place so children can
communicate through play (Knell, 2015). Both types of play therapists provide
therapeutic responses to increase children’s understanding during their play and
fantasy (Razak et al., 2018). In contrast to traditional nondirective play therapy,
CBPT therapists focus on goals and provide selected activities as well as instruc-
tion to shape behaviors (Razak et al., 2018).
64 Chapter 5

Collaborative Session Structure

CBPT provides session structure, but the play therapist does not solely lead this
structure. The therapist puts the session structure in place and then collaborates
with the client to meet current needs and treatment goals (Knell & Dasari, 2010).
With this said, in CBPT, the therapist maintains a similar structure each session.
This can begin with a client check-­in, consisting of a mood check, reconnection,
review of the previous session to bridge sessions, review of concerns, updates
from the client about their week, and establishing a session plan (Okamoto,
Dattilio, Dobson, & Kazantzis, 2019). In a CBPT session, check-­in includes a
self-­report of the week’s positive and negative parts. This time helps facilitate
discussion regarding choices the client made and build rapport by accepting and
normalizing both positive and negative experiences. The check-­in allows time for
problem solving and learning new strategies. Session planning is collaboratively
created during check-­in with input from both counselor and client to determine
activities and interventions aligned with treatment goals (Knell, 2011). At first
glance, session structure may appear rigid. However, the process ebbs and flows
based on the client’s need and can be as short or as long as appropriate based on
client age, abilities, and developmental stage. Okamoto et al. (2019) state that
adhering to a collaborative, predictable, yet flexible session structure is related to
positive response toward treatment goals.

Strategies
CBPT therapists use a variety of treatment strategies. Common CBPT strate-
gies are self-­expression and abreaction as part of nondirected play; direct/indi-
rect teaching; stress inoculation; behavioral rehearsal/role-­play; creative problem
solving within therapist-­directed interventions; and psychoeducation to increase
children’s awareness of their strengths and weaknesses (Knell, 2011). Other
activities and experiential learning using varied techniques to enhance client self-­
regulation, attention, and flexibility have been identified by Doulou and Drigas
(2022). CBPT strategies help children develop positive core adaptive cognitions
that prevent maladaptive automatic thoughts and self-­talk from taking root in
the child’s development. The strategies also assist children in creating adaptive
self-­statements as a coping strategy and boosting adaptive thoughts and behav-
iors (Drewes, 2009). Coinciding play therapy with psychoeducation and parent
sessions reinforces adaptive core beliefs and coping self-­talk beyond the play
therapy sessions (Knell & Dasari, 2010).
During nondirective play, the CBPT therapist provides facilitative responses
to reflect observed actions, raises hypotheses around client thoughts, brings
awareness to problem solving, and states observed processing demonstrated by
the client. These play therapy facilitative response skills relate directly to CBPT
theory in that reflective and tracking statements focus on thoughts, feelings, and
actions, which can shift children’s awareness and lead to alternative outcomes.
Common reflective responses may include “I wonder what happens next,” or “I
 ADHD and COVID-19 65

noticed you stopped and thought.” The specific facilitative responses made by
the therapist align with the client’s treatment goals while also considering the
individual development and progress of the client. Example response statements
for a treatment goal of increasing body awareness may include “Your body really
was able to stop right then,” “I noticed how you were really focused on where
your body was stepping,” or “Your pause tells me you are thinking about what to
do next.” During nondirected play, the therapist gains a sense of how children’s
thoughts and perceptions are merging with their skills and strategies. Balancing
unstructured client-­led activities and structured counselor-­led interventions is an
important aspect of the CBPT process (Knell & Dasari, 2010).

Case Study Application

I will apply CBPT concepts and strategies in Benjamin’s play therapy sessions to
support him in reducing negative teacher reports, behavioral outbursts, noncom-
pliance, and incompletion of tasks. During the intake session with both parents,
they reported that Benjamin’s ADHD symptoms increased at school and home
as well as with peers during and after the COVID-19 quarantine. I collaborated
with his parents to develop treatment goals and objectives as follows.
Treatment Goals: Reduce impulsive actions, increase focus and completion of
low-­interest activities, and develop effective emotional and behavioral regulation.
Objectives:
1. Identify feelings and connect thoughts, feelings, and actions to choices.
2. Learn thinking and problem-­solving skills before acting on the first impulse.
3. Apply skills and increase compliance with rules in the classroom and at home.
I will use CBPT treatment strategies of psychoeducation as well as social-­
emotional and communication skill development to address Benjamin’s impulsiv-
ity, self-­esteem, compliance, executive functioning, and working memory. I will
conduct parent sessions to build parent skills and strategies to support Benjamin.
The treatment process begins in Benjamin’s initial session. I will work to build
rapport and assess Benjamin’s recognition of concerns, areas of desired changes,
ability to recognize and identify feelings, and his awareness of the effects of his
choices on relationships with others. Session structure in an initial session will
mirror the structure of future sessions to have session consistency of expectations.

Session 1
I began the initial session with Benjamin using a check-­in to briefly explain coun-
seling as a place to explore feelings and problems and develop problem-­solving
skills. Benjamin shared that he is currently getting in trouble at school and desires
to no longer be in trouble with his teacher. After checking in, I introduced the
playroom and session structure.
My directive intervention for the first session consisted of a prompt for a
kinetic family drawing with the goal of learning about Benjamin and his family,
66 Chapter 5

building rapport, and assessing coping with directives and transitions. A timer is
used at the end of each session. I set the timer when there are 5 minutes left in
the session and let Benjamin know that when it rang, it was time to clean up the
playroom and end the session. Using the timer supports building skills and treat-
ment goals of coping with transitions, building compliance, completing tasks, and
using self-­control.

TABLE 5.1. BENJAMIN: SESSION 1A

Transcript Analysis
T: “In the playroom, there are many things you Introduction of the play therapy room and
can do; if there is something you cannot do, I will structuring the session provide expectations for
let you know. Sometimes you will choose what to this and future sessions.
do; other times, I will choose. Today you can start
by choosing what to play, and later, I have a few
things for us to do.”
B: “Okay.” Benjamin explored the room, distracted by toys,
with some difficulty deciding what to choose.
This response is not uncommon during the first
session. Allowing time to explore while providing
facilitative responses helps Benjamin build
familiarity with the playroom while building rapport.
T: “Your pause tells me you are thinking about Tracking, reflecting, and attunement to Benjamin
what to do next.” to meet initial session goals.
T: “In five minutes, I have something for us to do. I The use of a timer provides structure as well as
will set this timer so we will know when to change a cue for transitioning activities. Children with
activities.” ADHD often have difficulty transitioning tasks,
and building transitions into sessions provides
opportunities to cope with transition and
compliance.

TABLE 5.2. BENJAMIN: SESSION 1B

Transcript Analysis
T: “The timer rang. Do you remember what that Prompt to assess working memory as well as
means?” bringing awareness to expectations and structure
B: “It means it is time to clean up. But I want to
keep playing.”
T: “You wish you had more time to play. However, Limit setting stating client desire, limit, and
our time is done for today. I wonder what you will opportunity to plan.
choose next week?”
 ADHD and COVID-19 67

Session 2
The second session began with a client check-­in with Benjamin. As Benjamin
shared about his week, I reflected his feelings, understanding of experiences, and
choices made while exploring together whether his choices helped make problems
bigger or smaller. In doing so, I helped process his feelings, choices, consequences,
and thoughts as well as built his self-­efficacy.
After check-­in, I introduced the concept of a “pause button,” explaining how
pausing to think through and/or take two breaths can shift choices made, often
resulting in reducing negative outcomes.
After the “pause button,” I introduced and engaged him in a new game. The
Bubble Pause game consisted of using a bubble blower to produce bubbles all
over the room with a prompt to pop all the bubbles he could until I said “pause.”
Once “pause” is said, Benjamin would freeze until I said “un-­pause,” and then he
returned to popping bubbles. While playing the game, my facilitative responses
focused on Benjamin’s actions, self-­control, and abilities.
Once the game was completed, Benjamin was invited to choose what to play.
During his play, my facilitative responses focused on reflecting choices, feelings,
and observations of pausing to think by Benjamin and/or play characters (such
as deciding what to do next or problem solving). These facilitative responses
brought awareness to times when Benjamin naturally used his pause skill in deci-
sion making and within his play, helping to bring awareness to bridge and expand
skills within and outside of sessions. I used a timer to indicate 5 minutes left in
the session and when the timer rang, Benjamin and I cleaned up the playroom.

TABLE 5.3. BENJAMIN: SESSION 2A

Transcript Analysis
T: “Before we play today, let us begin with a Building session structure and demonstrating will
check-­in. Tell me some good and not-­so-­good be exploring both positive and negative choices in
parts of your week.” which clients experience positive regard from the
therapist as well as problem solving and applying
to treatment goals.
B: “I don’t know.” Clients can often be uncertain how to respond in
the beginning phase of treatment.
T: “Okay, let us start with something not-­so-­good Provide guidance and prompt.
that happened this week either at school or
home.”
B: “I got in trouble for talking during work time.” Builds trust and rapport when negative aspects
are shared and accepted.
T: “One not-­so-­good thing this week was when Reflecting and accepting both positive and
you were talking instead of working. Okay, what is negative parts of the week equally creates safety
something good that happened this week?” within the session and acceptance.
TABLE 5.4. BENJAMIN: SESSION 2B
Transcript Analysis
T: “I want to share with you about using a “pause A pause button is a tool I use to practice self-­
button” to stop and think before making choices. control and the ability to stop and think with the
This often can help in pausing before acting. What goal of reducing impulsivity and increasing self-­
color would you like yours to be?” awareness and intentional choices.
D: “I pick blue; it’s my favorite color.” A pause button is drawn on Benjamin’s and my
hand.
T: “Let us practice. When I say ‘pause,’ we push This makes it a fun game to incorporate into
the pause button and freeze until I say ‘un-­pause,’ sessions.
then we continue with what we are doing.”

Figure 5.1. Pause Button Photo courtesy of Lisa Remey.

 ADHD and COVID-19 69

TABLE 5.5. BENJAMIN: SESSION 2C

Transcript Analysis
T: “You are really getting all the bubbles”; “Nice These facilitative responses build positive
pause, you got your whole body to stop quickly”; reinforcement as Benjamin builds self-­control and
“That can be hard to stop in the middle of body awareness.
something, but you did it!”

Session 3
Benjamin’s third session began with a check-­in. He shared using the pause button
during the week.
After the check-­in, we drew pause buttons on our hands, and I introduced the
Self Control song (Kisor, 2009). The song is an action song in which children fol-
low along, practicing body awareness and control, moving their body fast, slow,
and stopping. During the intervention, I reflected on Benjamin’s ability to control
his body and follow the song’s directions. The remainder of the session was non-
directive play chosen by Benjamin. I intermittently prompted him to “pause” and
“un-­pause,” practicing pausing our actions and word.

TABLE 5.6. BENJAMIN: SESSION 3

Transcript Analysis
B: “This week, I had some trouble listening during Reflective listening and acceptance of the client
group time.” demonstrated.
T: “I wonder if there is a way the pause button Prompt to apply strategy and build coping skills.
could help you during group time?”
B: “I could push the pause button and remember He demonstrated the benefits of the strategy and
to listen to the teacher, so I don’t get in trouble.” the ability to apply it to other settings.
T: “Good idea; I wonder if using the pause button Returning responsibility and decision making.
and reminding yourself to listen will help?”
B: “Yes, because then I will get to have recess.” Demonstrating awareness of the effects of
choices and benefits of using skills.
70 Chapter 5

Session 4
On the fourth session during check-­in, Benjamin shared drawing a pause button
on his hand each day before school. He then shared using the pause button often
without prompting, such as on the playground at recess. Another example was
when he became distracted while the teacher talked and used the pause button
to focus on teacher-­directed tasks. After check-­in, I introduced the My Pleasure
game. I created this game using a Thumball™, a softball with panels consisting
of printed phrases, words, or images for throwing or rolling, with prompts such
as “take 5 giant steps.” The ball was gently tossed between Benjamin and me. I
read the prompt my thumb landed on when catching and requested that Benja-
min complete the task. Prior to completing the task, a crucial rule of the game
that I had is for the player to first respond with “no problem,” “yes, ma’am/sir,”
or “my pleasure.” The game addresses both working memory and self-­control
through the steps of gameplay reinforcing pausing and thinking prior to taking
the action identified on the Thumball. Benjamin enjoyed playing the game and
needed reminders of the rules as he learned the steps. After game completion,
Benjamin was provided an opportunity for nondirective play with a timer used to
indicate the end of the session and clean-­up time.

Ethical and Cultural Considerations

Benjamin’s family sought counseling services due to experiencing school difficul-
ties and not meeting the expectations of his classroom environment. I obtained
written informed consent from his parents and written permission to contact
his teacher. To honor his family’s culture, during the intake session, I explored
his parents’ family rules, expectations, and parenting style to support and blend
strategies to meet treatment goals at home and school.
When using the My Pleasure game intervention, it is important to consider
family and cultural expectations for understanding tasks and compliance. For
example, Benjamin lives in a southern state where it is common for children (and
adults) to respond with “yes, ma’am” or “yes, sir,” and this may be expected
within the culture and community. However, this approach may not fit cultural
norms in other communities and may appear authoritative. As the therapist, I
take these aspects into consideration and adjust game response options accord-
ingly. At times, I engage the child in collaboratively deciding appropriate response
options that indicate understanding and compliance.

Parent Consultations
Parent session goals consist of reviewing play therapy sessions and how they
relate to addressing treatment goals and Benjamin’s progress observed in sessions.
Parents are provided with details of how interventions support Benjamin’s gain-
ing skills to process and cope with experiences and feelings, bring awareness to
choices, increase self-­control, and build sense of mastery. I shared how Benjamin
 ADHD and COVID-19 71

can pause his activity and then pick up where he left off, demonstrating increased
self-­control. His parents shared about his progress at school with reduced acting-­
out behaviors in class. I discussed parent strategies to implement a behavior man-
agement system to identify choices made at school, create a plan to encourage
and reinforce positive choices, and reward Benjamin’s use of coping skills and
strategies. Using a system to chart progress supports increasing parental obser-
vation of behavioral shifts and changes made and will also build Benjamin’s self-­
esteem and mastery. To support parents in enhancing reflective listening and limit
setting at home, I recommended the book How to Talk So Children Will Listen
and Listen So Children Will Talk (Faber & Mazlish, 2013) and discussed it in
future parent sessions.

Conclusion
After four sessions, Benjamin increased his ability to comply with tasks at school,
demonstrated his ability to pause before acting on impulses, and increased his
awareness of his feelings and experiences. Working with Benjamin taught me how
younger children can increase awareness of internal cognitions as a part of learn-
ing new skills. Benjamin’s ability to express using his pause button on his own
without prompting, as well as then sharing no longer needing the pause button,
further taught me how children can quickly work through the process to build
awareness, make positive changes, and formulate positive cognitions. Benjamin’s
excitement at the process and observing his own increase in self-­esteem shows me
the effectiveness of the CBPT process.

Sample Case Notes

Parent Consultation Session

The initial parent consultation session was an intake session with both parents
reviewing their history of concerns and currently seeking counseling due to Ben-
jamin’s difficulty at school. Parents reported some noncompliance at home. How-
ever, goals consist of supporting Benjamin to increase school compliance with his
teacher and decrease outbursts when given directives for undesired tasks. Benja-
min has a diagnosis of ADHD from his pediatrician. The treatment goals identi-
fied are to increase self-­control and compliance, build social-­emotional skills and
ability to cope with feelings, and increase positive choices to undesired tasks. Par-
ents are open to learning parent strategies and skills to support their son. Parent
sessions are to be scheduled after four therapy sessions.

Session 1
Initial session with Benjamin, who eagerly entered the playroom and was engaged
with me. I did a check-­in with Benjamin describing the play therapy process and
counseling goals, with Benjamin identifying a goal of not getting into trouble
72 Chapter 5

with the teacher. I had Benjamin complete a kinetic family drawing, which he did,
and shared enjoying swimming with his family. His play choice was to explore
the animal bins. I used facilitative responses focused on building rapport, feeling
identification, decision making, and mastery. Timer used at the end of the session
to prompt end of the session and picking up the playroom with initial hesitation
from Benjamin followed with compliance.

Session 2
Benjamin smiled and entered the session, engaging with me. Check-­in completed,
with Benjamin sharing positive and negative aspects of his week. Psychoeduca-
tion of introducing and exploring how choices make problems bigger or smaller.
Interventions included teaching Benjamin how to use a “pause button” to stop
and think about choices. I then drew a pause button on his hand, practicing the
skill. Gameplay of Bubble Pause game to continue practicing the skill and build-
ing self-­control. Benjamin’s play choice was floor play, creating a scene with vehi-
cles. My facilitative responses focused on choice, feelings, and decision making,
and when Benjamin naturally paused and thought about choices. The timer sig-
naled the end of the session, with Benjamin responding to the prompt, acknowl-
edging it as the time to clean up the playroom.

Session 3
Benjamin eagerly entered the session and engaged with me. During check-­in, he
shared using the pause button during the week and having difficulty listening
during group time. I reflect on experiences with inquiry to ideas of how Benja-
min could improve listening to the teacher. He identified using the pause button
during group as a coping strategy. Interventions of drawing pause buttons on our
hands, practicing pausing and unpausing during the session, and actively listening
to the Self-­Control song. The remainder of the session consisted of Benjamin’s
nondirective play selecting blocks, vehicles, and people to create a scene. Session
focus and my facilitative responses addressed choices, feelings, self-­control, body
awareness, and building self-­efficacy. A timer was used at the session’s end with
no prompts needed. Benjamin demonstrated his ability to understand and comply
with the session structure.

Session 4
Benjamin was involved in the session and with me. During check-­in, he shared
drawing a pause button on his hand during the week and using it without prompt-
ing at school as well as to increase focus during group time. Intervention was of
teaching Benjamin the My Pleasure game. I provided prompts as he learned the
rules of the game, with Benjamin showing interest and desire to comply with the
game rules. I observed and reflected on Benjamin having difficulty remembering
the steps of gameplay. Plan to play My Pleasure game in future sessions with
the goal of building working memory, increasing focus, and ability to complete
 ADHD and COVID-19 73

multiple-­step tasks. Benjamin’s play choice of floor play, with a battle scene cre-
ated with the theme of good versus bad. The timer used at the end of the session.

Resources

For Professionals
Kisor, D. (2009). Self-­control. I Can Settle Down: Songs of Self Control. Kisor
Music Studios, Fort Thomas, KY.
Mother May I Thumball™ [toy]. (2014). Maple Shade, NJ: Answers in Motion
LLC.

For Parents
Faber, A., & Mazlish, E. (2013). How to Talk So Kids Will Listen and Listen So
Kids Will Talk. Lagom.

Discussion Questions
1. How would you consider working with Benjamin moving forward to con-
tinue building and internalizing skills?
2. What other parenting skills and strategies would you work on with Benja-
min’s parents?
3. How can facilitative responses build client skills during non­directive play?
4. How could different cultures, socioeconomic statuses, and/or beliefs influence
working with a client such as Benjamin?

References
American Psychiatric Association. (2022). Diagnostic and statistical manual
of mental disorders (5th ed., text rev.). https://doi​​.org/​10.1176/appi​.books​
.9780890425787
Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond. Guilford Press.
Doulou, K., & Drigas, A. (2022). ADHD: Causes and alternative types of inter-
vention. Scientific Electronic Archives, 15(2). https://doi​.org/​10.36560/​
15220221514
Doyle, K. A., & Terjesen, M. D. (2020). Rational-­emotive and cognitive-­behavioral
treatment for attention-­ deficit/hyperactivity disorder among youth. In M.
Bernard & M. D. Terjesen (Eds.), Rational-­emotive and cognitive-­behavioral
approaches to child and adolescent mental health: Theory, practice, research,
applications (pp. 285–310). Springer Nature Switzerland AG. https://doi​
.org/10.1007/978-3-030-53901-6_14
Drewes, A. A. (2009). Blending play therapy with cognitive behavioral therapy:
Evidence-­based and other effective treatments and techniques. John Wiley &
Sons.
74 Chapter 5

Drewes, A., & Cavett, A. (2019, September). Cognitive behavioral play therapy.
Play Therapy, 14(3), 24–26.
Friedberg, R. D., & McClure, J. M. (2018). Clinical practice of cognitive therapy
with children and adolescents: The nuts and bolts. Guilford Press.
Halder, S., & Mahato, A. K. (2019). Cognitive behavior therapy for children and
adolescents: Challenges and gaps in practice. Indian Journal of Psychological
Medicine, 41(3), 279–283. https://doi​.org/10.4103/ijpsym​.ijpsym_470_18
Hall, C. L., Partlett, C., Valentine, A. Z., Pearcey, S., & Sayal, K. (2023). Under-
standing the impact of home confinement on children and young people with
ADHD and ASD during the COVID-19 pandemic. Child Psychiatry and
Human Development. https://doi​.org/10.1007/s10578-022-01490-w
Jackson, A., Melvin, G. A., Mulraney, M., Becker, S. P., Bellgrove, M. A., Quach,
J., Hutchinson, D., Westrupp, E. M., Montgomery, A., & Sciberras, E. (2022).
Associations between anxiety and home learning difficulties in children and
adolescents with ADHD during the COVID-19 pandemic. Child Psychiatry
and Human Development. https://doi​.org/10.1007/s10578-022-01338-3
Kaduson, H. G., Cangelosi, D., & Schaefer, C. E. (Eds.). (2019). Prescriptive play
therapy: Tailoring interventions for specific childhood problems. Guilford
Publications.
Khatoon, A., Iqbal, N., & Masroor, U. (2020). Efficacy of cognitive behavioral
play therapy (CBPT) for children with attention deficit hyperactivity disorder
(ADHD). Clinical & Counselling Psychology Review, 2(2), 16–27.
Knell, S. M. (1993). Cognitive-­behavioral play therapy. Rowman & Littlefield.
Knell, S. M. (2011). Cognitive-­behavioral play therapy. In C. E. Schaefer (Ed.),
Foundations of play therapy (pp. 313–328). J. Wiley.
Knell, S. M. (2015). Cognitive-­behavioral play therapy. In K. J. O’Connor, C. E.
Schaefer, & L. A. Braverman (Eds.), Handbook of Play Therapy (pp. 119–
133). https://doi​.org/​10​.1002/​9781119140467.ch6
Knell, S. M., & Dasari, M. (2010). Cognitive-­behavioral play therapy for pre-
schoolers: Integrating play and cognitive-­behavioral interventions. In C. E.
Schaefer (Ed.), Play Therapy for Preschool Children (pp. 157–178). https://
doi​.org/10.1037/12060-008
Kuygun Karci, C., & Arici Gurbuz, A. (2021). Challenges of children and adoles-
cents with attention-­deficit/hyperactivity disorder during the COVID-19 pan-
demic. Nordic Journal of Psychiatry. https://doi​.org/10.1080/08039488.2021
.1980610
Ogundele, M. O., & Ayyash, H. F. (2023). ADHD in children and adolescents:
Review of current practice of non-­pharmacological and behavioural man-
agement. AIMS Public Health, 10(1), 35–51. https://doi​ .org/10.3934/
publichealth.2023004
Okamoto, A., Dattilio, F. M., Dobson, K. S., & Kazantzis, N. (2019). The ther-
apeutic relationship in cognitive–behavioral therapy: Essential features and
common challenges. Practice Innovations, 4(2), 112–123. https://doi​ .org/​
10.1037/pri0000088
 ADHD and COVID-19 75

Razak, N. H., Johari, K. S., Mahmud, M. I., Zubir, N. M., & Johan, S. (2018).
General review on cognitive behavior play therapy on children’s psychology
development. International Journal of Academic Research in Progressive Edu-
cation and Development, 7(4). https://doi​.org/10.6007/ijarped/v7-i4/4842
Segenreich, D. (2022). The impact of the COVID-19 pandemic on diagnosing and
treating attention deficit hyperactivity disorder: New challenges on initializ-
ing and optimizing pharmacological treatment. Frontiers in Psychiatry, 13.
https://doi​.org/10.3389/fpsyt.2022.852664
Strelow, A. E., Dort, M., Schwinger, M., & Christiansen, H. (2021). Influences
on teachers’ intention to apply classroom management strategies for students
with ADHD: A model analysis. Sustainability, 13(5), 2558. https://doi​.org/​
10.3390/su​13052558
Wiest, G. M., Rosales, K. P., Looney, L., Wong, E. H., & Wiest, D. J. (2022). Uti-
lizing cognitive training to improve working memory, attention, and impul-
sivity in school-­aged children with ADHD and SLD. Brain Sciences, 12(2),
141. https://doi​​.org/​10.3390/brainsci12020141
 CHAPT E R 6

Anxiety and Asian Hate

Adlerian Play Therapy with
a Chinese American Child
Kristin K. Meany-­Walen

Huan is an 8-year-­ old, second-­

generation, Chinese American, second-­ grade
girl who lives with her parents, maternal grandmother, and 6-year-­old brother
in a small town in the Midwest United States. Huan and her classmates were in
kindergarten when COVID-19 pandemic protocols began in the United States.
When discussing COVID-19 with her grandmother, Huan said children at school
told her that she and her “people” are murderers and responsible for the pan-
demic. Huan is now experiencing anxiety, manifested by crying and not follow-
ing directions to get ready when going to school and public outings. At school,
she keeps to herself and has stomachaches when she must do group projects.
Huan’s parents are seeking counseling to “help her do the right thing.”

For this case study, consider:

1. What is the intersectionality of Huan’s age, culture, family, school, peers,
local community, global pandemic, and political context? How do these con-
tribute to Huan’s anxiety?
2. What is the rationale for using Adlerian play therapy with Huan? Which
strategies in each of the Adlerian play therapy phases seemed to help Huan?
3. What are culturally responsive strategies for working with Huan and her
family? How do Huan’s parents and teachers help her?

Chinese Culture and Virtues

Core Chinese virtues include Ren, Yi, Li, Zhi, and Xin (Yu & Xie, 2021). Ren
is the foundation of humanness and includes kindness, love, and benevolence.
Yi is righteousness or doing the right thing even at the sacrifice of self. Li is the
virtue of being civil, humble, and respectful. It is considered the primary method
of achieving social harmony and peace. Zhi and Xin support the other three and
involve lifelong learning and integrity. These virtues create a foundation for liv-
ing within Chinese culture and influence the daily lives of Chinese people as they

77
78 Chapter 6

interact with family, friends, school peers, coworkers, and members of their faith
community.
Children’s academic achievement is emphasized in Chinese families because
Chinese values link education with financial and social success. Children are
responsible to their parents, which creates pressure for children to perform well
so they can bring pride to their parents and family (Quach, Epstein, Riley, Fal-
conier, & Fang, 2015). These pressures can create distress for children, resulting
in mental health concerns such as anxiety. Parental warmth and support were
shown to moderate negative effects for the pressure and serve as a protective fac-
tor for ongoing negative mental health symptoms (Quach et al., 2015).

Anxiety
Anxiety is on the rise in Chinese children between the ages of 8 and 13 and is
rapidly becoming a top health concern (Gao, Liu, Xu, Mesman, & van Geel,
2022). As Chinese children acculturate to US values and become more indepen-
dent, anxiety becomes maladaptive, preventing them from achieving social and
academic competencies. Unfortunately, the traditional Chinese parenting style,
which is authoritarian in nature, contributes to Chinese American children’s anx-
iety (Gao et al., 2022). As generations become more acculturated in the United
States, an autonomy-­supportive parenting style rather than a controlling parent-
ing style helps decrease anxiety in Chinese American children. Parents who main-
tain high expectations, consistent with Chinese culture, and can also allow for
children’s autonomy to create ideal environments for children to thrive in their
current culture.
COVID-19 had a profound impact on children’s functioning and mental
health (Litam & Oh, 2021). In the United States, people of color experienced
challenges of COVID-19 beyond that of their White counterparts. Many Chi-
nese people experienced COVID-­related racial discrimination, which increased
the likelihood for this population to have diagnosable mental health concerns
and lower levels of life satisfaction (Litam & Oh, 2021). Asian children were
particularly susceptible to loneliness, low self-­esteem, and social anxiety due to
COVID-­related discrimination (Chen & Qin, 2020).

Adlerian Play Therapy

Adlerian play therapy (AdPT) is based on the theoretical tenets of Alfred Adler’s
Individual Psychology or Adlerian theory (Kottman & Meany-­ Walen, 2016).
Adler contended that people’s childhood influences their perceptions of how they
fit with others and their beliefs about themselves, others, and the world. He also
described the role of play in the lives of children, stating that it was their way of
communicating and learning (Adler, with Ansbacher & Ansbacher, 1928/1956).
However, he did not specifically describe how to work therapeutically with chil-
dren. Terry Kottman developed AdPT to meet the developmental communication
 Anxiety and Asian Hate 79

and learning style of children while using Adlerin theory as the foundation for
understanding and intervening with children (Kottman & Meany-­Walen, 2016).

View of Children
Adlerian play therapists believe that children—and all people—are socially
embedded, creative, and goal oriented (Kottman & Meany-­Walen, 2016). From
the time of birth, people strive to belong and find significance, or how they mat-
ter in the world. Their original social group is their family, followed by extended
family, neighborhoods, schools, spiritual or religious influences, and other com-
munities or organizations. The family constellation and family atmosphere are
significant contributors to lifestyle. Family constellation is how it looks, similar
to the representation of a genogram. This includes parental relationships (mar-
ried, divorced, widowed, same sex parents, adopted, etc.), birth order, sex or
gender roles and order, attachment breaks or deaths, blended families, and so
forth. Family atmosphere is how it feels to be in this family, which could include,
for example, anxious, athletic, achieving, outdoing, relaxed, chaotic, disengaged,
enmeshed. Because people are socially embedded, they must be understood in
relation to their social context and roles.
Children are creative. They create unique and individualized “lifestyles,” or
patterns of thinking, behaving, and feeling, based on their perceptions of how
they belong and gain significance within their family and then within other social
spheres (Kottman & Meany-­Walen, 2016, 2018). They create beliefs about them-
selves, others, and the world and then interact in the world as if their beliefs are
true. Lifestyles are the amalgamation of multiple components that include such
concepts as personality priorities, goals of misbehaviors, life tasks, and Crucial
Cs, which will be described later in this section.
Adler believed that children are goal directed, and their behaviors are pur-
poseful; the goals and behaviors are often out of people’s awareness (Adler,
1927/1998). Their behaviors have the goal of meeting their perceived needs, and
others’ reactions to their behaviors reprove what they already believe to be true
about themselves, others, and the world. They continuously seek—and find—
feedback that supports their lifestyles, which reinforces their thoughts, emotions,
and behaviors. Most often, without intervention this loop continues over time
and across situations.
According to AdPT, children and all people react to life from an encouraged
(well) or discouraged (unwell) lifestyle (Kottman & Meany-­Walen, 2016). People
who are discouraged have lifestyles that are not socially advantageous and are
potentially destructive. Because the lifestyles are consistent, they will continue
until they receive feedback or have experiences that disprove what they already
believe. Counseling and play therapy can be an experience that disproves some-
one’s lifestyle and creates new and encouraged beliefs, emotions, and behaviors
toward self, others, and the world (Kottman & Meany-­Walen, 2018).
80 Chapter 6

One of the hallmarks of Adlerian theory is social interest, or community feel-

ing. Social interest is people’s emotions, beliefs, and behaviors that provide evi-
dence that they care about their community and environment, make choices that
are in the best interest of the greater population, and act with compassion and
empathy toward others and the world (Kottman & Meany-­Walen, 2016). The
degree to which a person shows social interest is the indicator of a person living
an encouraged or discouraged life. Adler believed that people who acted selfishly
were unwell and had a greater degree of mental illness. A primary goal of therapy
is to increase a client’s social interest.

Four Phases of AdPT

AdPT moves through four phases of Adlerian theory:
1. building an egalitarian relationship with the child (and family, teachers, or
other important people in the child’s life);
2. investigating the child’s lifestyle;
3. helping the child gain insight; and
4. reorienting/reeducating the child to new ways of feeling, thinking, and behaving.
Alderian play therapists do this using foundational play therapy skills as well as
directed interventions such as creating art, making metaphors, telling stories, play-
ing games, using puppets, and cleaning the room together (Kottman & Meany-­
Walen, 2016). Because people are unique and creative, the therapeutic process is
individualized and responds to the individuality of each client’s lifestyle.
In the first phase, building an egalitarian relationship, the Adlerian play ther-
apist works with the child to develop a collaborative and shared partnership in
which the client feels respected and a part of the process, rather than feeling as a
recipient of interventions (Kottman & Meany-­Walen, 2016). In the second phase,
investigating the child’s lifestyle, the play therapist’s goal is to learn how the child
makes sense of their world and finds significance. Specifically, the Adlerian play
therapist uses nondirected play and directed intervention aimed to discover the
child’s personality priorities (Kfir, 2011), goals of misbehavior (Dreikurs & Soltz,
1964), life tasks (Mosak & Maniacci, 2008), Crucial Cs (Lew & Bettner, 1998,
2000), and assets (Kottman & Meany-­Walen, 2016).
Personality priorities are a pattern of beliefs and behaviors that help a person
to navigate through and predict life. The four personality priorities are pleas-
ing, control, superiority, and comfort (Kfir, 2011). Personality priorities each have
assets and liabilities; none is better or worse than another. Although people have
characteristics of each priority, people primarily operate from two priorities. The
first priority is used most consistently and is how people structure their daily life.
The second priority is how people respond to stress. Play therapists use this infor-
mation to help inform their interventions and treatment planning.
The four goals of misbehavior are attention, power, revenge, and prov-
ing inadequacy (Dreikurs & Soltz, 1964). The goal of misbehavior answers the
 Anxiety and Asian Hate 81

questions “What is this child trying to gain from this behavior?” “What does this
behavior communicate to others and reveal about the child?” Children use mis-
behavior because they feel discouraged and believe socially constructive behavior
is unable to meet their needs, or they have not had experience and support to
develop socially constructive behaviors.
The five life tasks are family, love/friendships, work/school, self, and spiri-
tuality (Mosak & Maniacci, 2008). All people are challenged with these tasks
throughout life. People meet these tasks with different degrees of success, and
some tasks can prove more challenging than others at different points of life.
Children in therapy often experience greater challenges in the life tasks of family,
friendships, and/or school.
Unlike the other elements of lifestyle described in this chapter, Crucial Cs
are the assets or the qualities people must possess to handle the challenges of life
(Lew & Bettner, 1998, 2000). The four Crucial Cs are count, connect, courage,
and capable. A child must believe that he or she counts or matters in the world,
is able to connect with others in meaningful ways, has courage to make mistakes
and be imperfect, and is capable of handling hardships and uncertainty. The play
therapist seeks to discover the child’s current Crucial C functioning, encourage
positive change, and strengthen areas that are lacking.
Nondirected play and directed interventions such as sand tray, storytelling,
doll play, puppets, dance or movement, and art among other strategies can be
used to help Adlerian play therapists learn about the child (Kottman & Meany-­
Walen, 2016, 2018). Counselors use what they have learned about the child’s
personality priorities, goals of misbehavior, functioning at life tasks, Crucial Cs,
and assets as well as family constellation and atmosphere, support and resources,
and other information to develop their conceptualization of the child. The cli-
ent conceptualization provides a framework from which Adlerian play therapists
develop treatment plans (Kottman & Meany-­Walen, 2016).
Next, the Alderian play therapists move into the third phase, helping the child
gain insight. Here, therapists create interventions that are intentionally geared
toward helping children become aware of their lifestyle characteristics (Mosak
& Maniacci, 2008). As children become more aware of their typical patterns of
emotions, thoughts, and behaviors, they are more able to make informed deci-
sions about the changes they want to make and how they want to make those
changes (Kottman & Meany-­Walen, 2016).
During the last phase of AdPT, helping the child gain insight, therapists teach
and/or provide opportunities and experiences for the child to replace destructive
patterns with constructive patterns (Kottman & Meany-­Walen, 2016). Thera-
pists capitalize on the resources, assets, and interests of the child to help teach
and practice new skills. Some children need specific instruction and repeated
opportunities to try new ways of being. Other children naturally begin to imple-
ment new patterns of emotions, thoughts, and behaviors in and out of play ther-
apy sessions.
82 Chapter 6

Case Study Application

Client Conceptualization
From an AdPT perspective, Huan is an 8-year-­old girl who is developing her
lifestyle through her interactions with family, peers, schools, and others in her
community. The dyadic and collective relationships between Huan and her fam-
ily as well as the intersectionality of her familial culture, her acculturation, her
geographical location, and the current significant social and political events con-
tribute to her lifestyle. Her familial culture holds to most traditional Asian vir-
tues of Ren, Yi, Li, Zhi, and Xi. They place particular importance on academic
achievement, interdependence, and “saving face” or representing the family pos-
itively. Huan has acculturated to some Midwest values of individuality, indepen-
dent achievement, and “Midwest nice” or being agreeable, friendly, and avoiding
conflict.
Huan’s family constellation includes living with biological parents and mater-
nal grandmother; she is the oldest sibling and identifies as female. As the old-
est child, she is responsible, caring, and helpful. She feels obligated to make her
parents proud. Her family atmosphere is one of safety and connection between
family members, with an expectation of seriousness and achievement. In addi-
tion, they distrust and are cautious with people who are outside their culture.
The grandma and parents also emphasize the importance of the traditional Asian
concept of “saving face” and representing the family well in social settings.
Huan’s primary personality priority is pleasing, and secondary is control. The
pleasing personality priority is characterized with a desire to be accepted and
liked and with a fear of rejection. Huan often worries about what others think of
her and her family. She strives toward being perceived as a “good girl” with her
peers and teachers. At times she sacrifices her own needs and boundaries to avoid
rejection. For example, she lets children go in front of her in line, avoids asking
too many questions of teachers, and frets about upsetting someone to the point of
anxiety and self-­isolation.
Huan is well-­behaved and has no history of problematic behaviors at school,
other than her anxiety. Proving inadequacy is Huan’s goal of misbehavior and
presents as avoidance of interactions and attempting new things. Her teachers
and grandmother have noticed a change in Huan’s behaviors in the past few
months. She had been willing to ask questions, made attempts at answering ques-
tions, tried new activities or games with friends at school, and approached other
children with relative ease. As of late, Huan avoids new activities and people.
She completes her schoolwork but no longer asks the teacher for help or makes
attempts at answering questions or trying new activities. The teacher reported
that Huan moves sluggishly and slowly in the classroom, chooses to sit alone at
recess and lunch, and tries to be unnoticed during class.
As an 8-year-­old, Huan is naturally engaged in the life tasks of family, friend-
ship, and school. She holds and values her family’s spirituality practices and
 Anxiety and Asian Hate 83

teachings, and she is steadily growing in her understanding of self. The spiritual
and self life tasks are not of significant concern at this point. Her family relation-
ships are strong and supportive. The family can be a source of support as she
struggles in other areas. She experiences more challenges with friendships and
school at the present time. She isolates from peers and friends, and reports feeling
shame and guilt because of their accusations. School has become a challenge as
Huan has increasingly become uninvested and disengaged in academics.
Huan showed the greatest strengths in the Crucial Cs count, connect, and
capable and a low level of courage. Huan had a history of collaborative and sup-
portive dynamics within her family and school relationships. She integrated feed-
back and experiences that supported her knowing that she was able to succeed.
Her perceptions of those experiences helped strengthen her Crucial Cs of count,
connect, and capable. Huan showed a reduced sense of courage over the past
year. Due to COVID-19 and its tertiary societal impact, which included negative
comments and behaviors from her peers, Huan has a fear of making mistakes and
causing problems. She becomes nearly stagnant in her ability to take risks and try
new things because of her belief that she will fail or cause harm to herself, family,
or others.
Huan has developed beliefs about herself, others, and the world that are dis-
couraged and unproductive to developing and employing social interest. She has
the mistaken beliefs that she is bad, is dangerous, and does not belong; others are
better than she is, are the deciders of good and bad, and belong in her commu-
nity; and the world is unkind, doomed, and a scary place.

Treatment Goals and Objectives

The primary concerns of Huan’s parents, grandmother, and teachers are (a) a
lack of motivation and effort put into schoolwork, (b) withdrawn and anxious
behaviors in peer social interactions, and (c) reduced classroom participation
and engagement. Huan’s primary concern is her fear of hurting people and being
disliked. The primary pattern of thoughts, emotions, and behaviors suggested
that Huan experienced symptoms of anxiety that was initially related to the
impact of COVID-19 and has become more generalized in nature. In addition to
these concerns and symptoms, Huan has started to fidget, complain of stomach-
aches and headaches, and request for herself and her family to wear protective
masks.
The treatment goals were collaboratively created between Huan, her parents,
and the therapist. The therapist took into consideration family and cultural val-
ues and expectations, Huan’s current state of functioning and reasonable expec-
tations, Huan’s lifestyle and development.
Two treatment goals with accompanying objectives were identified:
1. Huan will demonstrate motivation and academic engagement at home and in
school.
84 Chapter 6

To meet this goal, Huan will

a. Develop a collaborative relationship with the therapist in which she can
initiate play activities.
b. Cocreate a story that includes a character with courage who overcomes
challenging and unpredictable circumstances.
c. Engage in activities that create opportunities for Huan to take risks,
receive encouragement, and feel proud of herself (e.g., balancing a pea-
cock feather, juggling scarves, helping the therapist solve “problems”).

Huan will demonstrate success by:

a. Doing homework and/or studying for a minimum of 20 minutes, 5 days
a week.
b. Reporting a minimum of two things she learned/discussed at school to
parents or grandma.
c. Answering one question or prompt to the teacher in the morning and one
in the afternoon. This can be done in front of the class or one-­on-­one.
2. Huan will improve her self-­confidence and internal locus of evaluation.

To meet this goal, Huan will:

a. Do directed play activities focused on what is within her control and what
is outside of her control.
b. Create a “insecurity/security” blanket.
c. Engage in activities that create opportunities for Huan to take risks,
receive encouragement, and feel proud of herself (e.g., balancing a pea-
cock feather, juggling scarves, helping the therapist solve “problems”).

This is demonstrated by:

a. Being able to identify negative self-­talk and replace it with positive self-­
talk statements.
b. Showing appropriate risk-­taking behaviors such as approaching peers,
asking questions, and speaking in front of others.
c. Initiating play activities during sessions.

Strategies used during play sessions to accomplish these goals and objectives
included child-­led play, storytelling and metaphor, art, movement, and directed
play activities.

Treatment Process
Huan’s mother called me at the recommendation of Huan’s school counselor and
teacher. I held an initial meeting with Huan’s parents and grandmother to gather
background information about Huan, including Huan’s development, parents’
 Anxiety and Asian Hate 85

perceptions of the problem, identified concerns from the school, and their obser-
vations of Huan over the past couple of months.

Phase 1
In addition to gathering information, my goal was to initiate a relationship (phase
1) with the significant adults in Huan’s life as described in the parent and teacher
consultation section below. I built an egalitarian and collaborative therapeutic
relationship (phase 1) with Huan by using nondirective play, asking and answer-
ing questions, leading directed play activities, and using foundational play ther-
apy skills. I understood that setting clear and direct expectations is traditional in
Huan’s family and may facilitate comfort. I also knew that experiences in school
or other settings in predominantly the White, midwestern United States often
allow for children to be rather autonomous and to make choices, which could
contribute to Huan’s anxiety in school. I started the session using a nondirective
strategy and allowing Huan to explore the playroom independently. I was pre-
pared to make modifications to this plan as necessary.
This exchange was paced slowly to match Huan’s affect. Based on what I
knew about Huan’s presenting concerns and culture, I made the intentional and
therapeutic decision to be clearer and more direct about the expectations of the
play sessions while also allowing for and encouraging Huan to make choices.

TABLE 6.1. HUAN: PHASE 1A

Transcript Analysis
T: “Huan, this is our playroom. Here you can play Introduction to the playroom and the play therapy
with all the toys. Sometimes I’ll decide what we process.
play and other times you’ll decide what we play.”
H: [Wringing her hands, fidgeting with her clothes, Demonstrated her anxiety.
avoiding verbal interactions, and avoiding taking It can be common for children to feel uncertain or
initiative. She either stared at toys without anxious in their first session(s). This is a new and
touching them or tentatively held a toy without likely unusual experience for children.
playing.]
T: “You’re looking at all the toys.” Tracking her behaviors and communicating to her
that I notice, and I am paying attention.
H: [Stood in the middle of the room and blankly This gives me clues to her lifestyle. I take mental
looked at the toys] note that this might indicate anxiety, a desire to
do the “right” thing, fear of making mistakes, or
wanting to please.
T: “You notice that there are a lot of toys in this Tracking to communicating understanding and to
room.” normalize this experience.
H: [Nodded slowly while standing in the middle of I take mental note of her cautious, hesitant, slow
the room and looking at the toys] movements as these can be helpful in creating her
lifestyle conceptualization and treatment plan.
T: “Sometimes kids aren’t sure where to start.” Normalizing her experience.
H: [Nodded slowly]
T: “There’s a lot of new things going on and it can Reflecting feelings and doing so with an accepting
feel a bit scary.” [Pause] “You’re feeling unsure.” tone. I want to create a space where it is okay to
not know what to do.
86 Chapter 6

TABLE 6.2. HUAN: PHASE 1B

Transcript Analysis
T: “When people are nervous it can be hard to I took advantage of the learning opportunity by
make decisions. You could start by playing with providing information (phase 4) about making
the toys or you could play with the art materials.” decisions.
Because our main focus was building a
therapeutic relationship (phase 1), I moved on
to giving choices with the intent of increasing
comfort and reducing her anxiety.
H: [Moved slowly to the art table and reached Huan was easing into the process. Adlerians
for paper and colors. She looked at me and slid believe that all behavior is purposeful and goal
another paper to the side of the table.] directed. The goal of this behavior was to invite
me to draw with her.
T: [Followed Huan’s lead and sat down] “You I tracked her behavior and meta-­communicated
decided to draw, and you want me to draw with about the goal of her behavior.
you.”

Huan and I drew pictures. Huan drew pictures of a rainbow, trees, flowers,
and sun. I wanted to eliminate the suggestion of competition or any expectation
that they need to do the same thing, so I drew pictures of overlapping shapes. I
focused my verbal attention on Huan and her work. I reflected feelings, tracked,
and used encouraging statements. By the end of the session, Huan voluntarily,
and with some enthusiasm, showed me her picture and explained what she drew.
The primary emphasis during the next two sessions was to continue build-
ing a collaborative relationship in which Huan felt safe, valued, and respected.
Throughout the treatment process, the therapeutic relationship was fostered and
maintained. Therapy generally moves through the subsequent phases in order;
however, it is not a strictly linear process. Phases may overlap throughout sessions
as new information is revealed and opportunities to gain insight and practice new
strategies emerge in the session. For example, in the first session I provided infor-
mation, which is a focus of phase 4.

Phase 2
In phase 2 (investigating the client’s lifestyle), I continued to give Huan choices
and would sometimes have a directed activity planned. Huan still presented with
anxiety, but those behaviors reduced as she became more comfortable. My goal
was to gather enough information about Huan that I could create a lifestyle con-
ceptualization and treatment plan.
I started the third session by exploring Huan’s perception of her family.
Adlerian play therapists take notice of the product (what the child creates)
and the process (how the child goes about creating) of play and activity. At times
Huan would appear to be unsatisfied with her drawing. She turned over the page
or asked for another sheet of paper. I reflected feelings, encouraged, tracked, and
allowed for silence. I meta-­communicated about Huan’s goals of behaviors.
I was attentive to how Huan went about an activity, how she handled chal-
lenges, and how she perceived herself. Huan showed a desire for things to be just
 Anxiety and Asian Hate 87

TABLE 6.3. HUAN: PHASE 2A

Transcript Analysis
T: “Today I have an activity planned. I want to learn I specifically wanted information about her family.
more about your family. You can choose to draw Therefore, I gave choices about how an activity
a picture, or you can choose to do a sand tray. was done as opposed to if an activity was done.
Which do you choose?”
H: She hesitated for one minute before pointing Huan has colored in session before. She feels
at the colors and paper and said quietly, “Draw a comfortable with this task, which is why I offered it
picture.” as a choice.
I also consider this as I develop her treatment
plan. Coloring may be a self-­soothing activity for
her. It may also be something I avoid in future
sessions so she can practice courage.
T: [Used a bit of animation and still nearly matched I used encouragement to emphasize that she
Huan’s tone] “You decided you’d draw a picture. made a choice and had agency. I lifted my voice
With these materials, please draw a picture of slightly in an attempt to connect with her while
everyone in your family doing something.” also respecting her soft demeanor.

TABLE 6.4. HUAN: PHASE 2B

Transcript Analysis
T: “I noticed you turned the paper over and Meta-­communicated about her behaviors and
appeared disappointed. I’m guessing you’re reflected her feelings.
dissatisfied with what you’ve drawn.”
H: “Yes. This isn’t good enough, and I forgot to Huan is demonstrating the cultural values of Ren
include my grandfather who died.” and Li.
T: “Your grandfather is really important to you, and Reflecting her feelings about her grandfather and
you want to make sure you include him. You feel her feelings toward herself for forgetting.
bad that you forgot him.”
H: [Nodded]
T: “You can decide if you start over or if you keep I could have sat quietly and waited for her to
going with your picture.” proceed in whatever direction she chose. I made
the therapeutic judgment to offer two choices.
I believed it was more therapeutic to see what
she decided and how she moved forward as
compared to sitting in ambiguity and anxiety.

as she expected, a limited flexibility in handling challenges, and a critical view of

herself when she makes mistakes.

Phase 3
Huan and I gradually moved from phase 2 to phase 3 (helping the child gain
insight). Here, my goal was to help Huan understand patterns of her thoughts
about herself, others, and the world; how she belongs; and how she believes she
gains significance. I helped Huan develop insight into the goals of her behaviors
and how they have or have not been working for her. I used what I learned about
Huan to develop a conceptualization and treatment plan. In addition to the skills
I used in previous phases, I used more meta-­communication and directed activi-
ties to help Huan develop awareness.
88 Chapter 6

Through previous sessions, I learned that Huan had internalized messages

from peers and believed she and her family were responsible for COVID-19 and
its impact such as the shutdown of schools and business, requirement of masks
and quarantine, loss of jobs, and death rates. She became overwhelmingly wor-
ried of doing anything without a predictable and guaranteed outcome for fear
of wreaking havoc and embarrassing her family and culture. She had mistaken
beliefs that she made bad things happen because of who she was, and believed
that if she were good enough, she could keep people safe. She believed it was her
responsibility to be good and keep people safe.
I intentionally designed various interventions to help Huan become aware
of her mistaken beliefs and discouraged lifestyle patterns. Huan admired Disney
princesses, particularly Elsa with her fair skin and blonde hair. Knowing this, I
created an intervention that drew upon the comparisons between Elsa and Huan
such as feeling guilty and alone, believing they are responsible for damage to peo-
ple and communities, and forsaking themselves to protect their family and others.
In later sessions, I came back to this intervention to recognize their differences
and assets particularly related to appearance, culture, self-­acceptance, and their
beliefs about others’ perception.

TABLE 6.5. HUAN: PHASE 3A

Transcript Analysis
T: [In response to the hula hoop game] “It’s really Meta-­communicated about how she makes
important to you that you are careful in making decisions.
decisions.”
H: “Yes. Kids told me it’s my fault that bad things An example of COVID-­related discrimination.
happened to their family.”
T: “You’re worried that if you’re not careful, more Reflecting feelings and meta-­communicated
bad things will happen.” about her fears.
H: “Uh-­huh.”
T: “You decided to believe what other kids said.” I wanted to gently make notice that she had the
choice to believe or not believe other kids without
belaboring the point.

TABLE 6.6. HUAN: PHASE 3B

Transcript Analysis
T: “It’s hard to trust yourself.” Reflecting feelings and meta-­communicating.
H: “Yes. Kids told me it’s my fault that bad things
happened to their family.”
T: “I can understand why you might think this way. Meta-­communicating about her thinking patterns
You decided that if you stay away from people and goals of behavior.
and you work really hard at being perfect and
always doing the right thing, you’ll be able to
make sure nothing bad ever happens again.”
 Anxiety and Asian Hate 89

I implemented a movement game with hula hoops (see “Hoops of Control”

on page 91) in which Huan could gain awareness of what was within and outside
of her control.
I chose to use these specific words because I wanted to gently create aware-
ness that Huan had a choice. It was subtle and may have been missed by Huan. I
would not know for sure. Thinking ahead to phase 4, I started to make these soft
statements consistently and periodically with the goal of creating “aha” opportu-
nities and potentially planting small changes in her perspective.

Phase 4
The goal of reorienting/reeducating the client (phase 4) is for the client to learn
new perspectives, ideas, or skills and/or practices new ways of thinking, feeling,
and behaving. Some of the changes are made and practiced in session. Others are
developed outside of session such as at home or school. I attempted to use what I
knew about Huan to make the best use of time and resources. For example, one
intervention (taking risks) could be useful in both goals, or connecting things that
happen in session with things that happen at home or school (refuting mistaken
beliefs about her role in COVID-19).
In the sessions, I created challenges Huan could complete and feel success-
ful and challenges that would require her to handle adversity. This responded to
Huan’s treatment goals in which she would take appropriate risks and develop
courage to be imperfect, and she would try new things without a guarantee of
success. Examples of these interventions are juggling scarves; drawing pictures
with her nondominant hand; balancing a peacock feather; and creating a sculp-
ture with recycling, odds and ends and leftover materials such as egg cartons,
straws, cereal boxes, tape, and so forth.
I provided materials for Huan to create an “insecurity/security” blanket
(described below). This intervention was started in the play sessions and later was
taken back and forth between home and therapy. This allowed Huan to practice
positive self-­talk between sessions.
I believed Huan’s parents and grandmother would be best suited to give
their experiences and perspectives of the pandemic as well as how they had been
impacted because of their shared cultural experience and family values. Huan’s
family and I found statistics and evidence to counter Huan’s belief that their fam-
ily was responsible for COVID-19 and its effects.
Huan’s teacher was also made aware of Huan’s beliefs and the peer interac-
tions at school. The teacher created lessons that allowed all students in her class
to research facts about the pandemic and other current events. The goal was to
educate all students on this matter, create opportunities for students to express
their concerns, and to dispel inaccuracies and misunderstandings between stu-
dents. Huan was also able to use this as study time at home and as a point of
discussion with her family, both of which are in her treatment plan.
90 Chapter 6

Ethical and Cultural Considerations

Ethically, it was my duty to be culturally responsive to Huan and her family.
Although I had limited experience working with clients from Asian cultures, I did
know that making the initial call was likely very stressful for Huan’s mother as
seeking outside help is not typical for Asian families. I wanted to create an atmo-
sphere of comfort and trust, so I prepared myself by researching information,
seeking professional consultation, and broaching the topic of culture and values
with the family.

Parent and Teacher Consultations

Approximately every two weeks, I conducted parent consultations in order to
maintain the therapeutic relationship with the parents (phase 1) as well as to
gather more information (phase 2); provide information about Huan’s lifestyle
and potential dynamics within the family (phase 3); and assess progress, provide
suggestions or information, and help the family to adjust to any changes that
may occur when any family member makes changes. In phase 4, I enlisted Huan’s
parents and teachers in reeducating Huan on accurate facts about the COVID-
19 pandemic so that she could change her belief from “my people and I caused
deaths” to “Each person is capable and can have courage to work together with
others to be as healthy as possible.”
I conducted consultations with Huan’s teachers and school counselor. Con-
sequently, they provided opportunities for Huan to practice and reestablish
friendships with peers. They implemented general lessons on tolerance, diversity,
empathy, and kindness, which helped all students develop their social interest and
friendship life tasks.

Conclusion
Huan developed a more logical awareness of the global pandemic, its origins, and
its impact. Huan practiced courage in the playroom, developed friendships in the
classroom, and reduced her sense of responsibility for the effects of the pandemic.
Then, she naturally started to take appropriate risks in the classroom and engage
more in academic work.
Our treatment plan targeted only a few specific areas of concern (academic
motivation and courage). At the end of fourteen sessions, Huan was regularly
showing courage to be imperfect. She took initiative and appropriate risks in the
play sessions, she laughed more and was silly at times as well. Huan’s parents
and teachers reported that she took appropriate academic and social risks, and
she was tending to schoolwork at home as parents desired. Huan’s fidgety and
avoiding behaviors faded without any direct attention to them. Likewise, she was
able to set boundaries by communicating her needs and limits in social situa-
tions, which suggested that her pleasing personality priority was being managed
in a more encouraged manner than before. With the collaborative approach to
 Anxiety and Asian Hate 91

Huan’s treatment that included her family, teachers, and school, Huan was able
to develop skills that helped her thrive.

Session Notes
Huan, 1/26/2023, 4 p.m.
Huan was present and engaged in the play therapy session. As is consistent for
Huan, she asked permission before initiating any play activity. For most of her
session, she chose to play with the dress-­up clothes and medical kit. Huan took
turns being the patient and the doctor. She showed themes of empathy and rela-
tionship, control, mastery, and being capable.
Huan appears to be practicing Crucial Cs courage and capable. She showed
courage by being vulnerable as the patient and by being willing to engage with
and help others by being the doctor. She also showed capable by believing that
she was able to help patients, which mitigates her goal of misbehavior, proving
inadequacy.
Huan strives for belonging by pleasing others. She has the mistaken beliefs
that she is responsible for the pandemic and for bad things happening. Huan
overcompensates for her mistaken beliefs by striving to be perfect and having
a lack of courage. She believes that if she is perfect and does not make any mis-
takes, she will not cause any more harm.
I will continue to allow Huan to make choices in the playroom, with the goal
of her practicing courage and experiencing positive feedback and natural conse-
quences. We will also play Hoops of Control next session to help her gain insight
into what is within her control and what is out of her control.

Hoops of Control
Age/Participants: 5 or older; 1–100 participants
Purpose: Participants will be able to identify situations that are within their con-
trol and situations that are out of their control.
Materials: One hula hoop for every 1–3 participants. Rope, tape, or other mark-
ers to section off different areas on the floor could be used in place of hula hoops.
Considerations: participant mobility, space, number of participants
Directions:
1. Place hula hoops on the floor.
2. One person will read a list (below) of scenarios. After each scenario, partic-
ipants jump inside the hula hoop if it is within their control, and they will
jump on the outside of the hoop if it is out of their control.
3. Repeat through all the scenarios.
Processing Questions:
Take a mental note of participants’ hesitancy, mistakes, or other reactions during
the game and refer to these during the processing questions.
92 Chapter 6

1. How do you know if something was in your control or out of your control?
2. Which ones were difficult? Easy?
3. What about (scenario) made it difficult or easy to know if it was within your
control?
4. In cases where the participant said, “It depends” (or something similar), what
were your thoughts about this scenario? What would your answer depend
on?
5. How do you feel when you do/don’t have control?
6. What are things in your life that are in your control? Out of your control?
7. What things do you wish you had control of?
Sample Scenarios: Due to space limitations, only a brief list for young kids was
included.
Make additions and adjustments as needed to fit your clients’ experiences.
Interweave serious and silly scenarios, pointed and general scenarios.
1.You have a substitute teacher.
2.It’s raining, and you can’t go outside for recess.
3.You didn’t brush your teeth.
4.You did your homework.
5.You are sad because you lost a toy.
6.You yelled at your parents because you were sad.
7.Who your friends choose to be friends with. Or how your friends act
toward others.
8. Your bedtime, chores, or routines at home (or other home expectations).
9. Your principal colored their hair pink.
10. How you treat/react to other people.

Security/Insecurity Blanket
(T. Kottman, personal communication, January 4, 2007)
Age/participants: 5 and older; individual, family, or group sessions
Purpose: To help participants gain insight into mistaken beliefs or negative self-­
talk. To identify assets and positive qualities.
Materials: blanket or comparable size cloth such as fleece material, fabric markers
Directions:
1. Explain that a security blanket is something that people use as comfort. They
wrap up in their security blanket when they feel sad or scared, or when they
want to feel cozy and loved. Define “security” and “insecurity” if necessary.
The counselor can explain that sometimes people focus on their insecurities
even if they aren’t true or don’t feel good. We’re going to focus on both (or
see modifications).
2. On one side of cloth, the participant writes or draws her insecurities. For par-
ticipants who have difficulty thinking of them or putting them into words, be
prepared to give examples that you think are true for the participant.
 Anxiety and Asian Hate 93

3. On the other side, the participant does the same as in step 2 with securities.
Have a list of these prepared as well.
4. This can be a multi-­session activity.
Processing Questions:
1. Which list was easier?
2. Which do you think of more often?
3. Which of the securities or insecurities do you think is most true?
4. What are your top three insecurities that would you like to erase or change?
5. What securities would you like to have on there that aren’t there yet?
6. What securities or insecurities do you think others would say about you?
7. Do you think it’s possible for anyone to have only securities and no
insecurities?
8. How can insecurities be helpful or motivating?
9. Where/how do you think you came up with your insecurities? Securities?
10. Which of the insecurities is/are not true, even though it/they feel true?
11. Which of the securities are you most proud of or thankful for?
12. How can you erase or change insecurities?
13. How do you add more securities?

Modifications:
1. Counselor makes a blanket for the participant.
2. Focus on one area (security or insecurity).
3. Write the insecurities with washable markers so when washed only securities
remain.
4. Make a smaller version for the participant to be able to keep in her pocket as
a transitional or comfort object.
5. Participants (or counselors) solicit securities from their family and/or friends
to reinforce assets.

Discussion Questions
1. Only two areas of concern were directly addressed through the treatment
process, despite other areas being identified as potentially problematic such
as Huan’s over-­functioning pleasing personality priority and proving inade-
quacy goal of misbehavior. Yet, these areas improved over the course of treat-
ment. What may account for these changes? What are your thoughts about
not specifically addressing these areas? What areas would you have addressed
or not addressed?
2. How has COVID-19 impacted your beliefs about self, others, and the world?
Why is this awareness important?
94 Chapter 6

3. Huan lived in a rural community, Midwest United States. How does this
impact your understanding of the client and the treatment plan? How did
culture influence Huan’s lifestyle?
4. How has your family of origin, atmosphere, and constellation influenced who
you are and how you believe you belong and find significance in the world?

References
Adler, A. (1998). Understanding human nature. Oneworld Oxford. (Original
work published in 1927.)
Adler, A. (with Ansbacher, H. L., & Ansbacher, R. R.). (1956). The individual
psychology of Alfred Adler: A systemic presentation in selections from his
writings. Harper & Row. (Original work published in 1928.)
Chen, C., & Qin, J. (2020). Emotional abuse and adolescents’ social anxiety: The
roles of self-­esteem and loneliness. Journal of Family Violence, 35, 497–507.
doi: 10.1007/s10896-019-00099-3
Dreikurs, R., & Soltz, V. (1964). Children: The challenge. Hawthorn/Dutton.
Gao, D., Liu, J., Xu, L., Mesman, J., & van Geel, M. (2022). Early adolescent
social anxiety: Differential associations for fathers and mothers’ psycholog-
ical controlling and autonomy-­supportive parenting. Journal of Youth and
Adolescence, 51, 1858–1871. doi: 10.1007/s10964-022-01636-y
Kfir, N. (2011). Personality and priorities: A typology. Author House.
Kottman, T., & Meany-­ Walen, K. K. (2016). Partners in play: An Adlerian
approach to play therapy (3rd ed.). American Counseling Association.
Kottman, T., & Meany-­Walen, K. K. (2018). Doing play therapy: From building
the relationship to fostering change. Routledge.
Lew, A., & Bettner, B. L. (1998). Responsibility in the classroom: A teacher’s
guide to understanding and motivating students. Connexions Press.
Lew, A., & Bettner, B. L. (2000). A parent’s guide to understanding and motivat-
ing children. Connexions Press.
Litam, S. D. A., & Oh, S. (2021). Effects of COVID-19 racial discrimination on
depression and life satisfaction among young, middle, and older Chinese
Americans. Adult Lifespan Journal, 20(2), 70–84. doi: org​.proxy​.lib​.uni​
.edu/10.1002/adsp
Mosak, H. H., & Maniacci, M. (2008). Adlerian psychotherapy. In R. J. Corsini
& D. Wedding (Eds.), Current psychotherapies (8th ed., pp. 63–106). Thom-
son Brooks/Cole.
Quach, A. S., Epstein, N. B., Riley, P. J., Falconier, M. K., & Fang, X. (2015).
Effects of parental warmth and academic pressure on anxiety and depres-
sion symptoms in Chinese adolescents. Journal of Child Family Studies, 24,
106–116. doi: 10.1007/s10826-013-9818-y
Yu, L., & Xie, D. (2021). Measuring virtues in Chinese culture: Development of
Chinese moral character questionnaire. Applied Research in Quality of Life,
16, 51–69. doi: 10.1007/s11482-019-09745-w
 CHAPT E R 7

Autism and Neurodivergence

Group Play Therapy with Children
Robert Jason Grant

Six boys, ages 11 to 13, were referred for counseling services. Four of the boys
had been diagnosed with Autism Spectrum Disorder (low support needs), and
two had been diagnosed with Attention-­Deficit/Hyperactivity Disorder with some
suspicion of other neurodivergence-­related diagnoses. According to their par-
ents, all the boys had difficulty with peer connection and social navigation. I will
refer to these boys as Andres, Brian, Cody, DeShaun, Ezekiel, and Farrell. Each
boy presented with a variety of strengths and needs. I sought to properly under-
stand each child individually to learn about their social connection strengths and
the needs that may require support.

In my experience and through networking with other therapists, social connec-

tion groups are often sought after in communities. These types of groups can
help children and adolescents recognize they are not the only person who iden-
tifies a certain way or struggles with a particular component. These groups offer
the prospect of connecting with peers and building friendships with other chil-
dren and adolescents. As a result, children can gain a level of self-­identified social
success. In the group, children practice and address social connection in a more
natural, affirming, less dysregulating environment. I am highlighting a case study
that showcases the many benefits of implementing group-­play therapy, rather
than individual social-­focused approaches, for preteens with autism and other
neurodiversity.
For this case study, consider:
1. What are important tenets and paradigms when working with autistic chil-
dren? What is the rationale for using an integrative process?
2. What are the procedures for implementing play-­group work with autistic
children? What was the outcome of social connection for the autistic chil-
dren in this play group?
3. What are the unique ethical and cultural issues that need to be considered?

95
96 Chapter 7

Autistic and Other Neurodivergent Children

The Centers for Disease Control and Prevention (2020) estimates that 1 in 44
children in the United States has an autism spectrum disorder diagnosis. Autistic
children fall within the identity of neurodivergent, which includes those with a
diagnosis of attention-­deficit/hyperactivity disorder (ADHD), sensory differences,
learning differences, developmental disabilities, and so forth. It has been roughly
estimated that 1.2 billion of the world population is neurodivergent (Grant, 2023).
Often, the misinterpretation is that autistic children prefer to be alone. Autis-
tic individuals typically want to have meaningful social relationships, but social
situations can be difficult and anxiety provoking, so they may choose to with-
draw instead (Grant, 2021). Studies have shown that compared to neurotypical
children, autistic children are less involved in group play and social activities,
engage in fewer play behaviors, and experience social rejection (sometimes bully-
ing) from peers (Chester, Richdale, & McGillivray, 2019). Jamison and Schuttler
(2017) proposed that social navigation and engagement can involve a complex
set of skills that evolves over the course of human development. Autistic children
may find the social functioning world confusing, frustrating, and even scary.

Group Approach
Before children or adolescents begin participating in a social group, it is essential
to assess their current social strengths and needs (Radley, Dart, Moore, Battaglia,
& LaBrot, 2016; Grant, 2017). For the group experience to be as smooth and
successful as possible, it is important that the children and adolescents participat-
ing be similar in their social strengths and needs. If the gap in social presentation
between the group members is too great, it will become challenging to improve
social navigation and may create further issues with children and adolescents
being uncomfortable in the group. This could affect group members’ willingness
to participate (Grant & Turner-­Bumberry, 2020).
Hull (2014) noted that the role of the therapist in neurodivergent focused
groups is to provide relationship. Further, the therapist can help model in an
affirming manner for group members a safe and natural way of learning what
they need or want to see in their life. Sweeney, Baggerly, and Ray (2014) espoused
that the group-­play therapist has a crucial role in the functioning and success of
the group process. It is important for the therapist to model what is expected and
exhibit a belief in the process as well as communicate this belief to group members.

Integrative Play Therapy

In the group I facilitated, I decided that an integrative play therapy approach
seemed best to support the social and connection preferences as well as needs of
each group member. Given the spectrum of presentation that exists among autis-
tic and other neurodivergent children, providing an integrative philosophy would
produce the best outcomes. An integrative therapy approach can be traced back to
 Autism and Neurodivergence 97

the 1930s (Seymour, 2011). Integrative therapy is defined as an approach to ther-

apy that involves selecting the techniques from different therapeutic orientations
best suited to a client’s particular problem. By tailoring the therapy to the indi-
vidual, integrative therapists hope to produce the most significant effects (Cherry,
2021). Integrative play therapy offers promise in its flexible use of integrating play
therapy theory and techniques so clients can experience the best therapy for their
presenting problems (Grant, 2023; Drewes, Bratton, & Schaefer, 2011).

AutPlay Therapy
AutPlay Therapy as an integrative family play therapy approach designed to
address the mental health needs of neurodivergent children (Grant, 2023). The
foundation of AutPlay Therapy consists of seminal play therapy theories and
approaches integrated within a neurodiversity affirming framework. This seemed
like a good basis for my group design as the process of integrating play ther-
apy theories and approaches while staying committed to neurodiversity affirming
practices is already established in the AutPlay framework.
AutPlay Therapy has an outlined play-­ group process. Grant and Turner-­
Bumberry (2020) stated that AutPlay Therapy groups provide a sense of belong-
ing for children. Many autistic and other neurodivergent children are left out of
groups and activities that involve neurotypical peers. In AutPlay Therapy groups,
children can develop relationships, practice navigation, and have positive recre-
ational experiences. Children and adolescents can gain a feeling of acceptance
and optimism about social situations, especially social situations with peers. They
may also discover they are not alone and that other peers have the same needs
they do. For guidance with my group, it felt important to follow the AutPlay
Therapy play and social groups affirming tenets:
• The group should be a safe and supportive environment for children and ado-
lescents to interact in a way they feel comfortable.
• Group processes should promote a natural and playful opportunity to learn
and practice connection and social navigation.
• The group experience should provide opportunities to build self-­esteem and
confidence, especially in social situations.
• The group should provide an opportunity to establish friendships.
• The group should also provide a supportive environment for parents.
As the therapist, I am the most important component of the AutPlay Therapy
group process. My affirming beliefs, attitudes, interactions, and selection of pro-
tocols would provide the foundation for a successful group experience. I under-
stood that the children participating in the AutPlay group would need me to be
flexible and adaptable, switching smoothly from child-­led relationship building to
psychoeducational teaching while maintaining a neurodiversity affirming stance.
This would require me to be a participant, a role model, and a guide—staying
present with the happenings of each group member.
98 Chapter 7

The Neurodiversity Paradigm

In my design of the group protocol, it was essential that I stay committed to the
neurodiversity paradigm and neurodiversity affirming processes. Walker (2021)
defined the neurodiversity paradigm as a specific perspective on neurodiversity. It
is a perspective or approach that embodies three fundamental principles:
1. Neurodiversity is a natural and valuable form of human diversity.
2. The idea that there is one “normal” or “healthy” type of brain or mind, or
one “right” style of neurocognitive functioning, is a culturally constructed fic-
tion, no more valid (and no more conducive to a healthy society or to the
overall well-­being of humanity) than the idea that there is one “normal” or
“right” ethnicity, gender, or culture.
3. The social dynamics that manifest regarding neurodiversity are similar to the
social dynamics that manifest in regard to other forms of human diversity (e.g.,
diversity of ethnicity, gender, or culture). These dynamics include the dynam-
ics of social power inequalities, and the dynamics by which diversity, when
embraced, acts as a source of creative potential (Walker, 2021, pp. 34–46).
Throughout the group process it was critical that I not only maintained a con-
sistent neurodiversity understanding but also avoided ableist processes—which
stand in direct opposition to the neurodiversity paradigm. Scuro (2018) described
ableism as a harmful bias, which is often trivialized but can be very damaging.
The embeddedness in cultural conditioning and societal system is widespread and
somewhat menacing. Often ableist constructs are put forth (without awareness)
by well-­intended and even established, respected, individuals and institutions.
Ableism would deny neurodiversity, instead insisting that there is one right type
of brain and one correct way to process, respond, communicate, and navigate.
Although neurodiversity applies to the totality of the human race, most atten-
tion is focused on those who are neurodivergent. Grant (2023) proposed that
neurodivergent refers to an individual who has a less typical (societally consid-
ered “normal”) cognitive variation. “Neurodivergence” is the term for people
whose brains function differently in one or more ways than what society con-
siders standard or typical. Neurodivergence is neither good nor bad. It is just
different. In this group case study, the members of the group were children who
had received a diagnosis of autism, ADHD, and/or sensory differences and were
all considered neurodivergent.
My challenge in working with the neurodivergent population in a group setting
was to provide an atmosphere that helped the children improve their well-­being
and success while respecting their neurodivergence. This required me to be mind-
ful in implementing neurodiversity-­affirming processes—carefully assessing needs
versus trying to make the neurodivergent children look neurotypical. This proved
to be an especially critical awareness for me because neurodivergent children who
may have needs with social navigation can easily find themselves in programs or
therapies that promote ableist concepts (Turner-­Bumberry & Grant, 2022).
 Autism and Neurodivergence 99

Case Study Application

I met with the six boys in 10 one-­hour group sessions. Previously, I prescreened
each boy by reviewing paperwork and consulting with his parents to ensure that
each boy was a good fit for the group. In the first group meeting, my goal was to
create a safe and familiar atmosphere. I was expecting that there would be anxi-
ety and possibly some dysregulation due to being in a new setting with new peo-
ple. Through pre-group screening processes, it was clear that all the boys shared
common interests in Minecraft, LEGO bricks, and constructive play. I planned
to use their special interest to help create relationships, nurture connection, and
facilitate social navigation. I copied images of Minecraft characters on pieces of
paper for coloring. This was to be used as an introduction activity and to help the
boys begin to feel comfortable in the group atmosphere.

Session 1
The group began with me introducing myself and sharing a bit about the group
goals (i.e., connecting, building relationships, and having fun). I also communi-
cated that the group was a safe place to be yourself and covered a few basic
group rules (i.e., different is okay, no bullying, participate at your own comfort,
and keep group happenings confidential). After explaining the group rules, I
introduced the Minecraft coloring activity.

TABLE 7.1. AUTPLAY GROUP: SESSION 1

Transcript Analysis
T: “Welcome to the group, everyone! I am so It was important to establish an atmosphere
glad you all are here! We are going to start with of safety and welcome. Many neurodivergent
a Minecraft activity to help us get to know each children will experience heightened anxiety in
other a little better. We have several Minecraft new places and around new people. I wanted to
coloring sheets here; pick the one you want and provide the boys with an activity that they would
color it any way you like. Feel free to color and/or all be familiar with (align with their special interests)
draw on it to represent yourself.” and thus help them relax.
C: “What if I don’t want to color and just draw on Some neurodivergent children have specific and
it?” strong preferences for how they do something;
the way they learn or process the best. I knew
it would be important to be flexible and let each
child produce in the way he felt most comfortable
T: “You can draw on it, write on it, color it, I reaffirmed that each child had choice in what to
anything you like that feels like the way you want do with his own paper. This permissiveness was
to do it.” intended to decrease anxiety.
E: “I am doing a Zombie Pigman; they are my The freedom provided facilitated spontaneous
favorite.” communication.
T: “For this activity, you can do anything you want. I reflected often so the boys could feel
All choices are okay.” empowered to make choices and know that
differences were okay. This became an important
ongoing message in the group for social
navigation and feeling empowered in their own
identity.
(continued)
TABLE 7.1. (CONTINUED)
Transcript Analysis
T: “It looks like everyone is finished. Let’s try going Due to the different ways neurodivergent children
in a circle and sharing yours with the group. You may communicate and the varying anxiety issues,
can show and say anything you want about it. You it was important that I communicate clearly that
can also decide not to share anything. I will go sharing in any way and not sharing at all are okay.
first. I colored Steve, but I gave his clothes colors Forcing a neurodivergent child to do something
that I like to wear myself. I also gave him a hat different from the way he navigates or ignoring his
because I like to wear hats. I like Steve because anxiety can increase his resistance and anxiety.
he seems very resourceful and can figure out what Further, it was important that I complete the
to do. Andres, do you want to share?” activity as well and that I go first in sharing my
creation. This helped the boys feel more relaxed
and provided a model for what I was asking them
to do.
A: “I choose Steve because he is the main
character, and he builds things and fights the
Zombies.”
B: “Mine is Enderman because it is the best one. I
made it all black.”
E: “I like your Enderman.”
T: Ezekiel, you like Brian’s Enderman. I like it also, I linked the boys’ interests and provided
and I like Andres’s Steve.” affirmation for A so he would not feel dismissed
but, rather, included.
C: “I did a Wither because it is the most powerful
character in Minecraft.”
E. “No it’s not!”
B: “Disagree! Sorry, not sorry!” Some neurodivergent children (as was the case
with this group), may have needs with perspective
taking. They find it challenging to understand that
it is okay when others’ feelings and thoughts are
different from themselves.
T: “Cody, you feel that Wither is the most powerful, This was a natural opportunity to address
but Ezekiel and Brian, you do not think so. We perspective-­taking issues in social navigation. I
can all have different thoughts and opinions; we reflected the different options and validated that
do not have to feel the same way. It is okay to let each child could have his own opinion, and this
someone feel differently from us. Some things we was okay. There does not have to be a right or
will agree on and some we will not; we can still wrong, and we can still have fun together with
enjoy each other.” different opinions. This was an ongoing reflection
throughout the 10 group meetings.
T: [after each child had shared] “Thank you all for I closed the group with an appreciation for
sharing. I really enjoyed seeing what everyone did each boy and what he had done and shared. I
and hearing what you said about it. I think it is fun also wanted to acknowledge what they had in
that we all like Minecraft. I think you all have a lot common with each other and that our group
of things in common. I am looking forward to us experience was going to be fun. I did this to
all having a fun group experience together.” further the group connection and help the boys
feel comfortable participating in the group.
 Autism and Neurodivergence 101

Later Sessions
In the next few sessions, we continued to complete various Minecraft-­themed
interventions that promoted connecting with each other. In session 4, we engaged
in a role-­play activity of having each boy choose a character and then we acted
out scenes from Minecraft. Each boy got to create a short scene for all of us
to play out together. My goal for session 5 was to transition to some LEGO
activities. I introduced creating a Minecraft environment using Minecraft LEGO
bricks. The boys all worked together on a large table to create a LEGO Minecraft
world. They communicated to establish what they wanted and how it would be
designed.

TABLE 7.2. AUTPLAY GROUP: SESSION 5

Transcript Analysis
T: “Today we are going to use all these Minecraft I wanted to transition from Minecraft-­themed
LEGO bricks and work together to create a interventions to LEGO-­based interventions. This
Minecraft world. It can be anything you all want, stayed consistent with the identified special interest
but you must work together with everyone having of the boys. I provided less detailed instructions
a chance to contribute. I will just be watching as we were moving along in the group because I
and provide help if needed.” wanted the boys to take more ownership of their
social navigation with each other.
B: “I’m ready!”
C: “What are we going to build?”
B, D, and E: [already starting to build without This activity highlighted the different spaces
saying anything] (variance) of social navigation and communication
that each of the boys possessed.
T: “Some people are already starting to build, and I reflected what I was seeing regarding the different
others are asking what to do?” approaches and comfort levels of interaction and
communication.
B: “Just build what you want; you can choose.”
T: “Brian, you think everyone can start building I reflected what “B” said to help communicate the
what they like.” concept of perspective—each person can build as
he likes, and this is okay.
A, C, D: “Yes.”
T: [Observed that for the majority of the time, the Parallel play can be common in autistic and other
boys worked more in parallel play while building. neurodivergent children. It is a way of playing
Occasionally someone would ask for a LEGO that can feel very connecting for autistic children.
or how to build a particular thing, and someone This was certainly observed in this activity with
would answer him.] the group. I would periodically make a reflective
comment such as “It looks like everyone is working
on it together” or “Everyone is doing what he wants
to do, and we are all here together.”
102 Chapter 7

Last Session
My goal for session 10 (the final group session) was to have the boys reflect on
their group experience and think about what they wanted to remember and take
with them from the group. I also wanted to celebrate each of them and their time
in the group and end the group on a positive feeling. I introduced an intervention
called All of Us Chain. In this intervention we each have seven strips of paper.
There is a strip of paper for each group member and for me. We signed the strips
of paper and wrote or drew something on each strip of paper that we wanted
to give to the other members. Once everyone received their strips of paper from
each member, each member used glue to link the strips received from others to
form their own individual chain. The end product was each of us having a chain
of seven links with things written or drawn on each one from our other group
members.

TABLE 7.3. AUTPLAY GROUP: SESSION 10

Transcript Analysis
T: “For our final group, we are going to complete I knew it would be necessary to have a closure
an activity to share something with each other activity at the end of the group that would help the
about our group time.” [I provided the boys with boys say good-­bye and remember what they had
the instructions and materials for completing the gained. I also wanted them to have a tangible,
All of Us Chain intervention.] visual item to take with them as a reminder.
T: [I observed the boys being mostly quiet and
each one completing his paper strips for each
other. Some wrote words, and some drew
pictures.]
T: [After all the boys had finished the intervention] I wanted to give the boys a chance to share any
“It looks like we are all finished and have our thoughts or feelings they were having. This helped
own chain links created. Does anyone what to the boys continue in their connection with each
comment on his links?” other.
B: “I do not want the group to end” [a comment I had expected this to be the reaction of the
that was then echoed by other group members]. boys, as the group had become a positive social
interaction space for each of them. I also knew
it would be important for me to hold space for
these feelings and allow the boys to express these
feelings.
T: “It is OK to feel sad about the group ending. It is It was important that I reflect and acknowledge
good that you had a positive time.” the boys’ sad feelings about the group ending.
They could see that these feelings were okay.
T: “We now know that we can have positive social I wanted to help the boys move forward and
connections and look for other opportunities take the group experience as empowerment to
in our lives. What are some things you can do find more spaces in their lives for positive social
moving forward to continue to have positive social connection.
connection times?”
T: [I wrote down a list of ideas that the boys I did this to provide something concrete that the
shared and some I added of ways they could boys could take with them to encourage them to
continue to have positive social connection. As continue their social connection journey.
the group ended, I gave each boy a copy of the
list and a card thanking him for his participation
and encouraging him to move forward in his social
navigation.]
 Autism and Neurodivergence 103

Ethical and Cultural Considerations

For ethical considerations I stayed informed about group ethical guidelines estab-
lished by my state licensing board. Further, I familiarized myself with the best
practices and ethical guides highlighted by the Association for Play Therapy
(APT) Best Practices (2023) considerations for play therapists conducting group
work:
The play therapist selects clients for group play therapy whose needs are compat-
ible and conducive to the therapeutic process and well-­being of each client. Play
therapists using group play therapy take reasonable precautions in protecting cli-
ents from physical and psychological trauma. Play therapists explain to group
members, and/or their legal guardians (when the group includes those who are
legally under guardianship) the importance of maintaining confidentiality out-
side of the group, instruct them in methods for doing so and make special efforts
to ensure confidentiality in settings where it may be more readily compromised,
such as schools or inpatient/residential treatment settings. Rules for the group
and consequences of breaking the rules should be clear to all group members. If a
member of the group cannot abide by the rules of the group, consequences need
to be enforced for the protection of others. (p. 6)

My focus in this group was on neurodivergent children and valuing neurodi-

vergence as an identity. As such, I conceptualized neurodiversity and more spe-
cifically, the cultural and diversity needs of neurodivergent individuals, within
the greater diversity awareness paradigm. An understanding of racism, discrim-
ination, prejudice, bigotry, and so forth provided for a greater understanding of
what neurodiversity means and how neurodivergent people and their allies are
leading efforts in the neurodiversity movement to help improve acceptance and
inclusion in societies that have historically lacked neurodivergent affirming con-
structs (Grant, 2023).

Parent Consultations
AutPlay Therapy functions ideally as a family play therapy approach involving
both the child and the parent in the therapeutic process. In AutPlay groups, par-
ents participate in initial meetings with the therapist to assess the child’s best
fit in a group. I gave instructions to the parents on how the group would prog-
ress through 10 meetings. I encouraged parents to take an active role in promot-
ing connection and social navigation with their child. At the end of each group
meeting, I provided the parents with an information sheet that described what
had been implemented and processed in the group. I further encouraged the par-
ents to connect with each other outside of group meetings to facilitate social
opportunities.
104 Chapter 7

Conclusion
Autism cannot be labeled as one thing, one “look,” or one manifestation of symp-
toms. It is a vast and varied spectrum. The differences between two individuals
with the same autism diagnosis can be many. As a professional working with
autistic and other neurodivergent children, it is important for me to remember
the individuality of the diagnosis and strive to understand each child with whom
I am working. This was especially true as I facilitated this group of six boys with
social connection goals. In this group, the children varied in their social navi-
gation needs and strengths, how socially capable they felt, and what particular
social situations were difficult. Despite these differences, the group of boys were
able to find social connections and navigate with each other through various
interventions with a positive outcome.

Sample Case Notes

Group Meeting 1
Subjective: The group members shared their Minecraft drawings and some brief
information about themselves. Each member shared something, and a couple of
members expressed excitement about being in the group. E: “I love this group!”
B: “This is going to be a fun group!”
Objective: Initially, each group member appeared to be reserved, likely anxious
about the new experience. The group members were slow to begin talking and
interacting.
Assessment: From an AutPlay and Neurodiversity Paradigm perspective, this first
group meeting looked typical. Neurodivergent children often have needs with
social navigation and connection. These processes can create high levels of anx-
iety, fear, and confusion. It was expected that the members would be anxious
and reserved, needing time and opportunity to feel comfortable and sure about
the process. The Minecraft intervention was chosen because it represented each
member’s special interest and would likely help them feel more comfortable shar-
ing about themselves. The whole group did relax some and were able to begin
interacting through the Minecraft intervention.
Plan: Structured play interventions that align with the group members’ special
interests will be implemented to encourage connection and positive social interac-
tion. This will be meshed with therapist reflections that support social navigation
and neurodiversity affirming principles.

Group Meeting 5
Subjective: The group members worked together to create a Minecraft world
from LEGO bricks. The group members worked mostly independently in parallel
play. Occasionally, a member would ask if something could be moved or added
or ask for help finding a LEGO piece. Communication such as “Can I use that
 Autism and Neurodivergence 105

piece?,” Does anyone have this piece?,” and “Can I add to this or move this?”
were made throughout the creation time with responses given.
Objective: The group members seemed to value each other’s space and ideas in
creating the world. When members needed to work together or needed help, they
communicated in appropriate ways. Once the creation was completed, all the
group members seemed pleased with the process and the final outcome.
Assessment: From an AutPlay perspective, the group showed progress from the
first session. They were now able to navigate some social situations on their own
without the therapist’s instruction. The LEGO creation provided an opportunity
for the members to work together, requiring them to interact and communicate.
Overall, the process went well and showed group members’ growth.
Plan: Structured play interventions focused on the group members’ special inter-
est in LEGO. Interventions will progress requiring more social group interaction
and less facilitation from the therapist.

Resources

For Professionals
Grant, R. J. (2023). The AutPlay therapy handbook: Integrative family play ther-
apy with neurodivergent children. Routledge.
Silberman, S. (2015). Neurotribes: The legacy of autism and how to think smarter
about people who think differently. Allen & Unwin. AutPlay Therapy. https://
autplaytherapy​.com/

For Children
Congratulations, you’re autistic! by Katie Bassiri (2022).
Some brains: A book celebrating neurodiversity by Nelly Thomas (2020).
Understanding autism: A neurodiversity affirming guidebook for children and
teens by Robert Grant (2021).

For Parents
Autistic Self Advocacy Network, https://autisticadvocacy​.org/
Autistic Women & Nonbinary Network, https://awnnetwork​.org/
Sincerely, your autistic child: What people on the autism spectrum wish their par-
ents knew about growing up, acceptance, and identity edited by Morénike
Giwa Onaiwu, Emily Paige Ballou, & Sharon daVanport (2021).

Discussion Questions
1. What were some of the reasons for focusing on connection and social naviga-
tion with a group of neurodivergent children?
106 Chapter 7

2. Why was it important to understand the boys’ special interests and use the
special interests in focusing on group goals?
3. As a therapist, what neurodiversity affirming constructs and cultural issues
would you need to be aware of to effectively facilitate a group of neurodiver-
gent children? Give specific examples.
4. What would be some of the benefits of an integrated group approach with
this population?

References
Association for Play Therapy. (2023). Play therapy best practices. https://www​
.a4pt​.org/page/Research
Centers for Disease Control and Prevention. (2020). Autism spectrum disorder.
https://www​.cdc​.gov/ncbddd/autism/data​.html
Cherry, K. (2021). What is integrative therapy. Very Well Mind. https://www​
.verywellmind​ . com/integrative-­t herapy-­d efinition-­t ypes-­t echniques-­a nd​
-­efficacy-5201904
Chester, M., Richdale, A. L., & McGillivray, J. (2019). Group-­based social skills
training with play for children on the autism spectrum. Journal of Autism and
Developmental Disorders, 49, 2231–2242.
Drewes, A. A., Bratton, S. C., & Schaefer, C. E. (2011). Integrative play therapy.
John Wiley and Sons.
Grant, R. J. (2017). AutPlay therapy for children and adolescents on the autism
spectrum: A behavioral play-­based approach (3rd ed.). Routledge.
Grant, R. J. (2021). Understanding autism: A neurodiversity affirming guidebook
for children and teens. AutPlay Publishing.
Grant, R. J. (2023). The AutPlay therapy handbook: Integrative family play ther-
apy with neurodivergent children. Routledge.
Grant, R. J., & Turner-­Bumberry, T. (2020). AutPlay® therapy play and social
skills groups: A 10-session model. Routledge.
Hull, K. B. (2014). Group therapy techniques with children, adolescents, and
adults on the autism spectrum: Growth and connection for all ages. Jason
Aronson.
Jamison, T. R., & Schuttler, J. O. (2017). Overview and preliminary evidence for
a social skills and self-­care curriculum for adolescent females with autism:
The girls night out model. Journal of Autism Developmental Disorders, 47,
110–125.
Radley, K. C., Dart, E. H., Moore, J. W., Battaglia, A. A., & LaBrot, Z. C.
(2017). Promoting accurate variability of social skills in children with
autism spectrum disorder. Behavior Modification, 41(1), 84–112. https://doi​
.org/10.1177/0145445516655428
Scuro, J. (2018). Addressing ableism: Philosophical questions via disability stud-
ies. Lexington.
 Autism and Neurodivergence 107

Seymour, J. W. (2011). History of psychotherapy integration and related research.

In A. A. Drewes, S. C. Bratton, & C. E. Schaefer (Eds.), Integrative play ther-
apy (pp. 3–18). John Wiley & Sons.
Sweeney, D. S., Baggerly, J. N., & Ray, D. C. (2014). Group play therapy: A
dynamic approach. Routledge.
Turner-­Bumberry, T., & Grant, R. J. (2022). AutPlay therapy play groups for
high needs autistic groups. In C. Mellenthin, J. Stone, & R. J. Grant (Eds.),
Implementing play therapy with groups: Contemporary issues in practice.
Routledge.
Walker, N. (2021). Neuroqueer heresies: Notes on the neurodiversity paradigm,
autistic empowerment, and postnormal possibilities. Autonomous Press.
 CHAPT E R 8

Grief after COVID-19 and Gun Violence

Sand Tray Therapy with a Mexican American Child
Clarissa L. Salinas and Jennifer N. Baggerly

Salvador is a 9-year-­old Mexican American boy with a learning disability who lives
with his mother, father, and 3-year-­old sister in a town on the Texas–Mexico border.
In 2021, Salvador’s grandmother died due to complications with COVID-19. Due
to limited income, she could not afford to stop her work in a factory and contracted
COVID-19 from an infected coworker. However, because Salvador’s grandmother
was undocumented, she did not have insurance and was afraid to go to the hos-
pital. She died in their family home. Afterward, Salvador experienced fear of dying
and grief but did not receive counseling due to quarantine restrictions. In 2022,
Salvador’s favorite older cousin, Rubin, was shot and killed by a semiautomatic
gun during community violence at a school-­sponsored soccer game. Afterward,
Salvador expressed his anger by being extremely disrespectful to teachers and
other adults in the community; avoided playing soccer, which he loved; persever-
ated on “what-­if” scenarios regarding Rubin and his grandmother; and stopped
trying at school because “what’s the use since I may die soon, too?” Salvador’s
school counselor recommended that his parents seek counseling to address his
compound grief.

For this case study, consider:

1. How do children’s symptoms of grief differ from traumatic grief?
2. What is the rationale for using sand tray therapy with Salvador?
3. What unique ethical and cultural guidelines need to be considered?

Grief and Traumatic Grief

COVID-19
According to the United States Centers for Disease Control (CDC, 2023), the
number of people who died in the United States from COVID-19 as of June
3, 2023, is 1,131,439. The race/ethnicity percentages of these deaths were first,
White, non-­Hispanic at 64%; the second largest race/ethnic group was Hispanic/
Latino at 16.8%, followed by Black at 12.6%, Asian at 3.3%, and American

109
110 Chapter 8

Indian/Alaska Native at 1.1%. People over the age of 65 represented 75.9% of

the deaths from COVID-19 (CDC, 2023).
With more than a million deaths by COVID-19, conceivably a million US
children experienced grief due to the loss of a loved one. Early in the pandemic,
December 2021, estimates of children who lost a parent or in-­home caregiver to
COVID-19 were already at 167,082 (Treglia et al., 2021), and that was before
another surge of deaths in January 2022. Non-­White children lost care-­giving
adults at higher rates than their White peers. Treglia et al. (2021) reported:
Some of the cruelest pain has come to a group with the least capacity to under-
stand and cope with it. . . . For these children, COVID-19 has done more than
hurt their lives; it has ended their world. . . . The sudden, seemingly unexplain-
able departure of a caregiver leaves a void of affection and direction that each
child will struggle to fill. And the outcome of that struggle will determine much
about their future. The traumatic loss of a caregiver has been associated with
depression, addiction, lower academic achievement, and higher dropout rates. It
represents lost potential for individuals and our society. (p. 4)

Grief
Grief is a normal process following the loss of a loved one (Treglia et al., 2021).
Grief in children after a family member’s death can result in an array of typi-
cal responses such as sadness, loneliness, anxiety, guilt, anger, and helplessness.
Grief can cause changes in thoughts (e.g., disbelief or protest, imagining alterna-
tive scenarios); behaviors (e.g., avoiding grief triggers, inability to connect with
others); emotions (e.g., guilt, anger); and physiology (e.g., stomachaches, head-
aches) (Center for Prolonged Grief, n.d.). Children’s ability to recover from grief
is based on several factors such as their age, support systems, and circumstances
surrounding the family member’s death. Although many children’s sense of secu-
rity, relationships, and meaning are challenged after the death of a loved one,
positive personal growth is possible if emotional support is provided (DeAngelis,
2022).
Unfortunately, during the COVID-19 pandemic, many children had caregiv-
ers who were also stricken with grief, hindering their ability to provide emotional
support. In addition, quarantine impeded interaction with other support systems
such as school staff, community members, and counselors. These circumstances
increased the likelihood of children’s atypical grief response of Prolonged Grief Dis-
order (PGD), defined as “intense yearning or longing for the deceased (often with
intense sorrow and emotional pain), and preoccupation with thoughts or mem-
ories of the deceased (in children and adolescents, this preoccupation may focus
on the circumstances of the death)” (APA, 2022). PGD is persistent and pervasive
and interferes with functioning (Center for Prolonged Grief, n.d.). About 10% of
children experience traumatic, complicated, or prolonged grief for which clinical
therapy may be required (Treglia et al., 2021).
 Grief after COVID-19 and Gun Violence 111

Community Violence
According to the CDC National Violent Death Reporting System, 20,663 people
were victims of homicide in 2020, with the most common method being fire-
arms (Liu et al., 2023). “Violence erodes entire communities—reducing produc-
tivity, decreasing property values, disrupting social services, and making people
feel unsafe in the places where they live, work, and learn” (CDC, n.d., p. 1). The
National Child Traumatic Stress Network (NCTSN, n.d.a) stated that chronic
community violence can destroy children’s sense of safety, put them in survival
mode, make them ready to gear up for fight or flight, and dampen their outlook
on the future as well as their sense of control.

Traumatic Grief
Community violence that results in a sudden and unexpected death of a loved
one can cause childhood traumatic grief that is severe or prolonged and inter-
feres with children’s functioning (NCTSN, n.d.a). In addition to grief symptoms
discussed above, traumatic grief is characterized by intrusive memories about the
death (e.g., nightmares, guilt, horrifying thoughts about the death); avoidance and
numbing (e.g., withdrawal, avoiding reminders of the person or events related to
the death); and physical or emotional symptoms of increased arousal (e.g., irrita-
bility, anger, trouble sleeping, increased vigilance, and fears about safety for one-
self) (NCTSN, n.d.a). Unfortunately, any thoughts, even happy ones, about the
person who died can trigger fears and upset the child. Reminders that may trig-
ger distress are trauma reminders (e.g., places, situations, people); loss reminders
(e.g., photos, special occasions previously enjoyed with the person who died); and
change reminders (e.g., situations, people, or things that change such as no longer
attending a sporting event). Intervention is needed to prevent ongoing mental
health problems in children with Prolonged Grief Disorder and Traumatic Grief.

Sand Tray Therapy

Prolonged grief and traumatic grief are often treated with Cognitive Behavior
Therapy and Trauma-­Focused Cognitive Behavior Therapy (Center for Prolonged
Grief, n.d.; Cohen, Mannarino, & Deblinger, 2006), which are both well described
in other chapters in this book. However, the American Psychological Association
recommends tailoring treatment to meet the developmental and cultural needs of
a particular client (DeAngelis, 2022). Given Salvador’s developmental level and
Hispanic heritage, I (first author) believe he will also benefit from sand tray ther-
apy for several reasons. First, due to Salvador’s developmental level and learning
disability, he has difficulty with abstract concepts and prefers hands-­on activities
but “not baby toys” (his perception of the standard playroom). Second, Salvador
does not like to talk about things as his traumatic grief tends to limit his verbal
ability, so he needs nonverbal engagement to activate his experiences in a non-
threatening manner. Third, sand tray has been shown to be a desired modality
112 Chapter 8

with children who are Latinx and/or struggling with grief (Deligiannis & Pinilla,
2022; Salinas, 2021; Thanasiu & Pizza, 2019).
Sand tray therapy is a child-­centered technique created by Lowenfeld (1979).
Also known as “The World Technique,” this child-­centered approach consists of
a tray of sand, water to be added into the sand tray, if the client chooses, and
miniatures of various items for the client to create an imaginative and symbolic
world in the sand tray to reflect their inner experiences (Lowenfeld, 1979). The
World Technique is based on the principles of psychoanalysis, particularly the
concept of the unconscious mind and the symbolic nature of play (Lowenfeld &
Brittain, 1982). During a sand tray session, the child is invited to create a “world”
in the sand tray, using the miniature figures to represent various elements of their
inner and outer worlds. The therapist encourages the child to freely express him-
self through the placement and manipulation of the figures within the sand tray.
Sand tray is particularly helpful for children with traumatic grief as it allows
for posttraumatic play to help them process death and unconsciously reenact
trauma in an effort to self-­soothe (Webb, 2010). When children use miniatures
in the sand tray, they project feelings, thoughts, and experiences onto miniatures,
creating a safe distance to process death emotionally and cognitively (Homeyer
& Sweeney, 2022; Salinas, 2021). Children can relive memories of their loved
one who died and re-­create what they would like to have said or done. Children’s
symbolic play in the sand tray allows counselors to view what a child under-
stands and thinks about the death, and it gives counselors an opportunity to
intervene appropriately (Webb, 2010). The burying theme is often seen in sand
tray of children who are grieving (Green & Connolly, 2009). It metaphorically
allows children to play out the burial of their loved one. It also allows avoidance
of the painful emotion when recalling and making sense of a death (Green &
Connolly, 2009).
As described by Lowenfeld and Brittain (1982), sand tray materials include
the following:
1. Sand: The central component of a sand tray, typically a fine-­grain, clean sand
is used. It should be easily moldable and provide a suitable texture for creat-
ing landscapes and designs.
2. Sand Tray: A container or tray specifically designed for the sand play. It is usu-
ally shallow, rectangular, and made of durable materials such as wood, plas-
tic, or metal. The sand tray is standardized at approximately 75 cm x 50 cm
x 7 cm and painted blue to create an image of sky or water that contains
the sand (Hutton, 2004). A tray that is too small can quickly be filled and
overwhelm a child who has been traumatized, and thus should be avoided
(Mattson & Veldorale-­Brogan, 2010).
3. Miniature Figures: These are small, three-­dimensional objects that represent
people, animals, objects, and symbols. They are placed in the sand tray to cre-
ate scenes and narratives. Miniature figures can include humans of different
ages, genders, and occupations; animals of various species; vehicles; natural
 Grief after COVID-19 and Gun Violence 113

elements (trees, rocks); and symbolic objects (bridges, fences). They offer a
wide range of options for the child to express her thoughts and experiences.
4. Natural Elements: Additional natural materials such as twigs, leaves, shells,
and stones can be provided to enhance the sand tray experience. These mate-
rials can be used to create landscapes, add details, or provide a sensory aspect
to the therapy.
5. Other Props: Depending on the therapeutic goals or specific interventions,
additional props may be included that target the client’s individual experience,
such as tombstones, religious items, beer bottles, cars, or hospital bed. These
props can provide opportunities for role-­playing, storytelling, or exploring
specific themes.
It is important to note that the selection of sand tray materials may vary
based on the therapeutic approach, the child’s age and preferences, and the ther-
apist’s assessment and goals for the session. In addition, ensuring the safety and
cleanliness of the materials is crucial to maintain a hygienic and secure therapeu-
tic environment.
When conducting sand tray, my role with the client is to
1. develop a warm relationship where he feels accepted and valued,
2. give him the freedom to lead in his sand tray creation,
3. accept his feelings and behavior unconditionally, and
4. encourage his self-­expression (Homeyer & Sweeney, 2022; Lowenfeld & Brit-
tain, 1982).

My goal with the client is to help him readjust to life without his grandmother
and cousin. Additional goals include helping him to process the fear he has related
to his own death and build coping skills for times that he feels sad or is reexperi-
encing trauma symptoms.
Sand tray treatment procedures and strategies that will be helpful to Salvador
are (1) introduction and explanation, (2) free play, (3) intentional prompts, (4)
symbolic play and storytelling, (5) processing and reflection, and (6) closure and
integration (Homeyer & Sweeney, 2022; Lowenfeld & Brittain, 1982). First, it is
important to explain the purpose of sand tray to Salvador in a mature manner
so that he does not confuse it with the idea of just playing in the sand. This is
important because he thinks he is “too old for kid toys.” Next, it is important
that Salvador has unstructured time to freely explore the sand tray and select
miniature figures to which he feels connected. Prior to the start of the session,
the counselor should equip the room with miniatures that Salvador can relate to,
given his loss—for example, a miniature mask to represent life during COVID-
19, a miniature soccer ball to represent his passion for the game, and a miniature
gun to represent the community violence leading to his cousin’s death. Having a
well-­thought-­out array of miniatures can allow the client to engage in symbolic
play in the sand, act out scenes, and create narratives. Further, the counselor may
use specific prompts or themes to guide the client’s play in the sand tray. These
114 Chapter 8

prompts can be related to the client’s current concerns or therapeutic goals. For
example, I suggested that Salvador create a scene in the sand of himself and his
family.
Finally, after the sand tray is created, the counselor should facilitate a reflec-
tion and discussion with the clients, allowing them to share their thoughts and
feelings about their creation. The counselor encourages the client to explore the
connections between the sand tray and real-­life experiences, promoting integra-
tion and understanding. The counselor also assists clients in summarizing their
sand tray experience. This can involve identifying insights gained, discussing cop-
ing strategies, and setting goals for future sessions or outside the therapy context.

Case Study Application

With this deeper understanding of grief, traumatic grief, and treatment approaches,
we can now apply them to Salvador. From a sand tray therapy perspective, I
conceptualize Salvador as a 9-year-­old Mexican American male struggling with
traumatic grief because he has not been able to safely express his thoughts and
emotions to the point of integration and understanding. His parents also iden-
tify as Mexican American and are grieving the loss of their mother and nephew.
Further, the family has a strong belief in the Catholic religion. It is important to
note that many Mexican Americans value family as a source of strength, which
supports their preference for interpersonal relationships, known as personalismo
(Garza & Bratton, 2005). Parents usually have very close relationships with their
children, especially mothers with their children. When death occurs in Mexican
American families, counselors can build rapport with their clients by identifying
support systems for the family to rely on (Doran, 2002). Along with having a
sense of family, most Mexican Americans value religion as a source of strength.
Counselors can benefit from understanding their client’s cultural connection to
religion and spirituality. For example, in the event of a death, a new relationship
with the deceased may be created, and families may gather to pay respects and
remember the deceased during Día de los Muertos (Day of the Dead).

Session 1
My goals for the first session were to develop rapport, assess Salvador’s working
diagnosis, identify his treatment goals, facilitate his expression, and provide some
beginning coping skills. I prepared by providing a room with a sand tray and
hundreds of miniatures categorized as described above. After introducing myself,
obtaining informed assent including limits of confidentiality, I invited Salvador to
engage with the sand tray.
After the sand tray, I asked what he would like to accomplish in our counsel-
ing together. We agreed on the following:
Treatment Goal: Decrease grief, anger, and disrespect and increase effective emo-
tional and behavioral regulation.
 Grief after COVID-19 and Gun Violence 115

TABLE 8.1. SALVADOR: SESSION 1

Transcript Analysis
T: “Hi, Salvador. Today we are going to use the Introduction of the sand tray and invitation to
sand tray. I have lots of miniatures here for you to choose miniatures. This informed the client that he
explore and choose from to include in your sand gets to take the lead in his sand tray.
tray. Take your time to look at all the miniatures
available, and when you are ready, I want you to
create a scene in the sand of you and your family.
I will sit here quietly until you finish your sand tray.”
S: “Okay. How many miniatures can I choose?” Children often look for rules in new situations.
T: “You can choose as many or as few miniatures Therapist returned responsibility to the client.
as you would like.” Here, the therapist encouraged Salvador to make
up his own mind about how many miniatures to
use.
S: [Quietly Salvador selects an adult male and Salvador felt safe to create a scene in the sand.
female miniatures and a young girl. He lines them He was unsure whether he was finished with his
up in the sand tray and then goes back to select a scene as evidenced by his pause.
young male miniature and older male. He looks at
his sand tray and pauses before announcing that
he is done.]
T: “It sounds like you are done with your sand tray. Reflection of content. This helped Salvador feel
Still, I’ll give you another second or two to decide heard. Therapist gives client permission to take
if you would like to make any changes or if it is additional time to finish his scene if needed.
good as is.”
S: “It is good as is.” Salvador used his voice and was assertive when
he assured the therapist that he was finished.
T: “Okay. Please tell me a story about your sand Invitation for client to share his sand tray with
tray.” therapist.
S: [Salvador points to each miniature as he Depending on the developmental age of children,
narrates] “This is my dad, my mom, my baby they may either tell you a story about their scene
sister, and my grandpa.” using metaphor or be literal in describing who
each miniature represents. Salvador, given his
developmental age of 9, appropriately shares who
each miniature represents.
T: “Ahh, I see. In your family is your mom, dad, Reflection of content helps Salvador feel heard.
sister, and grandpa. I notice a couple people Therapist reflects discrepancy between the
missing that you mentioned earlier in our information given at intake about client’s family
appointment were in your family—your grandma and how it is portrayed in the sand tray. It is an
and cousin Rubin.” invitation for client to elaborate on his grief.
S: “Yes they were in my family, but they died.” Salvador felt comfortable sharing his confusion
about whether to include his grandmother and
cousin in the sand tray.
T: “It sounds like you are unsure if they can still be Reflection of feeling and meaning. Here, the
part of your family because they died.” therapist acknowledged Salvador’s grief.

Objectives:
1. Express grief related to his grandmother and cousin and develop a restorative
understanding of their deaths.
2. Identify and connect experiences, emotions, and perceptions underlying grief
and anger.
116 Chapter 8

3. Replace thinking errors with balanced thoughts.

4. Develop effective coping and communication skills.
I also want to give Salvador at least two practical coping strategies for some
symptom relief. I explain and demonstrate box breathing and suggest that he
direct his upset feelings toward a soccer ball and kick it as hard as he can. See
Session 1 Note for a summary.

Session 2
My goal for the second session was to continue to develop rapport with Salvador,
understand the relationship he had with his grandmother and cousin, and help
him work through the pain of grief. By session 4, Salvador began to identify his
feelings related to grief, and his anger intensified as he talked about his loved
ones who died.
In the next few sessions, Salvador began to speak more openly about missing
his grandmother and cousin. He was able to identify feelings that made up his
grief, which included anger, sadness, shock, confusion, and joy. He also began
TABLE 8.2. SALVADOR: SESSION 2
Transcript Analysis
T: “Today, I want to invite you to create a scene This directive prompt is geared at helping the
in the sand of the moment you found out Rubin client begin to work through the pain of his grief.
died.”
S: [Salvador quietly brings to the sand tray a car, Working in the sand can elicit unconscious
cellphone, people, and road signs. He creates feelings for the client. As Salvador reflected on his
a scene in the sand of him and his family driving memory of learning about Rubin’s death, he was
home from dinner. Before he can announce that flooded with anger. He then refused to continue
he is done, Salvador destroys his scene and buries working in an effort to avoid his anger.
the miniatures in the sand.] “I don’t want to do this
anymore!”
T: “I can see that you are angry. Thinking about Reflection of feeling and meaning. Here, the
Rubin is difficult.” therapist acknowledged Salvador’s anger.
S: [Salvador remains silent] Children are often unsure how to respond to
reflections of feelings.
T: [Matches Salvador’s silence] I gave Salvador space to sit with his thoughts.
S: “I wish he was still here.” After giving Salvador time to process his
thoughts, he expressed his yearning for Rubin.
T: “You wish Rubin was still alive. It’s okay to be Reflection of content. Therapist normalized
angry. I noticed you working hard in the sand tray Salvador’s feelings of anger and then reflected his
until something upset you.” nonverbal behavior to elicit a response.
S: “Yeah, I remember my mom getting a phone Salvador felt comfortable and safe with the
call from my tía on our drive home, and she was therapist to describe his memory.
screaming. I heard everything. She said Rubin had
been shot and was rushed to the hospital, but he
did not make it.”
T: “So, you remember being in the car when you Reflection of content helps Salvador feel heard.
got the news and hearing your tía’s pain. Wow, that Therapist empathized with the client.
must have been a lot for you to take in.”
S: “Yeah, I do not like thinking about it. I should Salvador makes deeper meaning of feeling guilt
have been there with him.” for not being present when his cousin died.
 Grief after COVID-19 and Gun Violence 117

to adjust to life without his grandmother and cousin. The counselor provided
Salvador a prompt, “On one side of the sand tray, create a scene of ‘family time’
before your loved one died, and on the other side, create a scene of ‘family time’
now after your loved one died.” Salvador was able to understand that he could be
happy even after his loved ones died and that playing soccer was a great way to
honor his cousin rather than it be reminder of his death. Once Salvador practiced
his coping skills and better understood his grief, his disrespect toward teachers
also decreased.

Ethical and Cultural Considerations

One major ethical consideration in Salvador’s case is the health inequities that
occurred during COVID-19. The CDC (2022) stated, “The population health
impact of COVID-19 has exposed longstanding inequities that have systemati-
cally undermined the physical, social, economic, and emotional health of racial
and ethnic minority populations and other population groups that are bearing
a disproportionate burden of COVID-19.” Many low-­income Hispanic families,
especially with undocumented family members, did not receive needed health ser-
vices during the COVID-19 pandemic. According to the American Counseling
Association advocacy competencies (Toporek, Lewis, & Ratts, 2010), counselors
are to engage in social justice advocacy on behalf of or preferably with clients. I
did this by helping Salvador write a letter to his state and US Congress represen-
tatives asking them to (a) fund public health clinics and agencies for Latinx fam-
ilies, regardless of immigration status, and (b) enhance gun control by banning
semiautomatic guns.
An important cultural consideration was to honor Salvador’s Mexican Amer-
ican cultural values of familism (i.e., family is a source of support and guidance,
and family needs come before one’s needs) and respect (e.g., youth must respect
their elders) while recognizing the stigma associated with counseling (Choi et al.,
2023; Knight et al., 2010). As a counselor, I worked to engage in “la plática”
(i.e., small talk) to build rapport; demonstrated respect to Salvador’s parents by
addressing them as Señor and Señora and asking con permiso (for permission) to
work with Salvador; and explained that counseling helps typical children with
difficulties to decrease the stigma. In addition, I recognized that the Mexican
American emphasis on machismo for males seems to have contributed to Salva-
dor’s misperception that because he is a “man,” he should have demanded care
for his grandmother and stopped his cousin’s shooting. I reminded him that the
events leading up to his grandmother’s and cousin’s death were not in his control,
but he does have control in helping to make his community better.

Parent Consultations
I collaborated closely with Salvador’s parents by meeting with them at the begin-
ning of each session while Salvador drew or colored a mandala in the waiting
118 Chapter 8

room. Recognizing that his parents were also grieving, I gave them resources
described below, encouraged them to practice positive coping strategies with Sal-
vador, use a thermometer scale to illicit the intensity of his feelings on a regular
basis, talk with him about grandmother and his cousin, and engage in religious
rituals (e.g., lighting candles at church).

Conclusion
Salvador made remarkable progress in understanding his grief and expressing it
to others. Sand tray provided him an expressive outlet to process his experiences
and create hopeful scenes of the future. Salvador accepted that the deaths were
out of his control, but he could control how he coped with the loss. Salvador and
his parents decided together to honor his grandmother and cousin on their birth-
day anniversary by doing a balloon release. This encouraged Salvador to stay
connected to his family even after death and send them messages of love.
As a therapist, I learned to trust the process of grief work. During some ses-
sions, Salvador was too angry to participate in sand tray, at which point I allowed
him to engage in free play. There were also sessions in which we did not discuss
grief at all. It was important for Salvador to be in control of his grief journey and
open up when he was ready.

Sample Case Notes

Session 1
Subjective: Client expressed his perception of his family unit in the sand tray.
He included adult male and female miniatures to represent his mom and dad,
young girl and boy miniatures to represent his sister and himself, and an older
adult miniature to represent his grandfather. Client did not include his grand-
mother or cousin in his sand tray. Client reported that his grandmother died from
COVID-19, and his cousin was shot and killed. Client also reported to have a
close relationship with his grandmother and cousin. Client’s parents report him
to be disrespectful toward his teachers and is displaying anger. Identified treat-
ment goals include expressing grief and coping with anger.
Objective: Client was cooperative and displayed appropriate affect. He was cau-
tious when working in the sand tray but displayed developmentally appropriate
behavior. He was oriented to time, place, and situation.
Assessment: Client presents with traumatic grief and is having outbursts at
school. He currently reports low motivation to attend school and play soccer;
however, he is motivated for treatment.
Plan: Provided weekly individual therapy. Work through Worden’s 4 Tasks of
Mourning in the sand tray. Next session, focus on helping client work through
the pain of his grief by having client share memories of his loved ones in the sand.
 Grief after COVID-19 and Gun Violence 119

Session 4
Subjective: Counselor provided client prompt for sand tray, “create a scene in the
sand of the moment you found out Rubin died.” The goal of the prompt was to
help client work through his pain of grief. Client included a car, cellphone, peo-
ple, and road signs in the sand. Client became angry while working in the sand
and buried miniatures. He reported learning about his cousin’s death while driv-
ing home with his family. Client realized that he had guilty feelings for not being
with his cousin when he died. Counselor demonstrated box breathing to client in
which he draws the outline of a box with his finger and takes a deep breath in
and out each time he draws out a line. Also, counselor and client agreed that it
might help client to focus his anger on a soccer ball and kick it as a way to cope.
Objective: Client became angry during session as evidenced by him burying his
miniatures. Then, he displayed sad affect when talking about his cousin. His
behavior was developmentally appropriate. Client was oriented to time, place,
and situation.
Assessment: Client is working through the pain of his grief and remains moti-
vated for treatment.
Plan: Next session, help client adjust to life without the deceased according to
Worden’s task 3 by providing directive prompt for sand tray. For example, on one
side create a scene of life before grandmother and cousin died, and on the other
side create a scene of life now. Process with client.

Resources

For Professionals
Creative Interventions for Bereaved Children by Liana Lowenstein (2006).
NCTSN. Cultural and Contextual Considerations in the Treatment of Childhood
Traumatic Grief. https://www​.nctsn​.org/​resources/​cultural-­and-­contextual​
-­considerations-­treatment​-­childhood​-­traumatic-­grief
Sandtray Therapy: A Practical Manual, Fourth Edition by Linda E. Homeyer &
Daniel S. Sweeney (2022).

For Children
NCTSN. Ready to Remember: Jeremy’s Journey of Hope and H ­ ealing. https://
www​.nctsn​.org/resources/ready​-­remember​-­jeremys​-­journey​-­hope-­and-­healing
NCTSN. Taking Care of You. https://www​.nctsn​.org/resources/taking-­care-­of-­you
When Someone Dies: A Children’s Mindful How-­To Guide on Grief and Loss by
Andrea Dorn (2022).

For Parents
NCTSN Video and Resources. I Don’t Know How to Support My Child through
Loss: Multigenerational Cultural Perspectives. https://www​.nctsn​.org/
120 Chapter 8

resources/i​ -­dont-­know-­how-­to-­support-​ ­my-­child-­through-­loss-­multigeneratio

nal​-­cultural​-­perspectives
NCTSN. Rosie Remembers Mommy: In Her Heart Forever. https://www​.nctsn​
.org/resources/rosie-­remembers​-­mommy​-­forever-­her-­heart
NCTSN. Información en Español. https://www​.nctsn​.org/resources/informacion-­
en-­e spanol?search=&resource_type=All&trauma​ _ type=All​ & language​
=86&audience=29&other=All

Discussion Questions
1. What were some of Salvador’s unique experiences and needs as a result of his
compound grief?
2. How did sand tray facilitate the achievement of Salvador’s treatment goals?
Give specific examples.
3. As a therapist, what beliefs, biases, and/or emotions would you need to
bracket to effectively work with Salvador and his family?
4. What actions could you take to promote social justice advocacy related to
medical services for undocumented families and gun violence?

References
American Psychiatric Association. (2022). Diagnostic and statistical manual
of mental disorders (5th ed., text rev.). https://doi​​.org/10.1176/appi​.books​
.9780890425787
Centers for Disease Control and Prevention. (2022). CDC COVID-19 Response
Health Equity Strategy: Accelerating Progress Towards Reducing COVID-
19 Disparities and Achieving Health Equity. https://www.cdc.gov/coronavi-
rus/2019-ncov/community/health-equity/cdc-strategy.html
Centers for Disease Control and Prevention. (2023). COVID data tracker. https://
covid​.cdc​.gov/covid​-­data​-­tracker/​#data​tracker​-­home
Centers for Disease Control and Prevention. (n.d.). National violent death reporting
system. https://www​.cdc​.gov/violence​prevention/​datasources/nvdrs/resources
.html
Center for Prolonged Grief. (n.d.). Complicated grief. https://prolongedgrief​
.columbia​.edu/professionals/complicated​-­grief​-­professionals/overview/
Choi, N.-Y., Li, X., Crossley, R., Gibbs, J., & López-­Harder, J. (2023). Men-
tal health and attitudes toward seeking counseling in Mexican Americans:
Exploring values and social class. Counseling Psychologist, 51(4), 560–589.
https://doi​.org/​10​.1177/00110000231160766
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and trau-
matic grief in children and adolescents. Guilford Press.
DeAngelis, T. (2022). Thousands of kids lost loved ones to the pandemic. Psy-
chologists are teaching them to grieve, and then thrive. American Psychologi-
cal Association. https://www​.apa​​.org/​monitor/2022/10/kids-­covid-­grief
 Grief after COVID-19 and Gun Violence 121

Deligiannis, A., & Pinilla, M. (2022). Migratory phenomenon and expressive

sandwork in vulnerable populations. Journal of Analytical Psychology, 67(1),
88–104. https://doi​.org/​10​.1111/​1468-5922.12751
Doran, G. (2002). Family grief experience at the death of a child in the Mexican
American community [ProQuest Information & Learning]. In Dissertation
Abstracts International: Section B: The Sciences and Engineering (Vol. 63,
Issue 5–B, p. 2578).
Garza, Y., & Bratton, S. C. (2005). School-based child-centered play therapy with
Hispanic children: Outcomes and cultural considerations. International Jour-
nal of Play Therapy, 14(1), 51–80. https://doi.org/10.1037/h0088896
Green, E. J., & Connolly, M. E. (2009). Jungian family sandplay with bereaved
children: Implications for play therapists. International Journal of Play Ther-
apy, 18(2), 84.
Homeyer, L., & Sweeney, D. (2022). Sandtray therapy: A practical manual (4th
ed.). Routledge.
Hutton, D. (2004). Margaret Lowenfeld’s “world technique.” Clinical Child Psy-
chology and Psychiatry, 9(4), 605–612.
Knight, G. P., Gonzales, N. A., Saenz, D. S., German, M., Deardorff, J., Rossa,
M. W., & Updegraff, K. A. (2010). The Mexican American cultural values
scale for adolescents and adults. Journal of Early Adolescence, 30, 444–481.
https://doi.org/10.1177/​027​243161609338178.
Liu, G. S., Nguyen, B. L., Lyons. B. H., Sheats, K. J., Wilson, R. F., Betz, C. J., &
Fowler, K. A. (2023). Surveillance for violent deaths—National violent death
reporting system, 48 states, the District of Columbia, and Puerto Rico, 2020.
Morbidity and Mortality Weekly Report, (SS-5), 1–38. http://dx​.doi​.org/​10​
.15585/​mmwr​.ss7205a1
Lowenfeld, M. (1979). Play in childhood. Free Association Books.
Lowenfeld, M., & Brittain, W. L. (1982). The world technique. In L. McMahon
(Ed.), The handbook of play therapy (pp. 313–338). Routledge.
Mattson, D. C., & Veldorale-­Brogan, A. (2010). Objectifying the sand tray: An
initial example of three-­dimensional art image analysis for assessment. Arts in
Psychotherapy, 37(2), 90–96.
National Child Traumatic Stress Network (n.d.a). Community violence. https://
www​.nctsn​.org/what-­is-­child-­trauma/trauma​-­types/​community-­violence/effects
National Child Traumatic Stress Network (n.d.b). Traumatic grief. https://www​
.nctsn​.org/what-­is-­child-­trauma/trauma-­types/traumatic-­grief
Salinas, C. L. (2021). Playing to heal: The impact of bereavement camp for chil-
dren with grief. International Journal of Play Therapy, 30(1), 40–49. https://
doi​.org/10.1037/pla0000147
Thanasiu, P. L., & Pizza, N. (2019). Constructing culturally sensitive creative
interventions for use with grieving children and adolescents. Journal of Cre-
ativity in Mental Health, 14(3), 270–279. https://doi​.org/10.1080/15401383.
2019.1589402
122 Chapter 8

Toporek, R. L., Lewis, J. A., & Ratts, M. J. (2010). The ACA advocacy com-
petencies: An overview. In M. J. Ratts, R. L. Toporek, & J. A. Lewis (Eds.),
ACA advocacy competencies: A social justice framework for counselors (pp.
11–20). American Counseling Association.
Treglia, D., Cutuli, J., Arasteh, K., Bridgeland, J., Edson, G., Philips, S., & Bal-
akrishna, A. (2021). Hidden pain: Children who lost a parent or caregiver to
COVID-19 and what the nation can do to help them. COVID Collaborative.
https://www​.hiddenpain​​.us/
Webb, N. (2010). Helping bereaved children: A handbook for practitioners. Guil-
ford Press.
 CHAPT E R 9

Family Stress
Filial Therapy with an
Indigenous American Family
Risë VanFleet

Kallik was an 8-year-­old boy who originated from arctic Alaska. He bore a tra-
ditional Inuit name, although the one here is substituted to preserve his privacy.
His tribal affiliation is not included here, either, for privacy reasons. His father had
been killed in a fishing accident two years prior, and when his 16-year-­old sister
attempted suicide, his mother, Kanani, moved both her children to the “lower 48”
to live near her sister and her family. This represented a considerable change from
their close-­knit arctic village to an East Coast town of 50,000 people. Kallik had
difficulty adjusting to his new physical and cultural environment. He was some-
times heard crying during the night, and he resisted going to school. In school
he often refused to do his work and said very little when asked what the problem
was. The school counselor asked Kanani if she would seek help for him. His sister
was already in treatment for her own issues. Kallik had not made many friends
and often stayed in his room at home. Kanani said she was unable to get him to
talk about what was on his mind. Kanani then contacted some key people in her
former Native Alaskan district who directed her to me.

For this case study, consider:

1. How did Kallik’s new environment contribute to his behavior problems at
school?
2. Why is Filial Therapy an appropriate intervention for Kallik and his family?
How is it culturally appropriate?
3. What did Kallik’s play reveal about his experience? How did his mother facil-
itate his change through Filial Therapy?

Indigenous Cultural and Environmental Context

There were no therapists from Kallik’s culture, or even from Alaska, who prac-
ticed within 100 miles of the family’s new location in the northeastern United
States. The family had learned of another professional who was from a differ-
ent indigenous culture, but she was prohibitively far away. I (author) had been

123
124 Chapter 9

recommended to them by an Alaska Native program for whom I had provided

several training workshops in Filial Therapy (FT) in the past and who thought
the method would be very useful for this family.
Because Kallick’s withdrawn behavior at home and the various problems
reported at school were new behaviors, it seemed that the grief over his father’s
death, the attention given to his sister’s attempted suicide, followed by the move
from his familiar home community to a very foreign environment had a cumu-
lative detrimental effect on Kallik’s psychosocial well-­being. These factors all
needed to be considered in this case and should be borne in mind by readers.
The family stress must be considered as well. Kanani certainly had her own
feelings about the loss of her husband and her daughter’s suicide attempt, and
they seemed to have prompted her to move from her home community to be
closer to her sister. She was worried because of the high rate of suicide among
young people in arctic villages and believed that a different environment might
prevent further attempts by her daughter. She was carrying a lot of family stress
on her shoulders, and that, too, is an important consideration in her decisions
and the subsequent therapeutic process for her family.
Significant cultural and social factors also need to be considered. As happened
with many indigenous peoples in the United States and elsewhere, indigenous
Alaskan villages experienced an erosion of their cultural integrity and heritage
when confronted by Westerners who assumed power over their traditional lands,
engaged in heinous acts, and removed much of their sovereignty and agency
(Rosita, 2010). Core beliefs and ways of living with the land and each other
were affronted and disregarded in a manner that had devastating impact that
continues as intergenerational trauma. The historical and continuing difficulties
faced by this family’s village and neighboring communities and indigenous people
throughout the United States are relevant as they influence many factors import-
ant for mental health and a sense of belonging. The loss of land and culture was
accompanied by the loss of language, traditions, spiritual beliefs, and how people
lived their daily lives with each other (Donovan et al., 2015; Stringer, 2018). The
separation of children from their families and other physical and psychological
atrocities left their mark as well.
This child and his family had experienced these challenges in their own com-
munity in arctic Alaska, and now they had been uprooted in an effort to protect
the children and in hopes of providing them more opportunities. Kanani also
wanted to connect her children with other family members who had moved from
the community about a decade earlier and appeared to be doing well.
Bronfenbrenner (1979) proposed the Ecological Systems Theory of child
development. This theory offered a broader and deeper framework from which
to understand child development and things that interfere with it, posing chal-
lenges to child and family adjustment. It provides a useful frame to consider the
difficulties that Kallik and his family faced. In it, Bronfenbrenner looked at the
impact of different levels of “systems” in which the child was embedded. These
 Family Stress 125

nested environmental structures included (a) the microsystem of the child’s imme-
diate settings and relationships, such as family, school, friends, and neighbors; (b)
the mesosystem of interrelationships between and among these settings directly
involving the child such as the intersection of family and school, family and the
child’s friends and neighbors; (c) the exosystem of events and interactions that
have indirect impact on the child and family, such as the parents’ employment,
extended family, social media, local governments; (d) the macrosystem of wider
systems that also have indirect influence such as social norms, socioeconomic
status, political systems, culture, laws; and finally, (e) environmental changes
that take place throughout the child’s and family’s life, including planned and
unplanned events (Bronfenbrenner, 1979; VanFleet, 1985). It is clear in Kallik’s
case that factors at each level were operating, and careful consideration of them
would potentially influence the success of any intervention.

Filial Therapy
Filial Therapy (FT) is a systematic and time-­limited family intervention cre-
ated and developed by Drs. Bernard and Louise Guerney over the past 60 years
(Guerney & Ryan, 2013; Topham & VanFleet, 2011; VanFleet, 2014; VanFleet
& Guerney, 2003). Based on a psychoeducational model, FT empowers fam-
ilies in direct ways. The therapist trains and supervises parents as they learn
to conduct one-­to-­one nondirective play sessions with their own children. As
parents develop competence in the four play sessions’ skills of structuring,
empathic listening, child-­centered imaginary play, and limit-­setting, they begin
to understand more clearly the meaning of their children’s play themes, from the
children’s points of view. This allows them to deepen their empathy and demon-
strate fuller understanding of their children’s dilemmas, worries, and problems,
as well as their hopes, desires, and dreams. FT has been shown through contin-
uous research on the Guerneys’ family model as well as several derivative pro-
grams to be effective in ameliorating children’s problems while strengthening
the family (Bratton, Ray, Rhine, & Jones, 2005; Guerney & Ryan, 2013; Van-
Fleet, 2014). It has also been shown in controlled research that the most dysreg-
ulated children and most dysregulated parents show the greatest gains with FT
(Topham, Wampler, Titus, & Rolling, 2011).
FT is based on an elegant integration of multiple theories. It includes psycho-
dynamic, humanistic, behavioral, interpersonal, cognitive, developmental/attach-
ment, and family systems perspectives and applications. Its core values include
genuineness, empathy, relationship, empowerment, collaboration, humility, and
playfulness, among others (VanFleet, 2014). Its reliance on nondirective parent-­
child play sessions makes it particularly well suited for children ages 3 to 12
years, but it can be adapted for adolescents as well. Ideally, all children in the
family are involved.
The therapist typically trains parents how to conduct the play sessions in three
training sessions, and then observes five or six sessions in person. Each training
126 Chapter 9

activity and each play session is followed by the therapist going through a collab-
orative feedback process with the parent in which they cover the things that the
parent has done well followed by just one or two things to work to improve the
next time. As parents gain skills, additional discussion about the play themes and
parent reactions are included. Parents typically can become very skilled in these
play sessions.
When the parents are competent in conducting the play sessions, they are
moved to the home setting. The parent conducts the sessions on their own and
then meets with the therapist to discuss what went well, what presented problems,
the primary play themes, and parent feelings about the sessions and the play. All
of this is processed with parents in an empathic, supportive manner while moni-
toring the child’s progress. FT focuses not only on empowering the child through
the play sessions, but on building self-­efficacy in the parents through this collab-
orative process.
Because FT is a process-­oriented, relationship-­centered approach, it has many
complexities that are sometimes overlooked by those unfamiliar with it. These
subtleties are critical so that the parents feel understood and supported, just as
the FT process helps them become more empathic and supportive of their chil-
dren. Limits are used sparingly during the play sessions but are important in rees-
tablishing parental authority in some cases. Problems typically begin to show
resolution within four to six sessions, and this in turn increases parental moti-
vation to continue. Near the end of the FT process when parents are conducting
weekly half-­hour play sessions with each of their children, the therapist helps
them generalize what they have learned to daily life. By this time, the parents are
quite skilled, and this generalization to the more complex realm of daily life is
done with relative ease.
FT can be used in conjunction with other forms of play therapy or behavioral
intervention, depending on the nature and severity of presenting issues. It is a
flexible approach that has been used successfully in many countries and cultures,
in large part because family is so important to human existence everywhere, and
play is universal in children.
I have trained countless professionals throughout the world to conduct FT.
Within North America, this has included more than 90 indigenous American/
Inuit professionals representing approximately 20 different tribal affiliations. I
have been invited repeatedly by several native organizations to offer FT to indig-
enous professionals and paraprofessionals through the years. Many have noted
the compatibility of the approach with their cultural values. Frequently, during
professional training sessions, when I showed a listing of the FT values next to
documents detailing tribal and cultural values, participants’ suspicions of yet
another intervention ill-­suited to tribal social values dissipated. During one such
workshop, all the participants asked for copies of both documents and later con-
firmed that their experiences with FT bore out the harmony of the method with
their families. Glover (1996, 2003), who applied and researched a variation of FT
 Family Stress 127

with Native American parents on the Flathead Reservations in Montana, noted

the empowerment of parents as the change agents for their own children and
the FT emphasis on parent-­child relationship over individual child problems as
aligned with indigenous American parenting values.

Case Study
Case Conceptualization
Using Bronfenbrenner’s Ecological Systems Theory, Kallik and his family had
experienced trauma and pressure from virtually all of the system levels within
which they were embedded. Within the microsystem of the immediate family,
they had experienced the unexpected and traumatic death of Kallik’s father and
the suicide attempt by his sister. Kallik had struggled in school, and his mother
was at a loss as to how to reach and help him. The teacher meetings suggested
that no one knew how to help Kallik, and they seemed to expect Kanani to “fix”
the problem. Kallik also had few opportunities to make new friends.
On the mesosystem level, because of their relocation, Kanani had good sup-
port from her sister and family, but she felt displaced from the village she had
lived in her entire life and disconnected from her culture. The indirect influences
on Kallik included Kanani’s job, which was low paying while her expenses had
mounted, and she was away from home longer due to having to commute to it. On
the exosystem level, Kanani was unsure of the impact of social media on both her
children, and she worried they could come under bad influences because she was
not there to monitor them. The economic pressures only compounded the stress
Kanani felt and added to her feelings of helplessness. Within the macrosystem, she
said she felt like she was in a totally different country where she did not understand
what was expected of her. She also had experienced occasional overt racist remarks
when in the vicinity of her work. Although she tried to provide love and care for
her children, she felt inadequate to the task when immersed in such a different
environment.

Treatment Goals
The treatment goals were set after an individual meeting between Kanani and
me followed by a family play observation, one of the assessment methods used
in FT. I also conducted a nondirective play session demonstration with Kallik
that Kanani observed, and she and I discussed it afterward. I then held another
meeting with Kanani individually so we could discuss all questions she had, the
play session she had observed, and my recommendation of Filial Therapy as
the primary intervention. I recommended FT because of its alignment with the
family’s cultural values, as Kanani readily recognized, and its potential to build
family empowerment, not only for the children, but also for Kanani. Because
Kanani’s sister was an important support, and their traditional values empha-
sized extended family and community, I asked if Kanani would like her sister
128 Chapter 9

to participate as well, and we could have all the children in the two families
participate in the FT play sessions. Kanani quickly accepted this idea, and her
sister was immediately accepting of it as well. For the sake of brevity, this chap-
ter focuses only on the FT sessions held with Kanani and Kallik, but both entire
families were involved eventually in the one-­to-­one parent-­child play sessions
and discussions with me.
Goals were developed through a collaborative process with Kanani, and later
with Kallik and his sister. Kanani had clearly stated her goals from the start, so
they were discussed in more detail, and plans to meet them were set in place. For
Kallik, goals were to help Kallik overcome his discomfort of going to school,
and for him to participate in some neighborhood events and play with his cous-
ins, in hopes that this would facilitate his making new friends. Goals for Kanani
included learning the FT skills and applying them in her play sessions with Kallik,
and her modified FT sessions with her daughter. Family goals were to strengthen
all their relationships, help them all feel understood, foster their adjustment to
their new life, and find ways to have fun together. Kanani also wanted to find
opportunities through which she and her children could engage in traditional cul-
tural rituals, practices, and games.

FT Treatment Process

Beginning Training Sessions

Filial Therapy was implemented in the usual sequence. After the play session
demonstration that I held with Kallik, we moved into the parent training phase.
This entailed three sessions with Kanani and her sister. I discussed the four skills
of structuring, empathic listening, child-­centered imaginary play, and limit-­setting
and gave examples of them drawn from the prior play demonstration. I then
asked Kanani and her sister to take turns practicing the empathic listening skill
with me playing the part of a child playing by myself. I stopped periodically to
give them positive feedback and immediately returned to my child role. At the
end, I went through the usual FT feedback process to tell each parent what they
had done well and making suggestions for one or two things to work on. This
first training session was followed by two more in which I helped them practice
all four skills in mock play sessions. Once again, I pretended to be a child and
played in ways that allowed each parent to individually practice all the skills.
Once again, I gave quick ongoing feedback in the midst of this play and more
dedicated feedback at the end of it. As is usually the case, I injected some humor
into the play, which helped ease the performance pressure that parents sometimes
feel. Kanani laughed during her practice sessions, but she caught onto the skills
quickly, as did her sister. They both commented at the end of the mock play ses-
sions that the nondirective nature of the play fit their cultural parenting beliefs
and practices very well. They commented that they could see how it allowed the
child (me) to open up more.
 Family Stress 129

TABLE 9.1. KANANI: TRANSCRIPT/ANALYSIS

Transcript Analysis
FT: “Now I’ll pretend to be the child, and Kanani, Naming the specific skill before role-­playing is
you can focus on empathic listening and child-­ less overwhelming for Kanani and helps parents
centered imaginary play.” develop that specific skill.
K: “Okay. I think I remember what you taught us. I Kanani’s hesitation and embarrassment are
will feel embarrassed, but I’ll try.” common when beginning.
FT: “You’re a little anxious about it but willing to Genuine empathic listening of Kanani’s feelings
give it a try. You have more wisdom than you helps her feel understood, and identification of her
think. Everyone is nervous at first. My role is to be strengths and reassurance of support facilitate
supportive and kind to you.” trust in the FT and process.
[Pretending to be child]: “Mom, this stuff is stupid.
I don’t know what to do.”
K: “Well, just try.” This response shows Kanani’s commitment to the
FT process, although she missed the feeling and
child-­centered imaginary play.
FT: “Watch my face and see if you can tell how I It is important to set parents up for success. This
am feeling. Then tell me what that is. Let’s try that process of modeling possible child reactions
again.” [Exaggerating facial expression this time] “I and exaggerating facial expressions and tone of
don’t want to do this stuff—it’s stupid.” [Turning to voice as needed help parents develop skills more
Kanani] “What am I feeling?” naturally. Giving Kanani an opportunity to say
[FT pauses while Kanani tries, then adds], “That’s a more accurate response strengthens parent
terrific—you got that I was unhappy about it.” confidence. Reinforcing her attempts while gently
shaping them builds parents’ motivation and
enjoyment of the process.
FT: [Later in the roleplay, using puppets] “I am a FT clearly explains the roles at the start of this
hungry polar bear. You are a little seal.” imaginary play skill practice.
K: [Holding the seal puppet] “Oh, no! A polar bear! Kanani demonstrates the imaginary play skills and
I have to find a place to hide from the bear!” FT follows the “child’s” lead well. Kanani’s accurate
smiles, quickly says, “That’s it!” [and continues responses and the FT’s positive feedback increase
with the role-­play]. her confidence.

During my initial play session with Kallik, he had played without speaking
with me, and Kanani had seen how I had responded by never requiring him to
speak. While I fully expected that Kallik would eventually talk more with his
mother than he had with me, I prepared Kanani in our next mock session how
to respond if he remained quiet, but also how to handle various limits and other
challenging situations.
We also discussed what play items might make the playroom more culturally
familiar to Kallik. I already had some items from my many trips to Alaska, such
as bears, moose, and caribou, as well as two authentic Alaska native-­made yo-­
yos (igruuraak, Inupiaq), sometimes called Eskimo yo-­yos, that I had purchased
from the Alaska Native Hospital gift shop in Anchorage. Kanani suggested add-
ing a few more drums, some sled dogs and a sled, snow machines, a kayak, a
seal, whales, some white material that could represent snow, traditional hunting
implements, and traditional clothing items. I acquired those items and included
them in the playroom for all future sessions.
130 Chapter 9

Office-­Based Parent-­Child Play Sessions

After the three training sessions with Kanani and her sister, we were ready to
begin their nondirective parent-­child play sessions with their children, one at a
time. With Kanani’s daughter, we decided to wait to involve her in some special
times after we got started with Kallik. She was already receiving therapy, so a
short delay did not seem to be problematic.
Kanani held her first play session with Kallik the following week. He had
played during the play session demo but had not spoken, and often he had turned
his back on me. I had reflected that he didn’t want me to see what he was doing,
and he nodded very slightly. When I could see what he was doing, I made sure
my empathic listening responses were short and worded in my own way so he
would not feel as if I was intruding. He mostly had explored the various toys
in the room, picking them up, looking at them, and in a few cases seeing how
they worked. When he had his first parent-­child play session with Kanani, he was
immediately more animated, showed his mother some of the items in the play-
room, and quietly spoke to her. He continued exploratory play and pulled out
more toys to look at or use for a short while. Kanani held a skilled first session,
remaining in empathic listening mode as he explored and showed her items. He
did not engage in any imaginary play, nor did he break any limits. During my
feedback session alone with Kanani afterward, she commented that it had felt
good to her to see how he wanted to show her items of interest to him and that
she had found it easier to show empathy than she had expected. We briefly dis-
cussed his play themes, and I explained that exploratory play is very common in
the early play sessions. They were off to a good start.
In the next session, Kallik’s play shifted from exploratory play to a lon-
ger focus on the animal figures in the room. He positioned together a group of
animals consisting of deer, caribou, elephants, and moose. A second grouping
included a lion, a bear, and a rhinoceros. He played briefly and intensely as the
first group moved around the playroom while the second group followed them
around, yelled at them, and told them they should fight. This play shifted sud-
denly to quieter play where he ran his fingers through the sand and made some
tracks in it. He told his mother that this was the very long road to danger. Kanani
followed his lead most of the time, and my feedback was overwhelmingly posi-
tive and specific. I suggested that she watch a bit more for Kallik’s feelings, or the
feelings of his characters, and to reflect them. I gave her examples of this: “That
group is saying some unkind things to the first group. . . . It looks like the first
group is moving around a lot and aren’t sure how to get away from the other
ones.” Or “You’ve put a road in the sand, and it goes to a risky place. . . . A road
to danger. It’s hard to find a safe place.” When talking about possible play themes,
I asked Kanani what she thought. She suggested that maybe this all had some-
thing to do with their move and the bullying he had experienced. I confirmed that
that was a possibility and added that it seemed he was dealing with perceived
or real threats and danger. I explained to her that she should not ask him about
 Family Stress 131

this part of his play at home as he would likely reveal more to us in subsequent
sessions.
Indeed, that is what happened. In the next two sessions that I observed
directly, he continued this theme, although it took different forms, sometimes in
the sand tray, sometimes with puppets, and sometimes with the animal groups.
The animal groups engaged in battles with each other, and usually the “bully
animals” prevailed. Kanani’s skills grew rapidly as she reflected more of the char-
acters’ feelings, narrated the battles, and followed his play beautifully.
His play during his fifth filial play session took another turn. He pulled out
one of my conga drums and sat on the floor and tapped it. He found another
drum and asked his mother to join him. She followed his lead with the rhythms
without being asked, but it appeared that that was precisely what he had intended.
He gathered his animal groups once again and then whispered something to the
“vulnerable” group. Kanani told me later he had said they needed better ways
to protect themselves. He then moved back and forth between the animals and
playing some rhythms on the drums. Once again, he asked Kanani to join him. At
this point, he asked Kanani to keep playing the drums, and he gathered the ani-
mal group that had been bullied and moved around the playroom while he made
dancing movements with them in his hands. During the next battle, the bullied
animals scared off the bully animals by telling the drummer (Kanani) to drum
very loud and fast. The bully animals ran away in fear.
For the first time, Kallik laughed aloud. Kanani commented, “Oooh, that felt
good to see how those bullies were so afraid.” As the play continued, she had
other excellent empathic listening responses that were very accurate, such as,
“Those animals don’t have to be afraid anymore. They know they are strong! The
bullies were full of hot air.” Kanani had been very skilled throughout the session,
and she immediately noted the themes when I asked her impressions. She saw
that the threat theme had morphed into one of power and mastery over the bul-
lies. She also commented on the drumming and how Kallik had once heard some
well-­known and impressive high school drummers in a program at the Alaska
Native Heritage Center in Anchorage.
We decided to hold one more play session in my presence before she would
transfer the play sessions to home. Before we headed into the sixth play session,
Kanani asked to talk with me privately. She excitedly told me that Kallik seemed
to be doing much better at school and had proudly walked away from one of the
other students who had called him names in the past. He had begun talking more
at home, seemed more relaxed, and smiled much more frequently. He had also
asked his mother if they could get some drums so that he and his cousins could
play with them together. There had been other reparative play themes besides the
ones mentioned here, but after just five filial play sessions, he had made notable
improvements at home. During the sixth session, Kallik involved his mother in
nearly everything and used the human figures to create a family in front of the
dollhouse. At the end of the session, he proudly showed his mother his skills
132 Chapter 9

with the Alaska Native–­made yo-­yo and then turned to me (in the corner of the
room “doing my work” as usual) and showed me his skills. Both his mother and I
reflected how proud he was of his ability to use them.

Home-­Based Parent-­Child Play Sessions

From this point on, Kanani held the play sessions at home with Kallik and
reported to me or showed me portions of videos she had taken. We continued to
discuss his play themes, her pleasure in seeing his confidence and interest in life
return, and her enjoyment in holding the sessions. She was surprised that he had
made progress so quickly, but I reminded her that it was because of her relation-
ship with him that he could feel safe so quickly and because of her empathy that
he could reveal and play through the issues that had been bothering him.
When Kanani and I met to discuss his home sessions, we also began work on
her generalizing her skills to the rest of their daily lives. She excelled at the skills
by now, so this was an easy process. We also began thinking about activities that
they could do together to help Kallik learn about and identify with his cultural
heritage. Kanani produced most of the ideas, and then we discussed the best ways
of implementing them. She ordered books at his reading level about their indig-
enous group affiliation; she ordered some traditional clothing items from their
home village, and Kallik asked his teacher if he could talk about life in the arctic
among his people during a show-­and-­tell time with his class. His confidence con-
tinued to grow. When his classmates heard of his Alaska Native traditions and all
he knew about survival as well as his Eskimo yo-­yo skills, they were impressed.
His mother also took him to the National Museum of the American Indian in
Washington, DC (part of the Smithsonian Institution), and he told her he would
need to come back many times. Kallik’s sister also enjoyed these outings, and
Kanani began holding special “fun times” with her individually as well.
No other interventions were necessary, and I discharged Kallik and his mother
after their fifth home play session, the fifteenth session total. Kanani and Kallik
continued to have play sessions at home, and Kallik made a much better adjust-
ment to his new life, which was sustained when I did a 4-month follow-­up call to
Kanani.

Ethical and Cultural Considerations

When facilitating FT with indigenous families, the most crucial ethical and
cultural consideration is to begin with cultural humility, which is the therapist
valuing and being a learner of the client’s culture and experience (Hook et al.,
2016). Maintaining cultural humility and a working alliance results in fewer
microaggressions toward indigenous people, particularly from nonnative and
White people (DeBlaere et al., 2023). To increase my cultural humility and cul-
tural responsiveness, prior to meeting Kanani I contacted a colleague and friend
in Alaska who had the same tribal affiliation as Kanani and asked questions to
refresh and extend my understanding. I also reviewed general information about
 Family Stress 133

mental health among Alaska Natives available at https://www​.ncbi​.nlm​.nih​.gov/

books/NBK539588/ and https://store​.samhsa​.gov/sites/default/files/sma08-4354.
pdf and reread two books I had been given when I attended a meeting in an arctic
village with the same native affiliation as Kanani’s several years before. Through-
out my sessions with the family, I asked them to let me know if I said or did
something that was not accurate or honoring of their culture. They were eager
to share their culture, history, and stories with me, and the partnership grew as a
result of this dialogue.

Conclusion
Filial Therapy was particularly useful with this family, in part because its val-
ues and practices were a good match with the traditional values and parenting/
family practices of this family. Empowerment of parents as change agents for
their own children coupled with empowerment of children through nondirective
play worked well in this case as both mother and son found their way in their
new home. Because FT honors and engages family members as individuals and
as partners, parent and family input about their own unique backgrounds and
cultural identity is incorporated easily into the process. One of the great strengths
of FT is that parents already have a relationship with their children; and even
though they might struggle, children and parents alike want to have a healthy,
secure attachment with each other. The therapist provides some guidance and
encouragement in learning the skills to create this, but the content of the sessions
belongs to the family members themselves. The flexibility of FT conducted with a
true partnership between therapist and family makes it possible to capitalize on
indigenous values and traditions in unique ways that empower and serve families
well.

Sample Case Notes

Kanani held her third play session with Kallik. She followed his lead beautifully
throughout, empathically listening when he chose to play alone and engaging in
child-­centered imaginary play when he asked her to play a role. She told me she
felt more confident with the skills and was excited to see how Kallik was express-
ing himself. She commented that storytelling was an important part of their cul-
ture and that letting Kallik lead the way allowed him to tell his own story. I
responded that I thought that was a wonderful parallel that she had noticed.
During the play session, Kallik engaged in a hunting theme. He walked around
the playroom looking for game and then shot a pop gun at an imaginary moose. He
played rather intensely, and Kanani responded with lovely empathic responses such
as, “You’re on the hunt, looking for something. . . . Oh! You just spotted a moose! . . .
Pow! You got him! That makes you very happy.” Kallik nodded as she said this
and then told her to be quiet, so she stopped saying anything as he wished. He
then enacted tracking the moose, and Kanani reflected again about his stealth
134 Chapter 9

and care in finding the moose. After he had dragged the imaginary moose across
the floor to the kitchen set, he announced, “Now we will have food for the win-
ter.” Kanani responded, “That was very hard work, but you are proud you got a
moose to feed everyone.”
Kanani and I discussed possible play themes from this, and for the first time
she asked, “He saw his father and our whole village hunting. Do you think he is
filling in for his father?” We discussed this as a possibility and decided it would
be good to monitor the development of his play themes in the next session.
The play themes seem to relate to the goals of identity and relating to his
culture, working through the loss of his father, and development of competence
and confidence through traditional skills. For Kanani, this session showed her
skill development to be at a high level as she followed this powerful play. She
also expressed how touched she was that he was finally opening up and how his
indigenous heritage was so important to him. She reported that they were talking
and playing more in general at home, and the presenting problems were lessening
as Kallik seemed to be more “himself.”
The plan is to observe two to three more play sessions to see how the play
and the relationship develop.

Resources

For Professionals
Alaska Native Tribal Health Consortium. https://www​.anthc​.org/what-­we-­do/
behavioral-­health/
Children of the First People: Fresh Voices of Alaska’s Native Kids (Children of the
Midnight Sun) by Tricia Brown (2019).
Filial Therapy: Strengthening Parent-­Child Relationships through Play (3rd ed.)
by Risë VanFleet (2014).

For Parents
A Parent’s Handbook of Filial Therapy: Building Strong Families with Play (3rd
ed.) by Risë VanFleet (2022).

Discussion Questions
1. What did you learn about working with indigenous people and Alaskan
natives that you did not know?
2. Which parts of Kallik’s play were particularly revealing or moving to you?
What impressed you about Kanani’s responses to Kallik?
3. How will you show cultural humility when working with indigenous people
and Alaskan natives?
 Family Stress 135

References
Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy
with children: A meta-­analytic review of treatment outcomes. Professional
Psychology: Research and Practice, 36(4), 376–390.
Bronfenbrenner, U. (1979). The ecology of human development. Harvard Univer-
sity Press.
DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook,
J. N., & Owen, J. (2023). Multiple microaggressions and therapy outcomes:
The indirect effects of cultural humility and working alliance with Black,
Indigenous, women of color clients. Professional Psychology: Research
and Practice, 54(2), 115–124. https://doi​ .org/10.1037/pro0000497.supp
(Supplemental)
Donovan, D. M., Thomas, L. R., Sigo, R. L. W., Price, L., Lonczak, H., Lawrence,
N., Ahvakana, K., Austin, L., Lawrence, A., Price, J., Purser, A., & Bagley, L.
(2015). Healing of the canoe: Preliminary results of a culturally tailored inter-
vention to prevent substance abuse and promote tribal identity for native youth
in two Pacific Northwest tribes. American Indian and Alaska Native Mental
Health Research, 22(1), 42–76. https://doi.org/10.5820/aian.2201.2015.42
https://www​.ncbi​.nlm​.nih​.gov/pmc/articles/PMC4374439/
Glover, G. J. (1996). Filial Therapy with Native Americans on the Flathead Res-
ervation. [Unpublished doctoral dissertation, University of North Texas, Den-
ton, Texas.]
Glover, G. (2003). Filial therapy with Native American families. In R. VanFleet
& L. Guerney, (Eds.), Casebook of filial therapy (pp. 417–428). Professional
Resource Press.
Guerney, L. F., and Ryan, V. M. (2013). Group filial therapy: A complete guide to
teaching parents to play therapeutically with their children. Jessica Kingsley.
Hook, J. N., Farrell, J. E., Davis, D. E., DeBlaere, C., Van Tongeren, D. R., & Utsey,
S. O. (2016). Cultural humility and racial microaggressions in counseling.
Journal of Counseling Psychology, 63(3), 269–277. https://doi​.org/10.1037/
cou0000114
Rosita, W. (2010, April 2). Reconstructing sovereignty in Alaska. Cultural Survival.
www​.culturalsurvival​.org/publications/​cultural​-­survival-­quarterly/constructing​
-­sovereignty-­alaska
SAMHSA (2009). American Indian and Alaska Native culture card: A guide to
build cultural awareness. https://store​.samhsa​.gov/sites/default/files/sma08​
-4354.pdf
Stringer, H. (2018). The healing power of heritage. Monitor on Psychology, 49(2).
https://www​.apa​.org/monitor/2018/02/cover​-­healing-­heritage
Topham, G. L., & VanFleet, R. (2011). Filial therapy: A structured and straight-
forward approach to including young children in family therapy. Australian
and New Zealand Journal of Family Therapy, 32(2), 144–158.
136 Chapter 9

Topham, G. L., Wampler, K. S., Titus, G., & Rolling, E. (2011). Predicting parent
and child outcomes of a filial therapy program. International Journal of Play
Therapy, 20(2), 79–93. https://doi.org/10​.1037/a0023261
VanFleet, R. (1985). Mothers’ perceptions of their families’ needs when one of
their children has diabetes mellitus: A developmental perspective. [Unpub-
lished doctoral dissertation, Pennsylvania State University, University Park,
Pennsylvania.]
VanFleet, R. (2014). Filial therapy: Strengthening parent-­ child relationships
through play (3rd ed.). Professional Resource Press.
VanFleet, R. (2022). A parent’s handbook of filial therapy: Building strong fami-
lies with play (3rd ed.). Play Therapy Press.
VanFleet, R., & Guerney, L. (2003). Casebook of filial therapy. Play Therapy
Press.
 CHAPT E R 1 0

Divorced Parents
Child-­Parent Relationship Therapy
with Parents of a White Child
Dalena Dillman Taylor and Caitlin Frawley

Elijah is a 7-year-­old, White, cisgender boy who lives with his mother, Jessica. Eli-
jah’s father, Edward, lives nearby in a studio apartment with a new girlfriend. Elijah’s
parents, Jessica and Edward, divorced in July 2022 after a 10-year marriage. Jes-
sica reported that she and Edward divorced last year because of intense conflict
resulting from her occupation as an emergency room nurse during the COVID-19
pandemic. During the pandemic, Jessica was called to work long hours and often
needed to isolate from extended family because of her frequent COVID exposures
during this time. Edward, an auto mechanic, reported feeling lonely and isolated
from the world because of Jessica’s occupation as an emergency room nurse.
The resulting tension and constant arguments precipitated their divorce. Jessica
explained that she is seeking counseling for Elijah because of recent changes in his
behaviors at home, including frequent outbursts, rule breaking, and hitting. Also,
Elijah is having a difficult time adjusting to his new routine because of a shared
custody agreement (split week between mother’s and father’s apartments). Elijah’s
father, Edward, also wants to be involved in Elijah’s mental health treatment and is
willing to meet with the counselor as needed.

For this case study, consider:

1. What are some common problems among children experiencing divorce and
their reactions to new routines?
2. How did Elijah’s caregivers’ careers impact his experiences during the
COVID-19 pandemic?
3. What is the rationale for using Child-­Parent Relationship Therapy (CPRT)
with Elijah’s parents?
4. What are some unique ethical and legal issues that must be considered while
working with Elijah and his caregivers?

137
138 Chapter 10

Impact of Divorce on Children

Divorce is a serious concern for mental health professionals working with chil-
dren and families. Of the 331.4 million individuals living in the United States,
children under the age of 18 represent 25% or 73.1 million of these individuals
(Ogunuole, Rabe, Roberts, & Caplan, 2021). In the past decade, the number of
children living solely with their mother has doubled. Whereas 1% of children live
with their father only, 12% of children under the age of 18 live with their mother
only (Hemez & Washington, 2021).
The divorce of parents likely impacts children and their behaviors in negative
ways, including children having more difficulty paying attention and feeling over-
whelmed when compared to peers (Nusinovici et al., 2018). Children tend to be
at higher risk for behavioral difficulties even up to one year prior to the divorce of
their parents (Strohschein, 2005). These difficulties tend to include externalizing
problems (Sillekens & Notten, 2020; Tullius, De Kroon, Almansa, & Reijneveld,
2022), such as disruptive conduct (Amato, 2001), aggressive and rule-­breaking
behavior (Lansford et al., 2006), and delinquency (Tullius et al., 2022). Children
of divorce may also display increased internalizing problems such as anxiety and
depression (Bannon, Barle, Mennella, & O’Leary, 2018) and emotional malad-
justment (Harland et al., 2002). However, researchers have noted that children
did not seem to display cognitive difficulties if the divorce/separation occurred
within the first three years of life (Nusinovici et al., 2018). Yet, the implications of
divorce can have long-­term effects on children that persist into adulthood, such
as risk of increased internalizing problems (D’Onofrio, Emery, Maes, Silberg, &
Eaves, 2007), lower educational attainment, higher marital disagreements, and
poorer parental relationships (Amato & Cheadle, 2005). Timing of the parental
divorce can impact outcomes of the children: preteens and teenagers appeared
to be at higher risks for antisocial behaviors (Strohschein, 2005) and academic
problems (Lansford et al., 2006).

Child-­Parent Relationship Therapy

The origins of Child-­Parent Relationship Therapy (Landreth & Bratton, 2020)
began in 1964 when Bernard and Louise Guerney introduced Filial Therapy, a
child mental health intervention that involved training parents to conduct play
therapy sessions with their children. Guerney (2000) described a key rationale for
the development of filial therapy: children’s mental health and behavioral prob-
lems are “not the product of pathology of the parent but rather lack of parenting
knowledge and skill” (p. 2). That is, caregivers receive several messages about
“correct parenting,” and sometimes, these messages are not developmentally or
relationally appropriate. However, caregivers can learn to become therapeutic
change agents for their children through holding special playtimes (in an inten-
tional and specific manner) and becoming more attuned, sensitive, and responsive
to their children’s inner worlds.
 Divorced Parents 139

The caregiver-­child relationship is the child’s most important and cherished

bond—therefore, experiencing unearned acceptance, understanding, and atten-
tion from a caregiver (rather than a therapist) can be far more therapeutic for a
child (Bratton, Ray, Rhine, & Jones, 2005; Guerney, 2000). Therefore, Filial Ther-
apy is constructed to help parents gain more confidence in their parenting skills,
understand their children better, and build stronger parent-­child relationships
(Guerney, 2000). Filial Therapy builds upon the existing relationship between
the parent and child to positively influence the child’s adjustment to daily chal-
lenges and events (Landreth & Bratton, 2020; VanFleet, 2005). In this model,
trained play therapists teach parents how to use Child-­Centered Play Therapy
skills during special playtimes with their children.
With this grounding in the Guerneys’ Filial Therapy model, Landreth and
Bratton (2020) created the 10-session, manualized model titled Child-­ Parent
Relationship Therapy (CPRT). CPRT is designed as 10 two-­hour group caregiver-­
training sessions that caregivers attend without their child(ren) and is intended
for caregivers of children ages 3 to 10 years who may be experiencing emotional
or behavioral problems (Landreth & Bratton, 2020). A trained play therapist
facilitates the sessions by teaching the caregivers how to use Child-­Centered Play
Therapy (Landreth, 2012) skills and principles, integrating child development
knowledge, and instructing caregivers on the skills to implement in their weekly
30-minute special playtimes with their children. In addition, group leaders pro-
vide caregivers supervision and feedback on their video recorded playtimes and
encourage other parents to demonstrate support during the supervision process.
With this CPRT group process and psychoeducational approach, caregivers learn
therapeutic ways of responding to their children to improve the parent-­child rela-
tionship (Landreth & Bratton, 2020).
Landreth and Bratton (2020) identified a number of studies demonstrating
the effectiveness of CPRT with single parents (Bratton & Landreth, 1995), par-
ents from diverse cultures (Ceballos, 2009; Glover & Landreth, 2000; Jang, 2000;
Kidron, 2004; Lee & Landreth, 2003; Sheely, 2009; Villarreal, 2008; Yuen et al.,
2002), non-­offending parents of sexually abused children (Costas & Landreth,
1999), parents of children with chronic illness (Tew et al., 2002), incarcerated
parents (Harris & Landreth, 1997; Landreth & Lobaugh, 1998), parents of chil-
dren with learning difficulties (Kale & Landreth, 1999), parents of children who
have witnessed domestic violence (Smith & Landreth, 2003), and divorced par-
ents (Dillman Taylor et al., 2011). In view of these findings, CPRT appears to
be an effective treatment modality that addresses the specific needs of families
of divorce. In addition, Bratton et al.’s (2005) meta-­analysis of 93 play therapy
research studies revealed that play therapy by parents (i.e., filial therapy) had the
largest effect size of 1.15, meaning it is more effective than play therapy by pro-
fessionals and more effective than children not receiving treatment.
140 Chapter 10

Case Study Application

With this greater understanding of the impacts of divorce, medical profession-
als’ familial experiences during the pandemic, and CPRT treatment, we can
now apply these to our mental health treatment with Elijah and his family. We
selected CPRT for Elijah’s treatment because: (a) divorce-­related stress negatively
impacted the parent-­child relationship; (b) routine shifts decreased Elijah’s feel-
ings of connection and security; (c) Elijah is exhibiting new externalizing behav-
ior problems, which started post-­separation; and (d) Jessica and Edward are
experiencing high levels of parenting stress, which have direct impacts on the
quality of the parent-­child relationship (Dillman Taylor, Purswell, Lindo, Jayne,
& Fernando, 2011). We opted to use CPRT rather than individual CCPT with
Elijah because filial therapy can result in improvements within not only the child,
but also the caregiver and the overall parent-­child relationship (Bratton et al.,
2016). By using CPRT, we supported both Jessica and Edward in becoming ther-
apeutic change agents for their son, Elijah. As co-­facilitators, we worked with Jes-
sica and Edward in a group format with other caregivers for 10 weeks. Because
the caregiver-­child relationship is the primary vehicle for therapeutic change in
CPRT, we began treatment with one focus: supporting Jessica and Edward in
strengthening their relationship with Elijah. Thus, we focused on Elijah and his
caregivers’ capacities, rather than on a problem within Elijah or his family system.

Initial Intake Session

We met with Jessica and Edward for an initial intake session to gain a better
understanding of their present concerns with Elijah’s behaviors and reactions to
their divorce. We used the Intake Questionnaire for Child-­Parent Relationship
Therapy (Line & Ray, 2023) to guide the intake process. Following Line and
Ray’s (2023) recommendations, we started the CPRT intake process by providing
them with an overview of CPRT and what they could expect during the treatment
and group process. With the intention of building trust and providing Jessica and
Edward with clear expectations for treatment, we discussed our theory of thera-
peutic change, as well as expectations related to attending weekly group sessions,
facilitating 30-minute special playtimes, and recording sessions for supervision.
After the parents provided their informed consent for CPRT treatment, we
transitioned into information gathering and screening protocols. Through fol-
lowing Line and Ray’s (2023) intake questionnaire, we learned, in addition to
the information provided at the beginning of this chapter, that both Jessica and
Edward shared their dedication to working together to support Elijah’s mental
health and well-­being. Regarding mental health history, Edward reported no his-
tory of mental health diagnoses, medications, or treatments. Jessica shared that
she recently began individual therapy to process vicarious trauma and grief that
she endured as an emergency room nurse within a COVID unit.
Based on the information collected during screening, we agreed that Jessica
and Edward were appropriate candidates for CPRT treatment. Next, we gathered
 Divorced Parents 141

additional information about Elijah’s history. Elijah witnessed his parents argue
and often yell at each other during their marital distress period (roughly 1½ to 2
years). However, there was no reported history of intimate partner physical vio-
lence or domestic abuse in the household. In addition, the parents reported that
there were no previous experiences of child abuse, neglect, maltreatment, or addi-
tional adverse childhood experiences. Prior to this time, Elijah had not received
mental health diagnoses, therapy/treatments, or medication. Parents indicated
that Elijah had significant levels of externalizing problems. During the past year,
he started experiencing frequent emotional outbursts that were explosive during
times of transition (e.g., routine transition, leaving one parent’s house to go to the
other parent’s home). He had hit his mother during one of his outbursts. He has
also started “testing boundaries” and pushing back on household rules through
statements such as “mom lets me do that at her house,” despite their reported
consistent parenting practices and household rules. Jessica and Edward agreed
that they sought counseling because they want to help Elijah stay safe, as well as
experience relief from his high levels of distress.
Following the intake process, we determined that Jessica and Edward were
appropriate candidates for group CPRT with other caregivers and that Elijah’s
presenting concerns (externalizing problems) and areas of distress (divorce, fam-
ily transitions) were compatible with the goals and research-­evidence outcomes
associated with CPRT treatment. In the following sections, we describe Bratton,
Landreth, Kellam, and Blackard’s (2006) CPRT treatment manual process with
Jessica, Edward, and other caregivers in their group.

Treatment Objectives
1. Jessica, Edward, and Elijah will experience stronger parent-­child relationships
through increased feelings of trust, empathy, and connection.
2. Jessica and Edward will learn to sensitively understand and accept Elijah’s
emotional world.
3. Jessica and Edward will use Child-­ Centered skills and principles during
30-minute special playtimes.
4. Elijah will experience growth in feelings of self-­worth and self-­esteem.
5. Elijah will experience increased adaptive coping and communication capaci-
ties and decreased emotional outbursts.

Session 1
During the initial CPRT group session, we aimed to establish a safe space for
Jessica, Edward, and the other caregivers in the group so they could share their
experiences in a comfortable and nonthreatening manner. In addition, we ori-
ented them to the CPRT group and introduced the main objectives of treatment.
We provided an overview of how children communicate their inner world and
experiences through their natural language of play. During the session, Edward
asked whether he would learn some concrete methods of disciplining his son
142 Chapter 10

when he is acting out and behaving inappropriately. He further emphasized

his frustrations with the behaviors by stating, “I want to be a good dad, but I
sometimes feel like giving up when Elijah gets into one of his rage episodes . . .
I just wish I knew something to say or how to discipline him, so this stops before
getting too out of control.” We validated Edward’s frustrations and feelings of
being overwhelmed, and asked the group, “Has anyone else in the group experi-
enced frustration with their child’s behaviors this week?” Multiple group mem-
bers shared experiences and discussed similar emotional reactions. During this
session, we introduced caregivers to reflective responding skills and how reflec-
tive responding will allow the child to lead during special playtimes.

Session 2
For CPRT session 2, our objective was to help the caregivers prepare to facili-
tate their first special playtime with their children. We reviewed the “Be-­With”
Attitudes: I am here, I hear you, I understand, and I care (Landreth & Brat-
ton, 2020), and how parents may use and operationalize these principles during
their sessions. We discussed how parents will prepare for their special playtimes
through (1) gathering toys and materials for play sessions, (2) establishing a con-
sistent and predictable weekly time (e.g., Mondays at 3:30) for play sessions, (3)
choosing an appropriate and private setting to conduct play sessions each week.
Edward and Jessica discussed times that would work with their schedules on a
consistent and predictable basis that would also align with their shared custody
schedule. Jessica decided that she would facilitate special playtimes on Mondays
at 4:30 p.m., and Edward chose Wednesdays at 6 p.m. Jessica and Edward also
discussed shopping for toys together to maintain some consistency in materi-
als, because Elijah often feels frustrated when he is missing toys from the other
house.

Session 3
In session 3, we continued our work from the previous session with the objective
of preparing Edward, Jessica, and the other group members for their initial home
play session with their child this week. We covered the importance of structuring
the sessions and environment, allowing the child to take the lead during special
playtime, and provided a brief introduction to limit setting with concrete exam-
ples. We asked the caregivers to share their feelings and expectations related to
conducting their initial home play sessions, and Jessica and Edward shared sim-
ilar feelings of excitement and worry with other parents in the group. We asked
two caregivers to record their sessions the following week based on their previous
role plays (i.e., chose two parents who showed greatest potential for success and
openness to receiving feedback).
 Divorced Parents 143

Session 4
During session 4, we focused on checking in with group members about their
experiences conducting the initial special playtimes with their children. We
ensured that we had enough time to discuss their experiences, review previous
skills, and review recordings for the first time. As parents shared their experiences
during the initial home play sessions, we encouraged their efforts, validated and
normalized reactions, and reflected their feelings. Edward shared that he really
enjoyed his playtime with Elijah but asked a few questions by accident. We nor-
malized his use of questions during this initial session by emphasizing the fact
that they are learning a new language and way of being with their child. Edward
shared that Elijah invited him to play with musical instruments together, and how
he felt very connected with Elijah during this play. Jessica shared that she felt
some jealousy as Edward discussed his playtime and disappointment that Elijah
did not invite her to join in his play. Another caregiver in the group, Tom, let out
a sigh of relief, and shared, “I’m glad I’m not the only one . . . when Kate (Tom’s
wife) played with Jacob, they were doing all kinds of fun things together, and it
made me think—she should just do two sessions per week instead of me doing
one.” Jessica thanked Tom for sharing his experience, and we encouraged Jessi-
ca’s and Tom’s vulnerability in group while pointing out what they did well (e.g.,

TABLE 10.1 JESSICA AND EDWARD: SESSION 4

Transcript Analysis
J: “Well, I do feel a little embarrassed to show this Many caregivers experience an incongruence
video. I’m used to getting everything right at work, between their ideal self as a “perfect parent” and
and I know I didn’t here.” their experience as a beginner in the new CPRT
skill set.
T: “How many other of you may feel the same As the CPRT group leaders, we provided
thing? Yes, this is a common feeling. Let me normalization through group member validation as
reassure you that we all want to be supportive well as reassurance for all.
and encouraging to you.”
E: “Wow. A new bowling set.” Elijah is excited about the new toys.
J: “Yup. It is new.” Jessica was engaged but missed an opportunity
to reflect feelings.
T: “Let’s pause the video here and start with We start with positives and encouragement. Then
positive feedback for Jessica. Someone state we give a prompt by naming the skill that needed
what she did well.” . . . to be demonstrated.
[Tom said, “Your toes followed your nose, and
you were engaged with him.”] “Yes, I noticed that,
too. Jessica your nonverbals really showed your
interest. Now, let’s think about how you would
reflect a feeling here.”
J: “I could have said, ‘You are excited about the Jessica self-­corrects, indicating her understanding
new bowling set.’” of the skill.
T: “Yes, you got it! Now, I’ll rewind the tape, pause Inviting the parent to say it gives her the
it right after he says that, and ask you to say your opportunity to practice the skill. It also gives the
new response as if you were in the session with CPRT leader an opportunity for further guidance
him now.” on matching the child’s affect.
144 Chapter 10

allowing the child to take the lead, not inserting themselves into their child’s play,
using reflective responses). When it came time for selecting a participant for video
recording this week, Jessica volunteered because she desired the group’s feedback
and support.

Session 5
We facilitated session 5 with similar objectives as the previous session by pro-
viding support and encouragement as parents continue conducting play sessions.
Jessica shared her video recording of her week’s play session with Elijah, and we
worked to point out what Jessica was doing well during her session, such as her
use of reflections of feeling. After pausing the recording, we asked Jessica what
she felt most proud of during this session. Jessica shared that she was happy to
see her use of reflections and reductions in questions. Also, Jessica shared that she
felt more connected and sensitive to Elijah’s experiences during this session. She
shared that she felt happy when Elijah invited her to play with the musical instru-
ments; however, she also discussed her acceptance of Elijah when he decided he
wanted to move on and play more independently.
After reviewing tapes, we reviewed limit-­setting procedures to be used during
play sessions. We demonstrated limit setting for the parents (along with other
skills) and invited the group members to practice limit setting and reflecting
together in role-­plays. Edward expressed that he was unsure that this method
would work with Elijah, especially if he gets upset or distressed during the ses-
sion. We validated his worries and asked if other group members shared simi-
lar concerns about scenarios that are specific to their child. Jessica encouraged
Edward to “give it a try” and disclosed that she is similarly nervous about trying
out this new way of limit setting.

Session 6
We began session 6 by inviting informal sharing among the caregivers and dis-
cussing their experiences during this week’s play sessions with their children.
Edward shared that he needed to use limit setting during this week’s session
because Elijah desired to continue his special playtime. Edward shared that he
used the A-­C-T (i.e., Acknowledge the feeling, Communicate the limit, and Target
an alternative) limit-­setting approach but stumbled at first because he was avoid-
ing toys being thrown. However, Edward continued setting the limit, and even-
tually, Elijah was able to transition from the play session. Edward expressed that
he was surprised that it worked, but he wanted to “give it his best shot and stick
with it” based on Jessica’s words of encouragement during last week’s session.
After reviewing group members’ session recordings, we transitioned to discussing
age-­appropriate choice-­giving practices that provide children with opportunities
to make positive decisions. The parents practiced choice giving in role-­play exer-
cises, and Edward volunteered to share his recording during next week’s session.
 Divorced Parents 145

Session 7
Session 7 began similarly to the previous week, with caregivers sharing their expe-
riences with parenting and facilitating play sessions during the week. When it
came time for the supervision component, Edward shared his recording from his
special playtime with Elijah. We noted his use of appropriate limit setting, as well
as his use of reflective responses and overall connection with Elijah throughout
the session. Edward shared, “setting the limit felt easier this time. . . . The small
success last week gave me the confidence to continue setting limits and worry less
about Elijah doing the wrong thing or not listening. . . . I trust myself more, and I
trust Elijah, too.”
After discussing others’ sessions and providing video feedback, we transi-
tioned into a discussion about self-­esteem building responses that parents can use
during their play sessions. As we did with the other skills, we demonstrated self-­
esteem building for the parents to observe. Next, we invited parents to get into
role-­play pairs and practice self-­esteem building responses with each other.

TABLE 10.2. JESSICA AND EDWARD: SESSION 7

Transcript Analysis
Ed: “In the first part of my video, I messed up the Edward demonstrated understanding of A-­C-T
limit setting.” and acceptance of his own mistake. This
realization can promote empathy for his son.
T: “You already know how you want to improve. CPRT leader encourages him and increases his
You are also accepting of your mistakes, which awareness of his own change with potential for
is encouraging because it helps you increase change in his relationship with his son by showing
empathy of Elijah’s mistakes throughout the empathy when his son makes mistakes.
week.” [Turns on video]
El: “Watch out, Dad. I’m going to shoot you right Although he says it in a playful way, he still
between the eyes.” challenges dad to set a limit. Elijah’s play themes
of aggression and power illustrate his attempt to
gain self-­control of his own power.
Ed: “Don’t shoot me. You can choose to shoot Self-­awareness and self-­correction reveal his
the bop bag.” [Ed responds to watching this part learning of the A-­C-T skill.
and says], “See, I forgot the A and messed up the
C.”
T: “You’re teaching yourself just like Elijah will Makes a connection between dad’s own learning
eventually teach himself. I’ll back up the tape and process and his son’s learning process to extend
pause it so you can say it how you wanted.” empathy.
Ed: “Elijah, I know you are being playful and want Accurately says A-­C-T with confidence and pride,
to shoot me, but I am not for shooting. You can revealing his internal locus of evaluation and
choose to pretend the bop bag is me and shoot control.
that.”
J: “Way to go, Edward. I’m impressed.” Jessica’s trust in Edward as a parent is being
restored as she witnesses his skills.
146 Chapter 10

Session 8
For session 8, we continued providing space to discuss parenting experiences and
weekly play session experiences, as well as review videos. In terms of new group
material, we introduced encouraging skills and differentiated encouragement and
praise. We provided an overview of encouragement and how parents can pro-
mote their children’s self-­esteem and self-­direction/motivation through encourag-
ing rather than praising. Jessica and Edward both shared their tendency to praise
Elijah, and other caregivers discussed similar natural tendencies.

Session 9
During session 9, Edward and Jessica both shared that they noticed significantly
fewer outbursts during the day with Elijah. In addition, they agreed that choice
giving has been a “game changer,” and they notice that Elijah is feeling more
empowered to make positive choices with both parents. During this session, we
discussed and encouraged the use of A-­C-T limit-­setting practices outside of the
play sessions. Edward and Jessica agreed that this would be helpful for getting
on “the same page” and giving Elijah some extra consistency and predictability
during this time of change and transition. We further emphasized the power of
limit setting and how this approach to setting limits can promote safety within
the parent-­child relationship.

Session 10
For our final CPRT session, we invited the group members to think about their
own personal experiences, growth, and challenges during the previous 9 weeks.
Jessica and Edward shared that they feel more connected to Elijah, and that they
feel more connected in their co-­parenting capacities after learning these new
ways of relating with Elijah. We shared our observations of parents’ growth in
acceptance, empathy, and trust in their children during this treatment process. We
encouraged parents to continue their weekly play sessions even after the group
ended to maintain gains and their positive connection with their child.

Ethical and Cultural Considerations

Throughout the treatment process, there are several ethical obligations that we
needed to consider for Elijah, as well as Jennifer and Edward. First, we made sure
to take appropriate time to explain the CPRT treatment process with Jennifer
and Edward during our initial intake interview so they could make an informed
decision about whether to participate. In addition to reviewing the information
on the informed-­consent document, we made sure to include information related
to (a) what they may expect during CPRT group sessions, (b) time commitment,
and (c) monetary costs.
As professional counselors, we followed the American Counseling Associ-
ation (2014) Code of Ethics. Because play therapists represent professionals
 Divorced Parents 147

across mental health professions, we encourage counselors using CPRT to con-

sult their relevant ethics codes, such as the American Psychological Association
(APA, 2017) Ethical Principles of Psychologists and Code of Conduct, National
Association for Social Workers (NASW, 2021) Code of Ethics, and the American
Association for Marriage and Family Therapy (AAMFT, 2015) Code of Ethics.
Moreover, all play therapists should consult with the Play Therapy Best Prac-
tices: Clinical, Professional, and Ethical Issues document available on the APT
website (APT, 2022). During screening procedures, clinicians are ethically obli-
gated to consider whether the client(s) goals are compatible with the goals and
outcomes associated with treatment groups (ACA, 2014, A.9.a.).
During the intake session, we spent time gathering information to make
sure that Elijah’s presenting concerns (e.g., attachment-­related, externalizing
problems, high caregiver stress levels) aligned with CPRT goals (e.g., strengthen
attachment bonds) and research-­evidence outcomes (e.g., decreased externaliz-
ing problems, decreased caregiver stress). We also discussed the limits to confi-
dentiality associated with counseling/therapeutic groupwork, as well as the need
to record a session with their child and share during a group session. There are
also ethical considerations related to divorce. For example, during our initial
intake, we made sure to gather information about Edward and Jessica’s legal
rights and responsibilities and gathered documentation to ensure guardianship
rights related to treatment disclosures and consent (APT, 2022).
In our work with Elijah and his caregivers, we continually reflected on how
CPRT treatment would be appropriate for them within cultural contexts, as all
treatments are culture bound. Researchers have demonstrated that CPRT is cul-
turally adaptable and effective with racially and ethnically diverse caregivers,
including African American families (Sheely-­Moore & Bratton, 2010), Chinese
American caregivers (Yuen et al., 2002), Native American caregivers (Glover &
Landreth, 2000), and Latino/a/x families (Ceballos & Bratton, 2010). The CPRT
protocol is flexible, and facilitators can adapt the protocol to ensure that they are
delivering culturally responsive treatment. Given Jennifer and Edward’s cultural
identities as White, middle-­class caregivers, we did not identify clear cultural
adaptations that needed to be incorporated in treatment. However, familial fac-
tors played a large role in how we responded and interacted with these caregivers
(e.g., encouraging open dialogue surrounding Elijah’s behaviors at each home).
In addition, Jennifer and Edward identified as Christians during the initial
intake session. Scholars have noted congruence between Child-­Centered princi-
ples and Christian bible-­based caregiving practices, such as disciplining with love
and kindness, modeling acceptance, and promoting children’s capacities to make
healthy choices (Bornsheuer-­Boswell, Garza, & Watts, 2013). To practice cultural
humility, we did not make assumptions about the cultural fit of CPRT based
on our interview during the intake session. Instead, we sought to gain deeper
understandings and appreciations for Jennifer and Edward’s cultural identities
throughout the therapeutic treatment process.
148 Chapter 10

Conclusion
Divorce can be a challenge because of the many changes that occur within a short
period. Divorce coupled with the impact of the COVID-19 pandemic created even
more challenges for Elijah, Jennifer, and Edward. Although CPRT is an evidence-­
based intervention that would be a good fit, Jennifer and Edward still needed an
open mind and willingness to engage in the process together. This commitment
may not always be apparent or possible for divorced couples. We would encour-
age counselors to consider a parent’s potential for engagement in the process with
the other parent in the same group. Could divorced parents you work with, over
time, become more open to the CPRT process, or would individual parenting
work need to take place first?
In just over 10 weeks, Jennifer and Edward made significant strides toward
their goals for their relationship with Elijah and toward co-­parenting. Although
at times, commitment to the 10 weeks was a struggle, they persevered and found
meaning in their special playtimes with Elijah. Both reported a strengthening in
the parent-­child relationship as well as gaining tools to work together to help
Elijah during this transition. Parenting after divorce is not easy; and yet, when
parents put in time and effort in a CPRT group, parenting can be very rewarding.
These parents made the best of their situation, and Elijah benefited from their
efforts.
 Sample Case Note

TEXTBOX 10.1. CPRT PROGRESS NOTES: SESSION 1

Parent Name: Edward Case #: ____________
Location: PLAY Lab Date: 4/6/2022
___ Euthymic   ___ Depressed   ___ Angry   ___ Anxious   ___ Fearful
Mood: 
___ Agitated   ___ Apathetic   ___ Elevated   ___ Calm   ___ Cheerful
x Other: Nervous; overwhelmed
Behavior: x Cooperative   ___ Uncooperative   ___ Detached   ___ Agitated
___ Anxious   ___ Relaxed   ___ Hostile    x Open   ___ Hyperactive
___ Defensive   ___ Compulsive   ___ Other:
Participation:
Level:  x Responsive: (___ Highly  ___ Minimally)    ___ Resistant   ___ Variable
Quality: ___ Unexpected    x Supportive    x Sharing
x Attentive   ___ Intrusive ___   Monopolizing
Topics/Issues Discussed:
Introductions
Overview of CPRT training
Filial training objectives and essential concepts
Reflective responding
Goals of Session:
 x Assessment    x Psychoeducation
x Decrease symptoms of emotional outbursts
x Insight/Understanding     x Improve problem solving skills
x Develop coping/social skills    x Improve communication
x Behavior management    x Treatment compliance
Other:
Primary Intervention(s) Used: CPRT
Homework/Recommendations:
Notice some physical characteristic about your child you haven’t seen before.
 Practice reflective responding (complete Feeling Response: Homework Worksheet
and bring next week).
Practice giving a 30-second burst of attention.
Other Notes: (continue on additional page below if needed)
 Edward appeared open and vulnerable to the process as evidenced by tearing up and sharing
moments of doubt in his parenting abilities. He also appeared excited and enthusiastic about the
curriculum as evidenced by his statement that this is just what he needed and it fits with what he
was hoping for.
150 Chapter 10

Resources

For Professionals
American Association for Marriage and Family Therapy. (2015). Code of Ethics.
https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx
American Counseling Association. (2014). 2014 ACA code of ethics. https://www​
.counseling.org/docs/default-source/default-document-library/​2014​-code​-of​
-ethics​-finaladdress.pdf
American Psychological Association. (2017). Ethical Principles of Psychologists
and Code of Conduct. https://www.apa.org/ethics/code/ethics-code-2017.pdf
Association for Play Therapy. (2022). Play Therapy Best Practices: Clinical, Pro-
fessional & Ethical Issues. https://cdn.ymaws.com/www.a4pt.org/resource/
resmgr/​ publications/best_practices.pdf Bratton, S. C., & Landreth, G. L.
(2020). Child-­ parent relationship therapy (CPRT) treatment manual: An
evidence-­based 10-session filial therapy model (2nd ed.). Routledge.
Child-­Centered Play Therapy training at https://cpt​.unt​.edu/ccpt-­certification​
-­trainings
Child-­Parent Relationship Therapy training at https://cpt​.unt​.edu/child-­parent​
-­relationship-­therapy-­certification
Landreth, G. L., & Bratton, S. C. (2020). Child-­ parent relationship therapy
(CPRT): An evidence-­based 10-session filial model (2nd ed.). Routledge.
National Association of Social Workers. (2021). Code of Ethics. https://www​
.social​workers.org/About/Ethics/Code-of-Ethics
Research Evidence available at http://evidencebasedchildtherapy​ .com/research/
and https://cpt​.unt​.edu/researchpublications/meta-­analyses

For Parents
Siegel, D. J., & Hartzell, M. (2013). Parenting from the inside out: How a deeper
self-­understanding can help you raise children who thrive. Tarcher Perigee.
Siegel, D., & Payne Bryson, T. (2012). The whole-­brain child: 12 revolution-
ary strategies to nurture your child’s developing mind. Bantam Books Trade
Paperbacks.
Videos through the University of North Texas Center for Play Therapy at https://
cpt​.unt​.edu/cprt-­therapistparent-­resources

Discussion Questions
1. Prior to beginning CPRT, parents need openness, commitment, and goals that
align with the CPRT program. What other considerations would be import-
ant to ponder prior to parents/caregivers starting CPRT?
2. Based on the research presented regarding divorce and the potential long-­
term impact on children, what potential modifications may be needed to
CPRT for parents/caregivers who are not as likely to be on the same page as
Jennifer and Edward?
 Divorced Parents 151

3. In CPRT, the curricula do not address problematic behaviors/challenges

until session 9, given that the focus is on strengthening the parent-­child rela-
tionship. In what circumstances would it be necessary to pause the curric-
ula and address behaviors? Or would waiting until session 9 be okay for all
behaviors?

References
Amato, P. R. (2001). Children of divorce in the 1990s: An update of the Amato
and Keith (1991) meta-­analysis. Journal of Family Psychology, 15(3), 355–
370. doi: 10.1037/0893-3200.15.3.355
Amato, P. R., & Cheadle, J. (2005). The long reach of divorce: Divorce and child
well-­being across three generations. Journal of Marriage and Family, 67, 191–
206. doi: 10.1111/j.0022-2445.2005.00014.x
Bannon, S. M., Barle, N., Mennella, M. S., & O’Leary, K. D. (2018). Parental
conflict and college student functioning: Impact of child involvement in con-
flict. Journal of Divorce & Remarriage, 59(3), 157–174. https://doi​.org/10.10
80/10502556.2017.1402654
Bornsheuer-­Boswell, J. N., Garza, Y., & Watts, R. E. (2013). Conservative Chris-
tian parents’ perceptions of child−parent relationship therapy. International
Journal of Play Therapy, 22(3), 143.
Bratton, S. C., & Landreth, G. L. (1995). Filial therapy with single parents:
Effects on parental acceptance, empathy, and stress. International Journal of
Play Therapy, 4(1), 61–80. doi: 10.1037/h0089142
Bratton, S. C., Landreth, G. L., Kellam, T., & Blackard, S. R. (2006). Child-­parent
relationship therapy (CPRT) treatment manual: A 10-session filial therapy
model for training parents. Routledge/Taylor & Francis Group.
Bratton, S., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy
with children: A meta-­analytic review of the outcome research. Professional
Psychology: Research and Practice, 36(4), 376–390.
Ceballos, P. (2009). School-­based child parent relationship therapy (CPRT) with
low income first generation immigrant Hispanic parents: Effects on child
behavior and parent-­child relationship stress. [Doctoral dissertation, Univer-
sity of North Texas, 2008.] Dissertation Abstracts International, 69(08), A.
Ceballos, P. L., & Bratton, S. C. (2010). Empowering Latino families: Effects of a
culturally responsive intervention for low-income immigrant Latino parents
on children’s behaviors and parental stress. Psychology in the Schools, 47(8),
761–775. https://doi.org/10.1002/pits.20502
Costas, M., & Landreth, G. (1999). Filial therapy with nonoffending parents of
children who have been sexually abused. International Journal of Play Ther-
apy, 8(1), 43–66. doi: 10.1037/h0089427
Dillman Taylor, D., Purswell, K., Lindo, N., Jayne, K., & Fernando, D. (2011).
The impact of child parent relationship therapy on child behavior and parent-­
child relationships: An examination of parental divorce. International Journal
of Play Therapy, 20(3), 124–137. doi: 10.1037/a0024469
152 Chapter 10

D’Onofrio, E. T., Emery, R. E., Maes, H. H., Silberg, J., & Eaves, L. J. (2007). A
children of twins study of parental divorce and offspring psychopathology.
Journal of Child Psychology and Psychiatry, 48(7), 667–675.
Glover, G., & Landreth, G. (2000). Filial therapy with Native Americans on the
Flathead Reservation. International Journal of Play Therapy, 9(2), 57–80. doi:
10.1037/h0089436
Guerney, B., Jr. (1964). Filial therapy: Description and rationale. Journal of Con-
sulting Psychology, 28(4), 304–310. doi: 10.1037/h0041340
Guerney, L. (2000). Filial therapy into the 21st century. International Journal of
Play Therapy, 9(2), 1–17. doi: 10.1037/h0089433
Harland, P., Reijeveld, S. A., Brugman, E., Verloove-­Vanhorick, S. P., & Verhulst,
F. C. (2002). Family factors and life events as risk factors for behavioural and
emotional problems in children. European Child & Adolescent Psychiatry,
11, 176–184.
Harris, Z. L., & Landreth, G. L., (1997). Filial therapy with incarcerated moth-
ers: A five week model. International Journal of Play Therapy, 6(2), 53–73.
doi: 10.1037/h0089408
Hemez, P., & Washington, C. (2021). Percentage and number of children living
with two parents has dropped since 1968. US Census Bureau.
Jang, M. (2000). Effectiveness of filial therapy for Korean parents. International
Journal of Play Therapy, 9(2), 39–56. doi: 10.1177/0011000005283558
Kale, A. L., & Landreth, G. (1999). Filial therapy with parents of children expe-
riencing learning difficulties. International Journal of Play Therapy, 8(2),
35–56. doi: 10.1037/h0089430
Kidron, M. (2004). Filial therapy with Israeli parents. [Doctoral dissertation,
University of North Texas, 2003.] Dissertation Abstracts International, A,
64(12), 4372.
Landreth, G. L. (2012). Play therapy: The art of the relationship. Routledge.
Landreth, G. L., & Bratton, S. C. (2020). Child-­ parent relationship therapy
(CPRT): An evidence-­based 10-session filial model (2nd ed.). Routledge.
Landreth, G., & Lobaugh, A. (1998). Filial therapy with incarcerated fathers:
Effects on parental acceptance of child, parental stress, and child adjustment.
Journal of Counseling & Development, 76, 157–165.
Lansford, J. E., Malone, P. S., Castellino, D. R., Dodge, K. A., Pettit, G. S., & Bates,
J. E. (2006). Trajectories of internalizing, externalizing, and grades for children
who have and have not experienced their parents’ divorce or separation. Jour-
nal of Family Psychology, 20(2), 292–301. doi: 10.1037/0893-3200.20.2.292
Lee, M., & Landreth, G. (2003). Filial therapy with immigrant Korean parents in
the United States. International Journal of Play Therapy, 12(2), 67–85. doi:
10.1037/h0088879
Line, A. V., & Ray, D. C. (2023). Intake procedures for child–parent relationship
therapy: Moving toward an evidence-­based process. International Journal of
Play Therapy, 32(2), 79–94. https://doi​.org/10.1037/pla0000196
 Divorced Parents 153

Nusinovici, S., Olliac, B., Flamant, C., Müller, J.-B., Olivier, M., Rouger, V., Gas-
coin, G., Basset, H., Bouvard, C., Rozé, J.-C., & Hanf, M. (2018). Impact of
parental separation or divorce on school performance in preterm children: A
population-­based study. PLoS ONE, 13(9), e0202080. doi: 10.1371/journal​
.pone.0202080
Ogunwole, S. U., Rabe, M. A., Roberts, A. W., & Caplan, Z. (2021). Population
under age 18 declined last decade. US Census Bureau.
Sheely, A. (2009). School based child parent relationship therapy (CPRT) with
low income Black American parents: Effects on children’s behaviors and
parent-­child relationship stress, a pilot study. [Doctoral dissertation, Univer-
sity of North Texas, 2008.] Dissertation Abstracts International, 69(08), A.
Sheely-Moore, A. I., & Bratton, S. C. (2010). A strengths-based parenting inter-
vention with low-income African American families. Professional School
Counseling, 13(3), 175–183. https://doi.org/10.5330/PSC.n.2010-13.175
Sillekens, S., & Notten, N. (2020). Parental divorce and externalizing prob-
lem behavior in adulthood: A study on lasting individual, family and peer
risk factors for externalizing problem behavior when experiencing a paren-
tal divorce. Deviant Behavior, 41(1), 1–16. doi: 10​.1080/​01639625​.2018​
.1519131
Smith, N., & Landreth, G. (2003). Intensive filial therapy with child witnesses
of domestic violence: A comparison with individual and sibling group play
therapy. International Journal of Play Therapy, 12(1), 67–88. doi: 10.1037/
h0088872
Strohschein, L. (2005). Parental divorce and child mental health trajecto-
ries. Journal of Marriage and Family, 67, 1286–1300. doi: 10.1111/​j.1741​
-3737.2005.00217.x
Tew, K., Landreth, G., Joiner, K. D., & Solt, M. D. (2002). Filial therapy with par-
ents of chronically ill children. International Journal of Play Therapy, 11(1),
79–100. doi: 10.1037/h0088858
Tullius, J. M., De Kroon, M. L. A., Almansa, J., & Reijneveld, S. A. (2022). Ado-
lescents’ mental health problems increase after parental divorce, not before,
and persist until adulthood: A longitudinal TRAILS study. European Child
& Adolescent Psychiatry, 31(6), 969–978. doi: 10.1007/s00787-020-01715-0
VanFleet, R. (2005). Filial therapy: Strengthening the parent-­child relationship
(2nd ed.). Family Enhancement and Play Therapy Center.
Villarreal, C. E. (2008). School-­based child parent relationship therapy (CPRT)
with Hispanic parents. [Doctoral dissertation, Regent University, 2008.] Dis-
sertation Abstracts International, 69(2), A.
Yuen, T., Landreth, G., & Baggerly, J. (2002). Filial therapy with immigrant
Chinese families. International Journal of Play Therapy, 11(2), 63–90. doi:
10.1037/h0088865
PA RT I I
Adolescents
 CHAPT E R 1 1

Depression
Cognitive Behavior Therapy and Expressive Arts Therapy
with a Chinese American Adolescent
Yu-­Fen Lin and Chi-­Sing Li

Jade is a 16-year-­old Chinese American cisgender female whose family moved to

Texas from Wuhan, China, 20 years ago. Jade was born in 2006 and was raised
in Houston, Texas. In March 2020, Jade was finishing middle school and looking
forward to starting high school. However, at that time, the COVID-19 pandemic
resulted in school closures in the United States. Jade’s high school announced
that all classes would be held online. As a result, Jade did not step onto her high
school campus for an entire year and did not meet her teachers or classmates.
She did not get the chance to make new friends from school. Jade’s parents
started to feel worried and concerned about some of Jade’s behaviors. For exam-
ple, Jade isolated herself in her room, slept all the time, lost her appetite, was
not motivated to attend her online classes, and “hated” most of her teachers. At
one point, she even called the suicide hotline of her high school at 3 a.m. The
following day, her parents received a call from the school counselor about her sui-
cidal ideation. Out of desperation, Jade’s parents found a professional counselor
to help their daughter. The counseling sessions were set up as virtual sessions,
given that it was during the COVID-19 pandemic. The counselor used the client-­
centered approach, which helped to establish a working relationship with Jade
and reduce Jade’s initial stress. The counselor later had more success with Jade
and helped her overcome her depression through Cognitive Behavioral Therapy
(CBT) (Beck & Weishaar, 2018) and expressive arts therapy (Malchiodi, 2005).

For this case study, consider the following:

1. How did the pandemic crisis impact Jade’s mental health? Which characteris-
tics of Major Depressive Disorder did Jade experience?
2. Which aspects of CBT and Expressive Arts Therapy were helpful to Jade?
3. How did Jade’s cultural background, particularly the collectivist value and
Asian family values, impact the treatment approach?

157
158 Chapter 11

Depression in Adolescents
Adolescence is a significant period of change for many young people and was
termed “a period of storm and stress” by G. Stanley Hall due to frequent conflict
with parents, mood disruptions, and risk-­taking behavior (Stirrups, 2018). Typ-
ically, adolescents experience various emotions, including sadness, anxiety, and
stress. However, when these feelings persist and interfere with daily life, they may
be a sign of depression if symptoms occur for at least two weeks. Depression can
significantly impact an adolescent’s thoughts, emotions, and behavior and may
manifest in a variety of ways. Common symptoms include persistent feelings of
sadness or hopelessness, loss of interest in activities they used to enjoy, changes
in appetite or weight, difficulty sleeping or sleeping too much, fatigue or loss of
energy, difficulty concentrating or making decisions, feelings of worthlessness or
guilt, or thoughts of self-­harm or suicide (American Academy of Child and Ado-
lescent Psychiatry, 2017). If five of these symptoms occur over the same 2-week
period, a diagnosis of Major Depressive Disorder may be met (American Psychi-
atric Association, 2013).
Adolescents with depression may also experience physical symptoms such as
headaches, stomachaches, or other aches and pains (American Academy of Child
and Adolescent Psychiatry, 2017). Depression in adolescents can have severe con-
sequences if left untreated. It can impact their academic performance, relation-
ships with peers and family members, and overall quality of life. In some cases,
depression can lead to behaviors of self-­harm or suicide attempts.
Recent research suggested that Generation Z (Gen Z, born between 1997 and
2013) may be more inclined to depression than Generation X and Y (Parker &
Igielnik, 2020). This may be attributed to this generation’s heightened stressors
and demands, such as academic and career-­related pressures, economic instability,
social isolation, and the political climate. Moreover, Gen Z is the first generation
to grow up surrounded by digital communication. They spend less time in direct
face-­to-­face contact with others, which is one reason why they had the highest-­
ever generational reports of depression even prior to COVID-19 (Djafarova
& Bowes, 2021; Harari, Sela, & Bareket-­Bojmel, 2022; Saw, Aggie, & Jeung,
2021). The growing influence of social media platforms could also be a factor in
the elevated incidences of depression among Gen Z. Studies have linked social
media use to an increased risk of cyberbullying, social isolation, and negative self-­
comparisons, which can exacerbate depressive symptoms (APA, 2021; Tandoc,
Ferrucci, & Duffy, 2015). Recently, the US Surgeon General (2023) warned about
the negative impact of social media on adolescents’ mental health as follows:
• Social media may perpetuate body dissatisfaction, disordered eating behav-
iors, social comparison, and low self-­esteem, especially among adolescent
girls.
• When asked about the impact of social media on their body image: 46% of
adolescents ages 13–17 said social media makes them feel worse.
 Depression 159

• Roughly two-­thirds (64%) of adolescents are “often” or “sometimes” exposed

to hate-­based content.
• Some social media platforms show suicide- and self-­ harm-­related content
including even live depictions of self-­harm acts, content which, in certain
tragic cases, has been linked to childhood deaths.

COVID-19 and Adolescent Mental Health

The COVID-19 pandemic has significantly impacted the mental health of indi-
viduals globally, particularly Asian adolescents. Various studies have revealed an
upsurge in depression and anxiety among this demographic due to the pandemic
(Duan et al., 2020; Zhang et al., 2021). One factor that has led to an increase in
depression among Asian American adolescents is the rise of Asian hate crimes,
as Asians were blamed for the pandemic (Ramakrishnan, Wong, Lee, Sadhwani,
& Shao, 2021; Asian American Psychological Association, 2021). In addition,
the disruption of daily routines and social isolation added to adolescents’ stress.
Many had to adapt to online learning and had limited opportunities to interact
with peers and engage in extracurricular activities. Further, the pandemic brought
economic challenges for families, increasing stress levels and potentially exacer-
bating preexisting mental health conditions (Wu et al., 2021).

Asian Culture and Mental Health Stigma

The stigma surrounding mental health in some Asian cultures may also contribute
to depression among adolescents. In such cultures, seeking mental health support
can be perceived as a sign of weakness or a failure to uphold familial and socie-
tal expectations (Yee, 2021). Therefore, it is crucial to address the mental health
concerns of Asian adolescents during their times of stress. Parents and caregivers
can provide emotional support and help their children maintain structure and
routine. Schools can also provide mental health resources, including virtual coun-
seling and support groups. In addition, increasing awareness and reducing the
stigma surrounding mental health in Asian communities is essential. Promoting
open and honest conversations about mental health can help reduce barriers to
seeking treatment and support (Saw et al., 2021).

Cognitive Behavior Therapy and

Expressive Arts Therapy
Although various treatment options are available, Cognitive-­Behavioral Therapy
(CBT) (Beck & Weishaar, 2018) and Expressive Arts Therapy (Malchiodi, 2005)
have been found to be effective in treating depression in adolescents (National
Institute of Mental Health, 2017). CBT aims to help adolescents identify neg-
ative thought patterns and behaviors that contribute to depression and then
guide teens to replace the negative thoughts with more positive, realistic ones
160 Chapter 11

(Tompkins, 2018). On the other hand, Expressive Arts Therapy uses creative
processes such as art, music, dance, and drama to help individuals explore and
express their emotions in a nonverbal and creative way. This can provide an out-
let for emotions that may be difficult to express in words. It can also help adoles-
cents develop a sense of self-­awareness and self-­expression (Mealer, Cutcliffe, &
Gish, 2017).
When used together, CBT and Expressive Arts Therapy can provide a holistic
approach to treating depression in adolescents (Mavroveli & Papacharalambous,
2018). Expressive arts therapy can help adolescents become more aware of their
emotions and their physical sensations. This increased awareness can comple-
ment the cognitive strategies learned in CBT and help them develop greater self-­
awareness and emotional regulation skills. Empirical evidence has demonstrated
the efficacy of Expressive Arts Therapy in reducing depressive symptoms and
improving overall mental health in this population. For instance, Timulak and
Connelly (2012) reported that Expressive Arts Therapy was effective in reducing
depression and enhancing self-­esteem among adolescents who were experiencing
emotional difficulties. In addition, adolescents with depression may struggle with
low self-­esteem and confidence. Expressive Arts Therapy can provide them with
a sense of accomplishment and mastery, which can boost their self-­esteem and
confidence (Kaimal, Carroll-­Haskins, & Mensinger, 2016).
Expressive Arts Therapy (Malchiodi, 2005) has emerged as a potentially
effective intervention for treating depression in adolescents. By incorporating cre-
ative arts such as music, dance, drama, and visual arts, this therapeutic approach
offers a nonverbal outlet for adolescents to express themselves and process their
emotions. The effectiveness of Expressive Arts Therapy can be attributed to sev-
eral factors (Timulak & Connelly, 2012). First, the nonverbal nature of creative
arts can enable adolescents to communicate their feelings in a way that may feel
less intimidating than traditional talk therapy. Second, engaging in expressive arts
can promote a sense of accomplishment and empowerment, enhancing motiva-
tion to continue treatment and work toward recovery. Finally, the sense of own-
ership that adolescents may experience over the creative process in Expressive
Arts Therapy can provide a source of control and self-­determination.
In conclusion, Expressive Arts Therapy offers a safe and supportive envi-
ronment for adolescents to express themselves and process their emotions. Inte-
grating this with CBT can improve mental health and well-­being in adolescents.
However, further research is needed to better understand the mechanisms under-
lying Expressive Arts Therapy’s therapeutic effects and identify the specific fac-
tors contributing to its effectiveness.
 Depression 161

Case Study Application

Session 1
My (first author’s) counseling goals for the first session with Jade were to inform
her about the counseling process, develop rapport, and establish a therapeutic
alliance through compassionate listening, validation, and empathy. Being aware
of Jade’s Asian family background and culture, I tried to create a safe and trust-
ing environment so that she felt comfortable in counseling. I also allowed Jade to
take her time to open up and share herself, as she had not used counseling ser-
vices before. During our telehealth counseling session, Jade was initially unwill-
ing to show herself through the camera. Hence, I invited her to share with me a
piece of music that could represent her experience, and she did. I tuned in to her
emotions by reflecting on the sadness of the music she selected. Later, she felt
more comfortable and could share more about her anxiety and depression. Since
the COVID-19 pandemic, Jade indicated that she experienced multiple symptoms
of depression, such as sadness, irritability, crying spells, lack of concentration,
loss of appetite, and insomnia. Music seemed to be a channel for Jade to express
herself and her experience. At the end of the first session, I presented a simple
breathing exercise for her to practice, which seemed to help when she felt nega-
tive emotions.
I did not immediately set goals with Jade but gave space and time for the
process of relationship building. My immediate goal was for her to feel totally
at ease, reduce her defensiveness, and gradually trust the therapeutic process. In
addition, the breathing technique assisted her in gaining some level of control
and regulation of her emotions.

TABLE 11.1. JADE: SESSION 1

Transcript Analysis
T: “I know that this is your first counseling session. Attempt to join with the client and establish safety
So, we’ll take our time to get to know each other. and trust.
You don’t need to turn on your camera if you
don’t feel comfortable. I understand.”
J: “Okay. I don’t want to show my face. I’d rather Adolescents can sometimes be a bit cautious
just talk to you.” going into a new environment.
Therapist: “I wonder if there is a song or music I am introducing to the client a different channel of
you can share with me that illustrates where you communication through music.
are now?”
J: “This is the music I listen to almost daily.” Music seemed to open the door to the client,
[Shares a song] which surprised her.
T: “I tune in to the sadness of your music. How The client felt the support and was able to open
does this music reflect your emotions lately?” up more.
162 Chapter 11

Sessions 2 and 3
My goals for the second and third sessions were to continue encouraging Jade to
express her experience, thoughts, and emotions freely and strengthen our thera-
peutic alliance. Through deep listening and unconditional positive regard toward
her, I could assess her depression, loneliness, and sadness during the pandemic.
Jade also enjoyed painting with watercolors, which is a traditional and esteemed
Chinese art form, so part of the session was to discuss her painting and let her tell
her story. Through expressive arts and music, Jade found the medium to express
herself and gained more awareness of her thoughts, emotions, and behaviors.
During our third therapy session, some of Jade’s cognitive distortions, which
connected to her depression, were identified. Jade tended to see only the worst
possible result of any situation and overgeneralize the outcome. For example,
Jade saw her parents watching TV and enjoying each other (event); she jumped
to a conclusion that “they don’t care about me or need me” (cognitive distor-
tion); she felt neglected, left out, and unloved (emotional consequence); and she
locked herself in her room for 24 hours (behavioral consequence). Another exam-
ple is that Jade did not receive many texts from her friends in school (event);
she thought “all my friends hate me because I’m Chinese” (cognitive distortion);
she felt abandoned (emotional consequence); and she deleted phone numbers of
several friends (behavioral consequence). Based on these two experiences, Jade’s
thoughts exhibited the cognitive triad of depression that she was unlovable, her
world was falling apart, and there was no hope for her future. I offered Jade psy-
choeducation on the cognitive triangle; helped her understand that her thoughts,
emotions, and behaviors affected one another; and helped her develop balanced
thoughts of “my parents need time together, and they do spend time with me

TABLE 11.2. JADE: SESSION 3

Transcript Analysis
T: “Oh, this is beautiful! I appreciate you sharing Assisted client in communicating herself through
this water painting with me. Could you share with Expressive Arts Therapy.
me what this is about?”
J: “This is me all alone in my room. And look at She illustrated negative emotions of sadness in
what my parents and friends are doing without blue; anger in red; and helplessness in yellow.
me.” Her verbal response reveals her belief that others’
behavior must result in her isolation.
T: “Now I can see how you have been feeling Empathized with the client’s experience and
lately. Thank you for sharing with me and trusting provided immediate support and care.
me. I bet you’re feeling very lonely even now.
I want you to know I’m with you and support you.”
J: “I don’t think they [parents] love me or even Her cognitive distortion of jumping to a conclusion
care about me anymore. That is why my emotions surfaces. She believes her emotions are automatic
are so negative.” based on events.
T: “On the one hand, I can see that your emotions Mildly addressed the issue and educated the
are so real to you, and on the other hand, I’m not client on the cognitive triangle.
sure whether it’s true that your parents don’t love
you.”
 Depression 163

daily” as well as “my friends may also be feeling depressed or awkward, and I
have a choice to reach out to them.”

Case Conceptualization and Treatment Goals

Like many adolescents, Jade’s depression was influenced by the COVID-19 pan-
demic when public schools were closed in the United States. The platform of edu-
cational delivery had drastically changed from face-­to-­face to online education.
Consequently, adolescents were isolated in their homes with minimal social inter-
action. In addition, Asian Americans were blamed for the pandemic and became
the targets of many hate crimes. This seriously affected Jade, her family, and the
Asian community. The prolonged isolation kept Jade from social interaction with
friends, and later she became increasingly withdrawn even from her parents. She
had no channel to express her stress, frustration, and sadness, leading to her hav-
ing cognitive distortions and negative automatic thoughts. Thus, her overwhelm-
ing stress led to depression and mental breakdown. The call to the school hotline
was Jade’s outcry for help. Luckily, her parents responded immediately to the
crisis and supported her to seek counseling.
Based on this information and my interaction with her in the first two ses-
sions, Jade and I agreed on the treatment goals to (a) minimize depressive symp-
toms, frustration, and crying spells and (b) increase effective emotional regulation
and communication skills. Treatment objectives were as follows:
1. Assist the client in freely expressing herself to gain insight and self-­awareness
through Expressive Arts Therapy.
2. Give psychoeducation on the cognitive triangle and help the client identify
and understand the relationships of thoughts, feelings, and behaviors.
3. Replace distorted cognitive thoughts with more appropriate and positive
thoughts through CBT.
4. Develop effective coping, such as mindfulness techniques, to regulate the cli-
ent’s emotions.
5. Enhance communication skills so that the client can reestablish connections
with family members and friends.

Later Sessions
Because the third counseling session was a turning point for Jade, I continued
to encourage her to express herself through her water painting. I continued to
explain expressive arts and CBT strategies to her. As a result, she began making
connections between her depression and her lack of communication with fam-
ily and friends. With psychoeducation, she understood her cognitive distortions,
which impacted and deepened her depression. By using CBT strategies, I was able
to help strengthen her cognitive ability so that she could examine her thought
process and ultimately dispute her negative and distorted thoughts. The mindful-
ness techniques helped her regulate her emotions and lower her stress level. As a
164 Chapter 11

result, Jade was willing to practice more effective communication skills with her
parents and friends to express her needs.

Ethical and Cultural Considerations

Ethical and cultural considerations were imperative in Jade’s case for various
reasons. First, as Asian Americans, Jade and her parents were reluctant to seek
services because Asian Americans historically have viewed counseling as a West-
ern idea. For many traditional Asian Americans, focusing on emotions may cause
discomfort, shame, and embarrassment. Therefore, it was ethically essential for
me to educate Jade and her parents on the therapeutic process, which typically
requires at least 10 sessions. Doing so prevented Jade and her parents from pre-
maturely terminating counseling out of embarrassment.
Second, counselors should be mindful that most Asian Americans come to
counseling only when they are in crisis. Given Jade’s outcry of suicidal ideation, I
needed to clearly explain the limits of confidentiality, which included serious and
foreseeable harm to self, among other limits. I explained that I may need to call
the police if I believed Jade was going to seriously harm herself. I also needed to
develop a safety plan with Jade with a list of places and people to contact when
she had suicidal thoughts.
Third, because many people were blaming the COVID-19 pandemic on
Asians and Asian Americans, Asian American Pacific Islander (AAPI) hate crimes
increased rapidly. This racist dynamic contributed to mental health concerns
among many Asian Americans. Counselors need to view clients’ symptoms within
the societal context and political atmosphere rather than just individual factors.
Counselors have an ethical obligation for social advocacy such as joining ral-
lies to increase awareness of AAPI hate crimes, providing critical stress incident
debriefings for Asian churches and community centers, and communicating with
legislators about stricter laws to protect Asians.

Parent Consultations
Parent consultations in the context of Asian Americans play a significant part in
the success of therapy. The problem presented by the individual client is more
appropriately viewed as a family challenge in a collectivistic and systemic con-
text. Because the parents play a vital role in assessing and treating the problem,
regular parent consultations with the client’s consensus would be helpful. The
counselor needs to communicate with parents in a culturally responsive way and
view parents as a reliable resource for the adolescent client while protecting the
privacy of the adolescent within confidential limits.

Conclusion
Jade made incredible progress by participating in CBT and Expressive Arts Ther-
apy. After several sessions, Jade could express her inner world and gain insight
 Depression 165

and significant awareness of herself and her depression through Expressive Arts
Therapy. In addition, she identified her cognitive distortions and replaced her
negative and self-­defeating thoughts with more positive and reasonable thoughts
through Cognitive Behavioral Therapy. As her counselor, I learned that although
many Asian parents may hold biases toward counseling, many are willing to step
out of their comfort zone to access counseling to support their children, especially
in times of crisis. In addition, the fundamental therapeutic skills of empathy, con-
gruence, and nonjudgmental acceptance aided in building an effective therapeutic
alliance with Asian clients. Most importantly, I learned to be mindful of the cul-
tural background and the impact of the family system when working with Asian
clients. Integrating Expressive Arts and Cognitive Behavioral Therapy helped cre-
ate a successful outcome for Jade and her family.

Sample Case Notes

Session 1
Subjective: The client reported having anxiety and sadness as she had no social
interaction with her friends or schoolmates. She also said that she had no appetite
lately, and her energy was low. She reported that she stayed in her room most of
the time and was not motivated to even call her friends on the phone.
Objective: Initially, the client was reluctant to turn on the camera during our
telehealth counseling session. The client appeared passive and shy, only respond-
ing when the counselor asked her questions. However, after about 20 minutes of
warmup with her favorite music, the client understood the counseling process
better and could speak more.
Assessment: The client’s reluctance and shyness seemed to relate to her cultural
upbringing in an Asian family. It seemed apparent that the client experienced
some level of depression and withdrawal due to a lack of social activities and the
impact of the pandemic.
Plan: The main goal of the initial counseling process was to establish a therapeu-
tic alliance with the client and to create a safe and trusting environment for the
client to express herself freely.

Session 3
Subjective: The client expressed her perception of her relationships with her par-
ents and friends through water painting. In the painting, she positioned herself in
the dark corner of her room, crying while her parents watched TV in the living
room and her friends played happily in the playground. The client stated that she
felt isolated, abandoned, and unloved. When asked whether her parents cared for
and loved her often, the client admitted they did but said they should have played
with her instead of watching TV. She blamed her friends for not inviting her to
their gathering. However, the client did not express her needs to her parents or
friends.
166 Chapter 11

Objective: The client initially had low energy but was willing to turn on the
camera to have eye contact with the counselor. While showing the watercolor
painting of her family and friends, the client got teary and expressed some sad
emotions. The client was able to articulate more negative emotions through her
painting activity.
Assessment: The client seemed to have difficulty communicating her needs with
her parents and friends. Her depressive symptoms were associated with her cog-
nitive distortions that her parents and friends did not love and care about her as
they did not play with her. The drawing activity helped the client to recognize her
internal processing.
Plan: Introduce the cognitive triangle and educate the client on relationships
among emotions, behavior, and cognition. Encourage the client to communicate
her needs.

Resources

For Professionals
American Academy of Child & Adolescent Psychiatry AAPI Resource Library,
https://www​.aacap​.org/AACAP/Families_and_Youth/Resource_Libraries/
AAPI_Resources​.aspx
American Art Therapy Association, https://arttherapy​.org/
International Expressive Arts Therapy Association, https://www​.ieata​.org
National Asian American Pacific Islander Mental Health Association, https://
www​.naapimha​.org/
National Coalition of Creative Arts Therapies Associations, https://www​.nccata​
.org/

For Adolescents and Parents

Permission to Come Home: Reclaiming Mental Health as Asian Americans by
Jenny Wang (2022).
Stigma: Breaking the Asian American Silence on Mental Health by Tanaya Kolli-
para (2021).

Discussion Questions
1. What issues should a therapist pay attention to when working with an Asian
client, particularly after the COVID-19 pandemic?
2. As a therapist, what knowledge and understanding of the Generation Z pop-
ulation could help to build a therapeutic alliance with a Generation Z client?
3. What would be a culturally responsive way to explain Jade’s depression, CBT,
and Expressive Arts Therapy to her parents?
4. In what situation would you consider family therapy with the adolescent and
her parents?
 Depression 167

References
American Academy of Child and Adolescent Psychiatry. (2017). Depression in chil-
dren and adolescents. https://www​.aacap​.org/AACAP/Families_and​_Youth/​
Facts_for_Families/FFF-­Guide/The-­Depressed-­Child-004.aspx
American Psychiatric Association. (2013). Diagnostic and statistical man-
ual of mental disorders (5th ed.). https://doi​ .org/10.1176/appi​
.books​
.9780890425596
American Psychological Association. (2021). Stress in America™ 2020: A national
mental health crisis. https://www​.apa​.org/news/​press/releases/stress/2020/
report​-­october
Asian American Psychological Association. (2021). Written testimony from the
Asian American Psychological Association. Washington, DC. https://aapaon​
line​.org/wp-­content/uploads/​2021/03/AAPA-­Testimony-­to-­House-­Judiciary​​
-­on​-3.18.2 021​.pdf
Beck, A. T., & Weishaar, M. (2018). Cognitive therapy. In R. J. Corsini & D.
Wedding (Eds.), Current psychotherapies (11th ed., instr. ed., pp. 237–272).
Cengage.
Djafarova, E., & Bowes, T. (2021). “Instagram made me buy it”: Generation Z
impulse purchases in fashion industry. Journal of Retailing and Consumer
Services, 59. https://doi​.org/10.1016/j​​.jretconser.2020.102345
Duan, L., Shao, X., Wang, Y., Huang, Y., Miao, J., Yang, X., & Zhu, G. (2020).
An investigation of mental health status of children and adolescents in China
during the outbreak of COVID-19. Journal of Affective Disorders, 275, 112–
118. https://doi​.org/​10.1016/j​.jad.2020.06.029
Harari, T. T., Sela, Y., & Bareket-­Bojmel, L. (2022). Gen Z during the COVID-19
crisis: A comparative analysis of the differences between Gen Z and Gen X in
resilience, values and attitudes. Current Psychology. https://doi​.org/10.1007/
s12144​-022​-03501​-4
Kaimal, G., Carroll-­Haskins, K., & Mensinger, J. L. (2016). The effects of art
therapy on stress and anxiety in adolescents. Art Therapy, 33(2), 74–80.
Malchiodi, C. A. (2005). Expressive therapies: History, theory, and practice. In
C. A. Malchiodi (Ed.), Expressive therapies (pp. 1–15). Guilford Press.
Mavroveli, S., & Papacharalambous, A. (2018). Cognitive behavioral therapy
and expressive writing in the treatment of depressive symptoms among ado-
lescents. Children and Youth Services Review, 89, 276–283.
Mealer, L. L., Cutcliffe, J. R., & Gish, K. (2017). Expressive arts therapy for
adolescents with depression. Journal of Creativity in Mental Health, 12(3),
352–362.
National Institute of Mental Health. (2017). Depression in children and adoles-
cents. https://www​.nimh​.nih​.gov/health/topics/depression/index​.shtml
Parker, K., & Igielnik, R. (2020). On the cusp of adulthood and facing an uncer-
tain future: What we know about Gen Z so far. https://policycommons​.net/
168 Chapter 11

artifacts/616196/on-­the-­cusp-­of​-­adulthood-­and-­facing-­an-­uncertain-­future/1
596804/
Ramakrishnan, K., Wong, J., Lee, J., Sadhwani, S., & Shao, S. (2021). Tip of the
iceberg: Estimates of AAPI hate incidents far more extensive than reported.
AAPI Data. http://aapidata​.com/blog/tip-­iceberg-­march2021-survey/
Saw, A., Aggie, J. Y. H., & Jeung, R. (2021). Stop AAPI Hate mental health report.
https://stopaapihate​ . org/wp-­c ontent/​ u ploads/2021/05/Stop-­A API​ -­H ate
​-­Mental​-­Health-­Report​-210527.pdf
Stirrups, R. (2018). The storm and stress in the adolescent brain. Lancet Neurol-
ogy, 17(5) 404.
Tandoc, E. C., Ferrucci, P., & Duffy, M. (2015). Facebook use, envy, and depres-
sion among college students: Is Facebooking depressing? Computers in
Human Behavior, 43, 139–146.
Timulak, L., & Connelly, C. (2012). A comparison of psychotherapists’ and
expressive arts therapists’ perceptions of adolescents’ emotional difficulties
and treatment needs. Arts in Psychotherapy, 39(1), 10–17.
Tompkins, K. A. (2018). Cognitive-­behavioral therapy for depression. Journal of
Psychiatric Practice, 24(1), 12–20.
US Surgeon General. (2023). Social media and youth mental health: The U.S. Sur-
geon General Advisory. https://www​​.hhs​​.gov/​surgeongeneral/priorities/youth​
-­mental-­health/social​-­media/​index​.html
Wu, P., Fang, Y., Guan, Z., Fan, B., Kong, J., Yao, Z., & Hoven, C. W. (2021). The
psychological impact of the SARS epidemic on hospital employees in China:
Exposure, risk perception, and altruistic acceptance of risk. Canadian Journal
of Psychiatry, 48(9), 125–130.
Yee, A. (2021). COVID’s outsize impact on Asian Americans is being ignored.
­Scientific American. https://www​.scientific​american​​.com/article/covids​-­outsize​
-­impact​-­on​-­asian​-­americans​-­is​-­being​-­ignored/
Zhang, X., Yang, H., Zhang, J., Yang, M., Yuan, N., & Liu, J. (2021). Prevalence
of and risk factors for depressive and anxiety symptoms in a large sample of
Chinese adolescents in the post-­COVID-19 era. Child and Adolescent Psychi-
atry and Mental Health, 15. https://doi​.org/10.1186/s13034-021-00429-8
 CHAPT E R 1 2

Social Anxiety
Mindfulness-­Based Cognitive Behavior Therapy
with a Pakistani American Adolescent
Yu-­Fen Lin and Samuel Bore

Jasmin is a 15-year-­old Pakistani American cisgender female. Both of her par-

ents are engineers who came from Islamabad, Pakistan, to the United States in
1998 for college and are devoted Sunni Muslims. Jasmin was born in California,
attends public school, and follows some expectations of her Muslim community
and family. She wears a hijab and dresses modestly at her parents’ request but
recently became interested in wearing makeup to fit in with her school friends.
She refuses to go to school or other public places without wearing makeup
because she is self-­conscious about how she appears in front of others. As a
result, Jasmin goes to school early to put on makeup without her parents’ con-
sent and avoids going out as much as possible because she worries about how
others will perceive and judge her. Jasmin’s parents prefer for her to present her-
self with modesty, without makeup. They believe they should educate, shape,
discipline, and mold their daughter according to their Muslim teachings and that
their daughter should obey them. However, Jasmin wants to assimilate with her
peers and express herself fully, which has caused value conflicts and communi-
cation problems. She fought with her parents and stopped attending mosque,
receiving little emotional support at home. She feels unhappy, lonely, and isolated
at school, worrying about how others view her despite having a few friends. At
home, Jasmin also feels very anxious around her parents.

For this case study, consider the following:

1. What are common concerns of children experiencing social anxiety, and
what are Jasmin’s needs? To what extent does being a Muslim in a public
school impact Jasmin?
2. What is the rationale for using Mindfulness Cognitive Behavior Therapy
with Jasmin?
3. What ethical guidelines and cultural considerations need to be followed for
Jasmin?

169
170 Chapter 12

South Asian Muslim Adolescents

Pakistan is a South Asian country that is predominantly Muslim and has offi-
cial languages of Urdu and English. As of 2021, approximately 618,000 residents
of Pakistani descent were living in the United States (US Census Bureau, 2020).
Most Pakistani Americans are well educated and in the middle to upper class in
US society. After the September 11, 2001, terrorist attacks, Pakistani Americans
experienced increased incidents of discrimination due to Islamophobia (Muslim
Matters, 2017).
Muslim high school students frequently perceive themselves as similar to
their peers but navigate unique challenges such as difficulty implementing Islamic
practices (e.g., prayer) in their school day and coping with Islamophobia (Seward
& Khan, 2016). Ahmed (2012) elaborated that “Muslim adolescents . . . are often
scrutinized for fear of being the next homegrown terrorists and experience pres-
sures of Islamophobia during an already challenging developmental period” (p.
252). Muslim adolescents in the United States often experience acculturation
stress (i.e., internal and external demands from cultural adaptation and negotia-
tion that exceeds personal resources), which can lead to internalizing symptoms
such as anxiety (Goforth, Pham, Chun, Castro-­Olivo, & Yosai, 2016). Muslim
adolescent girls have been found to experience stricter parenting styles than boys
out of a desire to protect their modesty, which may contribute to their experience
of social anxiety (Peleg, Tzischinsky, & Spivak, 2021).

Social Anxiety
From a developmental perspective, social anxiety is a common mental health
issue affecting many adolescents who worry about being judged or evaluated
by others. Adolescents can experience excessive fear and self-­consciousness in
social situations, leading to avoidance and isolation. Adolescents with social anx-
iety may avoid social situations or struggle to interact with others. The DSM-5
defines social anxiety disorder (SAD) as a persistent and intense fear of social
conditions in which others may negatively evaluate the individual (American
Psychiatric Association, 2013). Adolescents with social anxiety may struggle to
identify and understand their emotions. Social anxiety in adolescents has been
linked to psychological inflexibility (Figueiredo, Alves, & Vagos, 2023), perfec-
tionism (Wang et al., 2022), social media (Barry, 2022), racial/ethnic teasing and
discrimination (Douglass, Mirpuri, English, & Yip, 2016), and parents’ exposure
to trauma (Cho, Woods-­Jaeger, & Borelli, 2021). Individuals experiencing social
anxiety need to seek support and treatment from mental health professionals,
which can significantly improve their quality of life.

Mindfulness-­Based Cognitive Behavior Therapy

Mindfulness can be defined as paying attention to the present moment (Kabat-­
Zinn, 2013). Mindfulness-­Based Cognitive Behavior Therapy (MB-­CBT) is a form
 Social Anxiety 171

of psychotherapy that combines mindfulness practices with cognitive-­behavioral

therapy techniques. This approach aims to help individuals become more aware
of their thoughts, feelings, and bodily sensations in the present moment non-
judgmentally while also addressing and challenging negative thought patterns
that contribute to social anxiety (Carlton, Sullivan-­ Toole, Strege, Ollendick,
& Richey, 2020). MB-­CBT can help adolescents become more attuned to their
thoughts and feelings, leading to greater self-­awareness and improved emotional
regulation. MB-­CBT can help adolescents identify maladaptive thinking patterns
and develop more realistic and positive perspectives, particularly by challeng-
ing negative thoughts that often trigger social anxiety (MacKenzie & Kocovski,
2016).
Mindfulness practices, such as meditation and deep breathing, can help ado-
lescents with social anxiety manage their symptoms and stay focused in the pres-
ent moment. By practicing mindfulness regularly, adolescents can develop greater
self-­compassion and acceptance, improving their overall well-­being. In addition,
MB-­CBT can provide adolescents with tools and strategies, such as assertive-
ness training and role-­playing exercises, to help them improve their social skills
(Eslami, Rabiei, Afzali, Hamidizadeh, & Masoudi, 2016).
MB-­CBT is considered a useful treatment option for Jasmin for the following
reasons. First, it can directly address symptoms of social anxiety. Second, it may
reduce the intense level of concern. Third, it is well received by anxious adoles-
cent clients who prefer a more interactive approach (Carlton et al., 2020). With
the guidance of mental health professionals trained in MB-­CBT, adolescents can
learn to manage their symptoms and build the skills they need to lead fulfilling
and meaningful lives.

Case Application
Based on the information about Pakistani American Muslim adolescents, social
anxiety, and MB-­CBT treatment approaches, we can now apply them to Jasmin.
Her desire for self-­expression and assimilation with her peers is typical for teen-
agers. According to Cognitive Behavioral Therapy (CBT), Jasmin presents with
social anxiety symptoms due to a combination of genetic, personality, and envi-
ronmental factors. Specifically, her social anxiety is exacerbated by an Islamopho-
bic environment; acculturation stress of wanting to be accepted and blend in;
social media; psychological inflexibility; genetic predisposition; and her parents’
exposure to September 11 trauma and discrimination. Currently, Jasmin’s Mus-
lim identity and school experiences play a role in her desire for self-­expression,
which conflicts with her parents’ expectations.
Triggers to Jasmin’s social anxiety include her peers’ influence to wear
makeup, which leads to her self-­consciousness and anxiety when not wearing
it. Jasmin’s conflicts with her parents over makeup and self-­expression have
created a stressful family environment, leading to anxiety and unhappiness.
Jasmin’s avoidance of going out without makeup increases her anxiety and
172 Chapter 12

self-­consciousness, compounded by her negative self-­talk and worries about how

others view her (Beck, 2011).
Jasmin’s parents brought her to counseling due to her intense and frequent
arguments with them, “disobedience,” isolation in her room when at home,
refusal to go out in public without makeup, avoidance of social situations other
than school, fear of performance at school, and irritability. Her parents did not
realize that these concerns were related to social anxiety.

Session 1
The goal for the first session with Jasmin was to develop a relationship, com-
plete an assessment, explain the MB-­CBT approach, and introduce some cop-
ing skills to help her begin to feel less anxious without fighting her anxiety but
rather learning to ride the anxiety wave. Before the session started, I (first author)
ensured that her parents had signed the parental consent in the file. After intro-
ductions, I obtained informed assent from Jasmin and discussed limits to confi-
dentiality. This was followed by assessing Jasmin’s mental health and well-­being
by evaluating her emotional, behavioral, and cognitive functioning; recognizing
her strengths and weaknesses; and identifying any underlying issues contributing
to her current difficulties.
To identify Jasmin’s level of anxiety, I administered the Reynolds Children’s
Manifest Anxiety Scale, 2nd edition (RCMAS-2) (Reynolds & Richmond, 2008).
RCMAS-2, a brief self-­report inventory, is used to identify the nature and level of
anxiety in children from 6 to 19 years. T-­scores below 39, from 40 to 60, from 61
to 70, or greater than 71 are categorized as less problematic, no more problem-
atic, moderately problematic, and highly problematic, respectively. Jasmin pre-
sented with moderately problematic anxiety with a score of 75 on the RCMAS-2
scale.
At the end of the first session, I asked Jasmin what she wanted to accomplish
in therapy. Jasmin and I agreed on the following goal and objectives:
Treatment Goal: Jasmin would manage her anxiety, improve her self-­ esteem,
develop practical communication skills, and develop a sense of self-­acceptance.
Treatment Objectives:
1. Decrease anxiety by practicing mindfulness techniques to regulate emotions.
2. Confront fears related to going out without makeup.
3. Increase self-­awareness and acceptance of thoughts and emotions.
4. Challenge and reframe negative thoughts and beliefs about herself and her
appearance.
After assessing Jasmin’s needs, I created a treatment plan with interventions
and techniques. My treatment strategies were to introduce MB-­CBT methods
such as breathing, cognitive restructuring, and exposure therapy to help Jasmin
manage her anxiety, challenge negative thoughts, and feel more comfortable with-
out makeup over time.
TABLE 12.1. JASMIN: SESSION 1
Transcript Analysis
T: “Hi, Jasmin. It’s nice to meet you. How are you Introduction and rapport building.
feeling today?”
J: “Hi, I’m feeling a bit nervous but also hopeful.” Clients, especially adolescents, often feel
nervous and awkward in the first counseling
session.
T: “That’s understandable. I’m glad you’re here. Can Supporting the client and assuring her
you tell me a bit more about what has been going on experience is common.
for you?”
J: “Yeah, it’s been tough. I go to school early Encouraging the client to express herself and
every day just to put on makeup, and I feel really tell her story.
uncomfortable when I’m not wearing it. I also feel
really lonely and isolated at school, even though I
have a few friends.”
T: “Your loneliness and uncomfortableness sound Paraphrasing and reflecting on the client’s
painful. I can imagine how difficult that would be.” feelings for understanding and empathy.
J: [Nodding, appears emotional] The client experiences empathy from accurate
reflection of feelings and is emotional.
T: “Mmm.” [Silence] Minimal encouragement and therapeutic
silence.
T: “I have some ideas on how to help. Have you Instilling hope. Introducing the mindfulness
heard of mindfulness before?” approach.
J: “No, not really.”
T: “Well, mindfulness is a way of paying Explaining the mindfulness approach in simple
attention to the present moment, without and age-­appropriate language.
judgment or distraction. It can help with
anxiety and stress, and can also help you
feel more connected to yourself and others.”
J: “Sounds interesting.” Indicates openness to process.
T: “And have you heard about Cognitive Introducing the CBT approach.
Behavior Therapy, or CBT before?”
J: “No.”
T: “Cognitive Behavioral Therapy (CBT) is a Explaining the CBT approach in simple and
therapeutic approach that focuses on the connection developmental-­level language.
between our thoughts, emotions, beliefs, and
behavior. Our perceptions and interpretations
of events are more significant than the events
themselves in determining how we feel and behave.”
J: “That is more interesting . . .” The client appears fascinated by the
explanation of CBT.
J: “I am not sure . . . but maybe paying attention to
the present moment and what I am thinking about?”
T: “You got that right; you pay attention.” I am encouraging the client and continuing to
build rapport.
J: [Smiles . . . appears proud of her achievement] Noticing the client’s nonverbals.

T: “You are proud you got it right. Let’s start with Validating the client by reflecting on feelings.
some deep breathing exercises today. I’ll guide you Introducing the client to the MB-­CBT approach
through it. Take a deep breath in through your nose and guiding her through techniques.
and hold it for a few seconds, then slowly exhale
through your mouth. Please
do that a few more times as you pay attention to
your breath.”
174 Chapter 12

Session 2
The goal for the second session was to work with Jasmin to master and practice
breathing exercises.

TABLE 12.2. JASMIN: SESSION 2

Transcript Analysis
T: “Hi, Jasmin. How are you doing today, and how Introducing the session and recapping the last
have you been since our last session?” session.
J: “I am doing fine. I’ve been practicing the Client report of practicing the technique.
breathing exercises you taught me last week.”
T: “Okay. You took time to practice what you Validating the client and checking on skill
learned last week. How has the practice gone?” development.
J: “They’ve been helpful. But I’m still struggling Many clients take time and a lot of practice to
with feeling anxious.” master techniques and see change.
T: “I understand. It takes practice to master the Empathy and encouragement. Set realistic
technique. Also, it will take time and doing this expectations as many adolescents expect instant
almost daily. How about we continue working on change after doing exercises once or twice.
the skill to help you master it?”
J: “Okay.”
T: “Sit comfortably and close your eyes. Begin Practicing for technique comfort and mastery.
by bringing your awareness and attention to your
toes, and notice any sensations there . . . , then
move up to your feet, and notice any sensations
there . . . , keep moving up your body and
noticing any sensations or tension . . . Don’t judge
anything. Just notice . . .
when you get to the top of your head, take a few
deep breaths . . . , and slowly open your eyes.”

Session 3
In the third session, I introduced the cognitive activity of identifying and challeng-
ing negative thoughts and beliefs. In addition, I encouraged Jasmin to be aware of
body sensations when experiencing anxiety.
During the next sessions, I assisted Jasmin in honing her awareness of her
bodily sensations and expressing them to me. We also worked on new meth-
ods, such as exposure therapy, to help her feel more comfortable with her nat-
ural appearance without makeup. I also motivated Jasmin to challenge herself
by going out without makeup more often and to acknowledge and reward her
successes.
TABLE 12.3. JASMIN: SESSION 3
Transcript Analysis
T: “How are you today, and how was last week?” Checking in with the client.
J: “Things have been good and better.” Client’s update
T: “Oh, tell me how the week was good and better.” Giving the client an opportunity to expand on
her experience
J: “The mindful exercises have been helpful, and it’s Client progress details
easy to perform them.”
T: “You are pleased that you are mastering the Reflection of feelings. Validation of client’s
breathing technique and happy it is helpful.” efforts.
J: “Yes, but I am still struggling with feeling anxious The client opens up about her struggles; an
and self-­conscious.” indication of a good rapport and trust between
the client and therapist.
T: “I am glad they are helping. You feel a little Reflection of feelings. Validation that her
discouraged in still feeling anxious and self-­ struggle is common. Encouragement for the
conscious. This is typical to see some progress client to go deeper.
and want more relief. I can help with that. Which is
occurring more?”
J: “I think the anxiety is less and the self-­ Demonstrates self-­awareness and understands
consciousness is more.” the difference between the two.
T: “I am glad you have been paying attention to your Paraphrasing and praising the client for effort
physical sensations, noticing that your anxiety is less. and introducing a new technique
That was one of the techniques we worked on last
week. How about we work on a cognitive technique
today?”
J: “Okay, sure.”
T: “This technique will help you identify the Explaining the nature of the technique before
connection between thoughts, feelings, and introduction
behavior. Then we develop a balanced thought.”
J: “Okay.”
T: “Here we go. Just like the last exercise we Technique details and practice
practiced; I would like you to be as comfortable as
you can . . . please think of a situation where you feel
self-­conscious . . . like when you’re at school without
makeup. What thoughts come to mind?
J: “All the other students are thinking ‘look at that Because of the therapeutic rapport, she was
ugly girl. Muslims are so weird and never will fit in.’” honest about her thoughts.
T: “Sounds like an all-­or-­nothing thought. When you Identify the type of cognitive distortion;
think that, how do you feel and then how do you introduce the cognitive triangle by drawing a
behave?” diagram of thoughts leading to feelings and
then behavior
J: “I feel self-­conscious, lower my eyes so I am only She connects the cognitive triangle.
looking at the ground, and avoid talking to anyone.”
T: “If you change the thought to something more Many adolescents need initial guidance when
balanced like ‘I am friendly, smart, kind, and have developing a balanced thought. Later, I will
pretty eyes and a warm smile even when I don’t help her challenge the cognitive distortion by
wear makeup’ then how would you feel and behave? examining the evidence and then prompt her to
More self-­conscious or less? More withdrawn or develop her own balanced thoughts.
less?”
(continued)
176 Chapter 12

TABLE 12.3. (CONTINUED)

Transcript Analysis
J: “Well, I would feel less self-­conscious and less Adolescents typically admit that the balanced
withdrawn. But I still think I look better with makeup.” thought would help. However, their validity of
cognition is low.
T: “You recognize changing your thought will at Encouraging her recognition of the concept and
least help you achieve your goal of feeling less validating her low belief followed by asking for a
self-­conscious. It is common not to believe it all commitment to try it.
the way until you practice it several times and see
the difference. Would you be willing to practice this
balanced thought two times this week—just as an
experiment to see what happens?”

Ethical and Cultural Considerations

I considered several ethical and cultural issues for Jasmin, starting with confi-
dentiality (Haraldsson et al., 2022). Jasmin hesitated to open up, fearing that I
would share her information with her parents. From the outset, I assured Jasmin
that information shared in counseling sessions is kept confidential, except for the
limits of confidentiality. I then explained the limits of confidentiality and the cir-
cumstances under which information may be disclosed.
Another ethical consideration was respecting Jasmin’s cultural background
and her family’s Muslim faith (Sue, Zane, Nagayama Hall, & Berger, 2009).
Although it was essential to help Jasmin express her desire to wear makeup and
feel comfortable, it was also important to avoid imposing other cultural values
and beliefs on her and her family. I was mindful of potential cultural biases and
maintained cultural sensitivity. As Amari (2021) suggested, I prioritized Jasmin’s
autonomy and right to self-­determination while respecting her parents’ role and
values. We discussed how Jasmin could balance expressing herself while respect-
ing her parents’ wishes and beliefs.
Finally, given that Jasmin is a Pakistani American Muslim adolescent girl, I
paid attention to issues of intersectionality (Byrd et al., 2022). I was nonjudg-
mental and created a safe environment trying to avoid biases and stereotypes for
Jasmin to express herself safely. I considered the larger social context, specifically
global events and political environment contributing to Islamophobia that was
impacting Jasmin’s development and mental health (Ahmed, 2012).

Parent and/or Teacher Consultations

Teacher consultation is essential to counseling treatment for children (Vilbas et al.,
2021). It is a necessary process with many potential benefits, including support-
ing and accommodating Jasmin’s anxiety and academic difficulties. I consulted
Jasmin’s teacher and discussed ways of helping Jasmin manage her anxiety in the
classroom, such as relaxation techniques like breathing or taking breaks when
needed. The meeting was also an opportunity to discuss ways to support Jasmin
to promote her success in school and to intervene when racist and Islamophobic
 Social Anxiety 177

remarks were made. In addition, I addressed the teacher’s concerns and questions
about her behavior and academic performance. On Jasmin’s teacher’s recommen-
dation, we referred Jasmin to the school’s Student Support Team (SST) for addi-
tional support and mentoring.
I also met Jasmin’s parents and educated them about the benefits of MB-­CBT
and how it could help them manage anxiety and healthily express themselves. As
I did for Jasmin, I assured Jasmin’s parents of my respect for their cultural and
religious values. To help them understand her treatment process, I explained the
rationale behind the treatment approach and goals and addressed their concerns
or questions. I addressed scheduling arrangements and transportation to ensure
that Jasmin attended her counseling sessions. In addition, I provided Jasmin’s
parents with a list of parent training community resources.

Conclusion
After implementing MB-­CBT, Jasmin made significant progress in her treatment.
At the termination of counseling, she could apply MB-­CBT techniques to identify
and challenge her negative thoughts and beliefs regarding her appearance and
interaction with her parents and friends.
Jasmin developed new coping strategies and self-­acceptance and reported
being more confident and less self-­conscious about her appearance. Her rela-
tionship and communication with her parents improved. Not only did Jasmin
become more autonomous, but she also expressed herself better while respecting
the divergent views of her parents. I was sensitive in considering cultural and
ethical issues concerning Jasmin and her parents as Pakistani Americans and their
Muslim faith. I also facilitated parent and teacher consultations to ensure that
Jasmin received appropriate support and understanding at home and school.
Overall, the MB-­ CBT approach has been effective in helping Jasmin to
improve her well-­being and relationships and to achieve a greater sense of self-­
awareness and acceptance. As a therapist, I was mindful of cultural and ethical
considerations and tailored the therapy to meet Jasmin’s specific needs.

Sample Case Notes

Session 1
Subjective: Jasmin expressed concern about her appearance and interest in wear-
ing makeup. In addition, she reported feeling very anxious about her parents.
Objective: Initially, Jasmin appeared sad and anxious during the session. Her
body language was closed off and tense, and she spoke softly and avoided eye
contact. However, Jasmin seemed a bit relaxed after the breathing exercise.
Assessment: Jasmin is experiencing value conflicts and communication problems
with her parents, contributing to anxiety, social isolation, and low self-­esteem.
Her fear of judgment and rejection is consistent with a diagnosis of social anxiety
178 Chapter 12

disorder. The pressure to conform to her parents’ beliefs and values exacerbates
her symptoms. Her grades have started slipping; she has missed several school
days due to anxiety and stress.
Plan: Mindfulness-­based cognitive therapy will provide Jasmin with skills to man-
age her anxiety and increase her self-­acceptance. She will learn to challenge her
negative thoughts about her appearance and develop a more positive self-­image.

Resources

For Clients
Butterfly hug, https://www​.youtube​.com/watch?v=iGGJrqscvt​U&t​=34s
Creating a mindfulness anxiety plan, https://positive​.b-­cdn​.net/wp​-­content/uploads/​
2021/12/Creating-­a-Mindfulness-­Anxiety​-­Plan​​​.pdf
Guided box breathing, https://www​.youtube​.com/watch?v​=zq07​gb​FLCAs&t​=148s

For Therapists
Body Scan Meditation guided meditation led by Kabat Zinn, https://​www​.you​
tube​.com/watch?v=u4gZgnCy5ew

Discussion Questions
1. What attention should a mindfulness-­based CBT counselor focus on when
working with adolescents dealing with social anxiety?
2. What developmental issues are worth considering in relation to adolescents’
social anxiety?
3. Describe some social justice advocacy strategies that counselors could use
with Muslim clients.

References
Ahmed, S. (2012). Adolescents and emerging adults. In S. Ahmed & M. M. Amer
(Eds.), Counseling Muslims: Handbook of mental health issues and interven-
tions (pp. 251–280). Routledge/Taylor & Francis Group.
Amari, N. (2021). Counseling psychology practice as the pursuit of the I-­thou
relationship. The Humanistic Psychologist, 48(4), 410–426. https://doi​.org/​
10.1037/hum0000155
American Psychiatric Association. (2013). Diagnostic and statistical man-
ual of mental disorders (5th ed.). https://doi​ .org/10.1176/appi​
.books​
.9780890425596
Barry, K. A. (2022). Guidance counselor perceptions on the influence of social
media on adolescent mental health in affluent middle schools in New Jersey
(Publication No. 28772181). [Doctoral dissertation, Saint Peter’s University,
2021.] ProQuest Information & Learning. https://www​.proquest​.com/open​
 Social Anxiety 179

view/c5cba129142d707a2532cd12531ff920/1?pq-­origsite=gscholar​ &cbl​
=18750​&diss=y
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guil-
ford Press.
Byrd, R., Luke, C., Lorelle, S., Donald, E., Blueford, J., Adams, C., & Huds-
peth, E. (2022). Counseling children and adolescents: A call to action. Jour-
nal of Counselor Preparation and Supervision, 16(1). https://digitalcommons​
.sacredheart​.edu/jcps/vol16/iss1/2
Carlton, C. N., Sullivan-­Toole, H., Strege, M., Ollendick, T. H., & Richey, J. A.
(2020). Mindfulness-­ based interventions for adolescent social anxiety: A
unique convergence of factors. Frontiers in Psychology, 11. https://doi​.org/​
10.3389/fpsyg.2020.01783
Cho, B., Woods-­Jaeger, B., & Borelli, J. L. (2021). Parenting stress moderates
the relation between parental trauma exposure and child anxiety symptoms.
Child Psychiatry and Human Development, 52(6), 1050–1059. https://doi​
.org/​10.1007/s​10578-020-01087-1
Douglass, S., Mirpuri, S., English, D., & Yip, T. (2016). “They were just mak-
ing jokes”: Ethnic/racial teasing and discrimination among adolescents. Cul-
tural Diversity and Ethnic Minority Psychology, 22(1), 69–82. https://doi​
.org/10.1037/cdp0000041
Eslami, A. A., Rabiei, L., Afzali, S. M., Hamidizadeh, S., & Masoudi, R. (2016).
The effectiveness of assertiveness training on the levels of stress, anxiety, and
depression of high school students. Iran Red Crescent Medical Journal, 18(1),
300–303. https://doi.org/10.5812/ircmj.21096
Figueiredo, D. V., Alves, F., & Vagos, P. (2023). Psychological inflexibility explains
social anxiety over time: A mediation analyses with a clinical adolescent sam-
ple. Current Psychology: A Journal for Diverse Perspectives on Diverse Psy-
chological Issues. https://doi​.org/10.1007/s12144-023-04650-w
Goforth, A. N., Pham, A. V., Chun, H., Castro-­Olivo, S. M., & Yosai, E. R. (2016).
Association of acculturative stress, Islamic practices, and internalizing symp-
toms among Arab American adolescents. School Psychology Quarterly, 31(2),
198–212. https://doi​.org/10.1037/spq0000135.supp (Supplemental)
Haraldsson, J., Pingel, R., Nordgren, L., Johnsson, L., Kristiansson, P., & Tind-
berg, Y. (2022). Confidentiality matters! Adolescent males’ views of pri-
mary care in relation to psychosocial health: A structural equation modeling
approach. Scandinavian Journal of Primary Health Care, 40(4), 438–449.
https://doi​.org/10​.1080/02813432.2022.2144999
Kabat-Zinn J. (2013). Full Catastrophe Living, Revised Edition: How to Cope
with Stress, Pain and Illness Using Mindfulness Meditation. Hachette.
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., Chap-
leau, M. A., & Kabat-­Zinn, J. (2013). Full catastrophe living: Using the wis-
dom of your body and mind to face stress, pain, and illness. Bantam Dell.
180 Chapter 12

Lahat, A., Lamm, C., Chronis-­Tuscano, A., Pine, D. S., Henderson, H. A., & Fox,
N. A. (2014). Early behavioral inhibition and increased error monitoring
predict later social phobia symptoms in childhood. Journal of the American
Academy of Child & Adolescent Psychiatry, 53(4), 447–455.
MacKenzie, M. B., & Kocovski, N. L. (2016). Mindfulness-­based cognitive ther-
apy for depression: Trends and developments. Psychology Research and
Behavior Management, 9, 125–132.
Muslim Matters. (2017). Who is Anila Daulatzai? Students urge boycott of
Southwest demanding justice for Muslim professor. https://muslimmatters​
.org/2017/10/23/who-­is-­anila-­daulatzai​-­students​-­urge-­boycott-­of-­southwest​
-­demanding​-­justice-­for-­muslim​-­professor/
Odgers, C. L., & Jensen, M. R. (2020). Annual research review: Adolescent men-
tal health in the digital age: Facts, fears, and future directions. Journal of
Child Psychology and Psychiatry, 61(3), 336–348.
Paquin, K., & Hofmann, S. G. (2013). Mindfulness-­based therapy: A comprehen-
sive meta-­analysis. Clinical Psychology Review, 33(6), 763–771.
Peleg, O., Tzischinsky, O., & Spivak, L. Z. (2021). Depression and social anxiety
mediate the relationship between parenting styles and risk of eating disor-
ders: A study among Arab adolescents. International Journal of Psychology,
56, 853–864. https://doi​​.org/10.1002/ijop.12787
Peterson, T. J. (2018). The mindfulness workbook for anxiety: The 8-week solu-
tion to help you manage anxiety, worry & stress. Althea Press.
Reynolds, C. R., & Richmond, B. O. (2008). Revised children’s manifest anxiety
scale (RCMAS-2): Manual (2nd ed.). Western Psychological Services.
Rezaei, S., Babapour, J., & Bolhari, J. (2016). The effectiveness of mindfulness-­
based cognitive therapy on social anxiety disorder in female adolescents. Ira-
nian Journal of Psychiatry and Clinical Psychology, 22(3), 214–222.
Semple, R. J., Lee, J., Rosa, D., & Miller, L. F. (2010). A randomized trial of
mindfulness-­based cognitive therapy for children: Promoting mindful atten-
tion to enhance social-­emotional resiliency in children. Journal of Child and
Family Studies, 19(2), 218–229.
Seward, D. X., & Khan, S. (2016). Towards an understanding of Muslim Amer-
ican adolescent high school experiences. International Journal for the
Advancement of Counselling, 38(1), 1–11. https://doi​ .org/10.1007/s10447​
-015-9252-5
Sue, S., Zane, N., Nagayama Hall, G. C., & Berger, L. K. (2009). The case for
cultural competency in psychotherapeutic interventions. Annual Review of
Psychology, 60, 525–548. https://doi.org/10​.1146/annurev​.psych​.60​.110707​
.163651
Twenge, J. M., & Campbell, W. K. (2018). Associations between screen time and
lower psychological well-­being among children and adolescents: Evidence
from a population-­based study. Preventive Medicine Reports, 12, 271–283.
 Social Anxiety 181

US Census Bureau. (2020). Pakistani Total Population 2020. https://data.census

.gov/table?q=pakistani&g=010XX00US&y=2020
Vilbas, J., & King-­Sears, M. E. (2021). An effective elementary school counsel-
or’s support of students with disabilities: A case study. Psychology in Schools,
58(5) 873–892. https://doi.org/10.1002/pits.22476
Vultaggio, G. (2023). The most anxious generation: The relationship between
Gen Z students, social media, and anxiety. SUNY Open Access Repository.
http://hdl​.handle​.net/​20.500​.12648/1916
Wang, Y., Chen, J., Zhang, X., Lin, X., Sun, Y., Wang, N., Wang, J., & Luo, F.
(2022). The relationship between perfectionism and social anxiety: A moder-
ated mediation model. International Journal of Environmental Research and
Public Health, 19(19). https://doi​.org/10.3390/ijerph191912934
Wuthrich, V. M., Rapee, R. M., Cunningham, M. J., Lyneham, H. J., & Hudson,
J. L. (2012). Randomized controlled trial of group cognitive behavioral ther-
apy for social anxiety disorder with and without mindfulness-­based modifica-
tions. Behaviour Research and Therapy, 50(11), 675–686.
 CHAPT E R 13

Divorce and Political Extremist Groups

Cognitive Behavior Therapy and Expressive Arts with a
White Adolescent
Jennifer N. Baggerly

David is a very intelligent 16-year-­old White male who lives with his mother, Debra,
and 12-year-­old sister, Suzie. David’s father, Ed, lives in a nearby apartment with
his new girlfriend. During the intake session, Debra said she has been divorced
for 1 year. She stated that the divorce was because Ed had become a radical
who joined an extremist political group. Yet, she knows that Ed tells people the
divorce was because she is a “crazy b—” who misunderstood him. Debra tear-
fully explained that she is seeking counseling for David because of his depression,
isolation from friends, and extreme disrespect as well as outbursts toward his
father. Ed does pay child support, so he insists on seeing David according to the
standard custody agreement despite David’s resistance. Ed does not believe in
counseling, so he refused to participate in the intake session.

For this case study, consider:

1. What are common concerns of adolescents experiencing divorce and what
were David’s needs? What are characteristics of people involved in extremist
political groups and how does it impact their children?
2. What is the rationale for using Cognitive Behavior Therapy (CBT) and
Expressive Arts with David? What are common strategies?
3. What unique ethical guidelines need to be considered?

Impact of Divorce
Although the United States divorce rate has declined from 944,000 in 2000 to
689,308 in 2021 (Centers for Disease Control, 2022), still 30% of 12- to 17-year-­
olds do not live with both parents (Anderson, Hemez, & Kreider, 2022). The
impact of divorce on adolescents is multifold. Harold and Sellers’s (2018) review
found interparental conflict such as divorce can result in adolescents’ (a) sleep
problems of getting to sleep and staying asleep; (b) externalizing symptoms of
aggression, conduct problems, and antisocial behavior; (c) internalizing problems

183
184 Chapter 13

of withdrawal, fearfulness, sadness, low self-­esteem, anxiety, depression, and sui-

cidality; (d) academic problems of lower performance; (e) social and interpersonal
relationship problems such as problem solving and wider social competence; (f)
physical health problems of fatigue, abdominal stress, and headaches; and (g)
intergenerational transmission of psychopathology and relationship distress such
as likelihood of partner violence in future romantic relationships.
The extent of impact from interparental conflict depends on the frequency,
intensity, and resolution potential of parental conflict as well as a particular ado-
lescents’ quality of parent-­child relationship, child temperament, child gender, and
history of exposure to conflict (Harold & Sellers, 2018). These factors influence
adolescents’ appraisal of the conflict and subsequent understanding as to why the
conflict occurs (e.g., responsibility and blame) and the adolescent’s ability to do
something about it. “Children who blame themselves for parental disagreements
or feel responsible for not helping to end them experience guilt, shame, and sad-
ness” (Harold & Sellers 2018, p. 379).
Tullius, De Kroon, Almansa, and Reijneveld (2021) also found divorce of par-
ents can increase adolescents’ risk for depression, anxiety, and substance abuse
(Tullius et al., 2021). In their study of 2,230 US 10- to 12-year-­old adolescents,
Tullius and colleagues discovered that externalizing problems (i.e., substance
use and delinquency) and internalizing problems (e.g., depression and anxiety)
increased over 4 years after a parental divorce compared to adolescents who did
not experience a divorce. Some reasons for these increased behavior problems are
linked to socioeconomic effects of moving to an area with more crime and attend-
ing a school with lower academic performance. Other reasons are estrangement
from one parent and feelings of guilt. Adolescents are particularly vulnerable to
the impact of divorce due to the plasticity of the adolescent brain and increased
cortical circuitry in response to environmental factors (Tullius et al., 2021). This
critical neurological period makes mental health interventions for adolescents of
divorced parents essential.
Based on this information, I believe the impact of divorce on David includes
his depression, relationship problems with his father, and potential problems in
his future romantic relationships. Because David is the oldest male child, he may
blame himself for not protecting his mother and he may feel powerless over his
ability to “fix” his father. Because David could be at risk for substance use, I will
consider the possibility of needing to screen for any use of weed, alcohol, or other
substances.

Impact of Extremist Groups

In 2021, the Southern Poverty Law Center documented 1,221 hate and antigov-
ernment extremist groups across the United States (Miller & Rivas, 2022). In
2020, there was a substantial increase in US domestic attacks at demonstrations
by violent domestic extremist groups (Doxsee, Jones, Thompson, Halstead, &
 Divorce and Political Extremist Groups 185

Hwan, 2022). Violent domestic extremist groups in the United States can be cat-
egorized into four ideologies of violent far-­right, violent far-­left, religious, and
ethnonationalists (Doxsee et al., 2022). Violent far-­right groups have extremist
ideology such as racial or ethnic supremacy, opposition to government author-
ity, hatred based on sexuality or gender identity, or conspiracy theories that do
not correspond to mainstream political parties in the United States. Violent far-­
left groups have extremist ideology such as opposition to capitalism, support for
environmental causes or animal rights, pro-­communist, or support for anarchism.
Extreme religious terrorist groups are motivated by a faith-­based belief system,
such as Christianity, Hinduism, Islam, Judaism, or other faiths. Ethnonationalists
are motivated by racial, ethnic, or nationalist goals. In each of these groups, vio-
lence is most often perpetrated by a single individual or a small network rather
than a larger group.
Extremist groups’ rhetoric is readily accessible on the internet, where ado-
lescents tend to spend hours of time (Rousseau & Hassan, 2019). The danger
for adolescents is that they are still developing their cognitive ability for discern-
ing facts versus opinions, moral judgment, ideology, and identity (Wong, Hall, &
Wong Hernandez, 2020). Not all adolescents reach formal operations with the
ability to consider various perspectives, systematically test hypotheses, or show
hypothetico-­deductive reasoning. This makes some adolescents prone to hold ide-
alistic beliefs without considering complexities of problems or contradictions of
values. Adolescents can be psychologically vulnerable to extremist groups if they
have preexisting mental illness, traumatic experiences, socialization problems,
experiences with discrimination, or delinquency (Harpviken, 2020).
In contrast, some adolescents have developed formal operations with the abil-
ity to understand why others have certain perspectives, so they are less prone to
be swayed by rhetoric of extremist groups. However, typically adolescents have
not reached post-­ formal operations with the ability to understand relativism
(e.g., knowing perspectives of truth are based on culture or historical context
and are not absolute) (Wong et al., 2022). Therefore, adolescents may understand
a different perspective but are insistent that their truth is the right way without
the cognitive ability to navigate complexities while maintaining emotional regu-
lation, which results in cognitive distortions, condemnation of others, and emo-
tional cutoff.
Based on this information, because David is very intelligent, he seems to be
the latter type of adolescent who has developed formal operations but not post-­
formal operations. David may understand that his father’s extremist group holds
ideas that are dangerous and against David’s values. However, David’s extreme
anger and emotional cutoff from his father seem to indicate that David has his
own cognitive distortions and needs help navigating cognitive complexities while
maintaining emotional regulation.
186 Chapter 13

Treatment Approach
Given David’s developmental level, he will benefit from both Cognitive Behavior
Therapy (Beck & Weishaar, 2018) and Expressive Arts (Rubin, 2011) for several
reasons. First, David has the developmental capacity to analyze his thoughts and
develop balanced thinking. Second, his depression and withdrawn stance require
a nonverbal engagement to activate his experiences in a nonthreatening manner
through expressive arts. Third, he needs coping strategies and conflict manage-
ment skills to use during interactions with his father.

Cognitive Behavior Therapy

Cognitive Behavioral Therapy is based on the theory that schemas (e.g., core
beliefs and basic assumptions about how the world operates) lead to automatic
thoughts that determine emotions and behaviors (Beck & Weishaar, 2018). For
example, David may have a schema that “I am only secure when my parents
get along and stay together” resulting in an automatic negative thought that “it
is a catastrophe that my dad got caught up in an extremist political group and
divorced my mom.” This results in David feeling angry and punishing dad with
withdrawn behavior. Common cognitive distortions are (a) arbitrary inference of
making conclusions without evidence (e.g., “my dad chats with extremists online,
so he must have committed a violent crime”); (b) over-­generalization of creating
a general rule from one incident (e.g., “all marriages are horrible”); (c) personal-
ization of attributing external events to oneself (e.g., “the divorce was my fault
because I could have talked dad out of it”); (d) dichotomous all-or-nothing think-
ing (e.g., “my relationship with my dad will always be terrible” and “my mom
has no responsibility in causing the divorce”); and (e) catastrophizing (e.g., “it is
a catastrophe that my dad is in a violent extremist group, and I must have noth-
ing to do with him”).
Beck believed these cognitive distortions can contribute to the cognitive triad
of depression. A person views (1) self as inadequate and worthless (e.g., “I am
worthless because I could not prevent my parent’s divorce or control my father’s
extreme beliefs”); (2) the world is devoid of pleasure (e.g., “No one will want to
be my friend when they find out how messed up my dad is, so there is no joy in
my life”); and (3) the future is hopeless (e.g., “there is no chance of my future
relationship with dad or others being better than the present”).
Fortunately, the evidence for CBT efficacy in decreasing depression in adoles-
cents is extensive (Thoma, Pilecki, & McKay, 2015). The role of the CBT counselor
is to be a warm, empathic collaborative guide exploring the adolescent’s world
(Beck & Weishaar, 2018). Together with the client, the counselor gathers infor-
mation for a functional and cognitive analysis to identify cognitive distortions,
examine evidence, develop balanced thoughts, and develop coping strategies. For
David, I will use CBT strategies of supportive reflection of emotions and percep-
tions, relaxation/deep breathing, mindfulness training, psychoeducation about the
cognitive triangle and types of cognitive distortions, examination of evidence for
 Divorce and Political Extremist Groups 187

cognitions, cognitive reframing to develop balanced thoughts, healthy coping and

communication strategies, role-­play/behavioral rehearsal, and structured problem
solving (Beck & Weishaar, 2018; Phifer, Crowder, Elsenraat, & Hull, 2020). In addi-
tion, I will use third-­generation CBT strategies from Dialectical Behavior Therapy
(Linehan, 2014; Rathus & Miller, 2014) such as mindfulness, emotion regulation,
distress tolerance, and interpersonal effectiveness as well as Acceptance and Com-
mitment Therapy (Hayes, Strosahl, & Wilson, 2016; Turrell & Bell, 2016) such as
thought defusion, acceptance, connecting with values, and committed action.

Expressive Arts
Expressive arts such as drawing, painting, collages, clay creations, sand tray,
music, dance, or drama can promote healing in clients when a therapist guides
clients in thoughtful reflection on the process (Malchiodi, 2005; Rubin, 2011).
Through expressive arts, adolescents can authentically and effectively express
their experiences, perceptions, feelings, and desires without the limits of words
(Malchiodi, 2005). D. W. Winnicott was credited with saying “it is only in being
creative that the individual discovers the self.” This deeper understanding of self
can promote self-­ acceptance, which can improve interpersonal relationships.
Recent research shows expressive arts with adolescents helped decrease their
stress and anxiety (Lindsey, Robertson, & Lindsey, 2018), increase empathy
(Gujing et al., 2019), and increase social competence (Forrest-­Bank, Nicotera,
Bassett, & Ferrarone, 2016).
Numerous expressive art strategies may be helpful to David. In the first ses-
sion, I will begin with a sand tray mindfulness activity, asking David to describe
how the sand feels and looks without judgment of good or bad but rather curios-
ity and attentiveness. This practice lays a foundation for him to use this mindful-
ness skill with people. Then I will ask David to select miniatures to represent each
member of his family followed by reflective processing (Homeyer & Sweeney,
2022). This activity helps me identify his perceptions and possibly negative cogni-
tions toward family members.
In a subsequent session, I will ask David to use markers or oil pastels to draw
a safe place as a visual reminder that he can self-­soothe by visualizing his safe
place (Guzman, 2020). I will ask David to select a current song that represents
himself now and a song that represents his hopes. This activity can help pro-
vide him motivation for the difficult work in therapy. The color-­your-­life activity
(O’Connor, Schaefer, & Braverman, 2015), representing prominent emotions with
different colors in an outline of a person (Drewes, 2001), will help David express
contrasting emotions he experienced before and after his parents’ divorce. I will
ask David to create collages of himself and his parents by finding pictures on his
phone and online that represent them as a method to help David appreciate their
unique characteristics and complexities.
To increase David’s sense of power, I will ask him to complete several other
art activities such as power affirmation (e.g., writing an affirmation using block
188 Chapter 13

letters); strength shield (e.g., drawing a shield and writing his strengths in it);
power and protection symbols molded from clay; building boundaries, not walls
(e.g., gluing paper around a drawing of self); and bridge drawing of where he
wants to go in his relationship with his dad and the obstacles he will have to
overcome (Guzman, 2020).

Case Study Application

Treatment Goals
My overall treatment goals for David are to decrease his depressive symptoms
and increase healthy coping and communication strategies. My treatment objec-
tives for David are:
1. verbally or artistically expressing his experiences, perceptions, feelings, and
desires with eventual emotional regulation by the end of each session;
2. consistent monitoring of automatic thoughts and either replacing with reality-­
oriented balanced thoughts or committing to value-­oriented actions at least
once a session;
3. developing a healthy understanding of his parents’ divorce as evidenced by
believing that it was not his fault and respecting parents’ freedom of choice;
and
4. demonstrating healthy and effective coping and communication strategies at
least once per session.
To accomplish these treatment goals and objectives, I will use the expressive art
activities and CBT treatment strategies described above.

Initial Sessions
With this deeper understanding of divorce, political extremist groups, and treat-
ment approaches, we can now apply them to David. My goals for the first session
were to develop rapport, assess David’s working diagnosis, identify David’s treat-
ment goals, facilitate his expression, and provide some beginning coping skills.
I prepared by setting out the sand tray and hundreds of miniature items orga-
nized into categories (e.g., people, domestic animals, wild animals, cartoon char-
acters, household items, nature, spiritual items, death and scary items, etc.). After
introducing myself, obtaining informed assent including limits of confidentiality, I
invited David to use the sand tray.
After the sand tray, I asked what he would like to accomplish in our counseling
together. We agreed on the treatment goals listed above. I also gave David at least
two practical coping strategies for some symptom relief. I explained and demon-
strated deep breathing to calm his body and the 5-4-3-2-1 grounding activity (e.g., 5
things he can see; 4 things he can touch; 3 things he can hear; 2 things he can smell;
and 1 thing he can taste) to calm his mind. See Session 1 transcript for a summary.
 Divorce and Political Extremist Groups 189

TABLE 13.1. DAVID: SESSION 1

Transcript Analysis
T: “As you can see, I have a sand tray here. I Introduction of a grounding technique. The
would like to invite you to place your hands into invitation allows him choice during a time when he
the sand if you would like.” believes that he has had little choice.
D: “Okay. This is a little weird.” Adolescents often feel awkward in general and are
sometimes surprised by expressive arts.
T: “You feel hesitant, which is common for the first Reflection of feeling and normalization helps him
time. You are welcome to go at your own pace or feel understood. Giving him a choice facilitates his
just watch.” personal power.
D: “I guess I’ll give it a try.” His willingness to engage aids in my assessment
of him as a brave young man who is motivated to
improve.
T: “How does the sand feel to you? Cool, warm, I guide him through a mindfulness activity to
hot? . . . What do you notice when you look at lay a foundation of nonjudgmental perspective.
it closely? Paying attention to describe things My hope is that he will experience me as
without judgment as good or bad is called nonjudgmental and accepting toward him.
mindfulness. Have you heard that term before? Eventually I hope he integrates mindfulness so we
What do you know about it? Doing this with can apply it to his father and himself.
inanimate objects helps us practice so we can
eventually do this with people.”
T: “Now, I would like to invite you to take some I sit quietly as David engages in the activity. When
time to look through these miniatures and select he is finished, I process his creation by saying, “If
some that represent each member of your family. you would like, you can tell me about your sand
Place them in the sand tray as you go along. You tray and what the items represent”; “looking at
can also use items to show how your world looks the position of the items in relation to each other,
right now.” what do you notice?”; “which family member are
you closest to and farthest from?”; “what is each
family member thinking and feeling?”; “if you could
make your life better, what would you change or
add to the sand tray?”; and “what feelings did you
become aware of doing this?”
D: “This princess in the cage is my mother. This Sand tray miniatures convey David’s perceptions
wild, angry ape is my father. This annoying yappy of his family members’ roles, thoughts, and
dog is my sister. I am a big dog trying my best to feelings. It is common for the oldest male to
protect the princess from the ape.” assume a protector role and yet feel ineffective at
that role.

For the second session, I asked David to use markers or oil pastels to draw
a safe space and helped him internalize the safe space through deep breathing,
mindfulness, and visualization. Then I explained the cognitive triangle. Afterward,
I used dominos to help him understand the connection between triggers such as
his dad’s voice, his physiological responses of tense muscles, thoughts, feelings,
and behaviors. Finally, I guided David in progressive muscle relaxation. During
the third session, we discussed categories of thinking errors such as all or noth-
ing, overgeneralization, personalization, and catastrophizing. To help David apply
this, I used an expressive arts technique of searching social media for examples of
thinking errors. He was quite enthusiastic about this and found a video of a young
child crying because he did not get to eat all the candy to illustrate all-or-nothing
thinking. He also found a video of a “Karen” (i.e., an entitled woman loudly com-
plaining about not getting what she ordered) to illustrate catastrophizing.
190 Chapter 13

Middle Sessions
During session 4, David’s anger toward his father became intense again.
To reinforce the concept of psychological boundaries, I guide David in the
expressive art activity of “building boundaries, not walls” (Guzman, 2020).
Throughout the rest of the sessions, I integrate DBT and ACT skills with expres-
sive arts activities.

TABLE 13.2. DAVID: SESSION 4

Transcript Analysis
D: “My dad is such an idiot. I hate him. How is Intense anger is expected at this point. David
that for all-or-nothing thinking!” feels awkward and hurt so he uses sarcasm as a
distractor.
T: “You get an A+ in that! [Therapeutic pause] And In response to his sarcasm, I attempt to add
it is clear you are furious with him. His actions comic relief to honor his need for a momentary
offend you.” break from the intensity. I also stay with his
feelings and link them to his perceptions.
D: “Well, what person in their right mind wouldn’t David’s voice tone, facial muscles, and arms are
be offended by his racist insults and gestures. tense as he expresses his rage. He seems to
This weekend, he . . . [describes an incident in accurately perceives his father’s actions as racist
which his father openly displayed racism].” and entangles them in his own sense of self,
resulting in a thinking error of personalization and
thought fusion.
T: [Deep sigh and shakes head] “Your rage about My deep sigh is intended to show empathy and
his racism comes from your values of respecting role model deep breathing. My shaking head is
all people.” intended to align with his values against racism.
My reflection is intended to disentangle his father’s
racism from David’s values.
D: “Yeah. I just don’t want to even be associated It is common for adolescents to believe everyone
with him at all. He’s embarrassing.” is looking at them and judging them. This leads to
an entangling thought that David owns his father’s
values. Consequently, David has all-or-nothing
thinking that he must always stay away from his
father.
T: “You believe people will assume you are racist I reflect the two separate thoughts. I invite him into
as well. Maybe you’re concluding that the only a process of examining evidence and eventually
way to separate others’ misjudgments about thought defusion. I elicit examples of David being
you is to stay a thousand miles away from dad. able to separate himself from a good friend’s
[Therapeutic pause] Let’s examine those two “crazy” idea while still being friends with him. I
thoughts separately. What’s the evidence for and reaffirm that David is the one that decides his
against people assuming you are racist? . . . own values and he does not have to allow others’
Your own nonverbal unapproving reactions and perceptions to fuse him with dad. I introduce
hanging back for a minute can show others you the concept of psychological boundaries
don’t agree. . . . What are ways to establish and interpersonal communication skills of “I
psychological boundaries with Dad?” statements” and assertively asking for what you
need.
 Divorce and Political Extremist Groups 191

Ethical and Cultural Considerations

Ethical considerations were crucial in David’s case for several reasons. First, I
must inform David’s dad that I am seeing David in counseling. Even though the
divorce decree gives his mother the right to obtain mental health services for
David, I am still legally and ethically obligated to contact his father. I emailed
his dad to introduce myself, invited him to schedule a session with me or email
me concerns, and explained the overall treatment goals. As expected, David’s dad
responded to the email that he believes counseling is “BS” but that he will contact
his lawyer if there is any trouble. I entered his email into my electronic notes. I
reviewed with my colleagues our policies and procedures to ensure that I was fol-
lowing all proper ethical and legal steps.
Second, although I obtained informed consent from David’s mother, I must
obtain verbal assent from David. I explained that counseling is a professional
relationship rather than a social relationship. I explained confidentiality, the lim-
its of confidentiality, and that I intended not to give details of what he says to his
parents but that his parents have a legal right to records. Third, because David
is a minor, I assumed that my notes will be subpoenaed at some point or at least
requested by his dad. I was careful to make sure my notes were clear enough to
me but vague enough to maintain David’s confidentiality. Fourth, I must carefully
consult with colleagues and legal counsel about what may be considered “serious
and foreseeable harm” or “duty to warn.” In Texas, there are legal limits against
duty to warn to protect confidentiality, but counselors can contact police. There-
fore, if David disclosed evidence such as an email his dad sent about a planned
violent activity, then I would have contacted police.

Parent Consultations
Given these ethical issues, it was crucial for me to have regular parent consulta-
tions with David’s mom and document due diligence in my communication with
his dad. At the end of each session, I gave his mother a brief overview of skills
that I had taught David such as deep breathing, progressive muscle relaxation, “I”
statements, and psychological boundaries. As I described the skill to the mother, it
not only reinforced the skill for David but also taught his mother to use the skills
as well. I coached his mother to not demand that David use the skill but rather
encourage him to use it by role-­modeling the skill for him. I found that focusing
parent debriefs on skills learned in session satisfies parents’ curiosity about the
session and gives them a sense of relief and empowerment. If the father requested
information about the sessions, I would focus on skills I had taught David.
In divorce cases, it is common for parents to complain about and disparage
the other parent. I manage this by reflecting feelings and perceptions. “You are
incredibly angry that his father said that, and you are worried that your son will
believe it. I will work on helping your son examine evidence about what is true
and what is not. I will help him learn strategies to set boundaries.” Sometimes
192 Chapter 13

volatile parents will not respond well to children using skills such as “I” state-
ments, so I asked David, “What do you think will happen if you tried this with
your dad?” David was up front by saying, “I can try it with mom but not with
dad, because he will punish me.” In this case, I coach David either to not use
the skill or modify it in some way. During a parent consultation with his dad, I
reframed the skill as important for David to use with peers and asked him to be
gentle and encouraging when David practices it at home.

Conclusion
David made remarkable progress in understanding that his parents’ divorce and
his father’s behavior were not his responsibility to “fix.” He was able to change
automatic negative thoughts into balanced thoughts such as “I prefer that my dad
would not believe these things, and I am only in control of staying committed to
my own values.” David experienced empowerment in setting psychological bound-
aries with both his mother and father through calming himself and communicat-
ing his desires. As a therapist, I learned that David was a resilient adolescent with
a bright future in managing his own relationships and being committed to creating
a just society.

Sample Case Notes

Session 1
Subjective: Client expressed his perception of family members in the sand tray by
illustrating his mother as a “trapped princess,” his sister as “an annoying yappy
dog,” his father as “an angry ape,” and himself as “a loyal big dog trying to pro-
tect the princess from the ape.” Client stated, “I’m not depressed, I’m just pissed
and embarrassed of my dad. I just want to chill in my room with video games
most of the day.”
Objective: Initially, client’s posture was slumped over, his speech lacked energy,
and his eye contact was minimal. During the sand tray, his speech gained more
energy, and he increased eye contact with counselor. After counselor explained
and demonstrated coping strategies of deep breathing and 5-4-3-2-1 mindfulness
activity, client’s body was more relaxed.
Assessment: From a Cognitive Behavior Therapy perspective, David appears to be
experiencing depressive symptoms due to thinking errors about himself, his fam-
ily, and his future. Expressive arts appear to motivate him to express his thoughts
and feelings.
Plan: Counselor will provide expressive arts activity of drawing safe place and
introduce concept of the cognitive triangle.
 Divorce and Political Extremist Groups 193

Session 4
Subjective: Client expressed intense anger at his father for a gesture that came
across as racist. Client stated that he felt embarrassed by it and was concerned
others would view him as racist. Client was able to identify evidence that oth-
ers would not necessarily assume he was racist. Client described strategies of “I”
statements and respectful assertiveness to help establish psychological boundaries.
Objective: At the beginning of the session, client’s voice tone, facial muscles, and
arms were tense, indicating anger. After discussing psychological boundaries and
expressive art activity of “building boundaries, not walls,” client’s body and face
were more relaxed.
Assessment: From a CBT perspective, client had a thinking error of personaliza-
tion and thought fusion that his father’s beliefs were imbedded in him. However,
examining evidence, thought defusion, coping strategies, and communication
strategies helped David decrease his anger and gain confidence in developing psy-
chological boundaries while still maintaining a respectful relationship with his
dad.
Plan: Explain distress tolerance of radical acceptance and interpersonal effective-
ness of DEAR MAN (a DBT acronym for Describe, Express, Assert, Reinforce,
Mindful, Appear, Negotiate). Expressive arts activity of online collages of himself
and his parents.

Resources
For Professionals
CBT Toolbox for Children & Adolescents by Lisa Weed Phifer, Amanda K.
Crowder, Tracy Elsenraat, & Robert Hull (2020).
Creative Interventions for Children of Divorce by Linda Lowenstein (2006).
Essential Art Therapy Exercises: Effective Techniques to Manage Anxiety, Depres-
sion, and PTSD by Leah Guzman, ATR-­BC (2020).

For Adolescents
CBT Workbook for Teens by David Lawson (2021).
Stuff That Sucks: A Teen Guide to Accepting What You Can’t Change and Com-
mitting to What You Can by Ben Sedley (2017).
Suffer Love by Ashley Herring Black (2016).

For Parents
General Guidelines for Parents to Talk to Children about Mental Health, https://
www​.mentalhealth​.gov/talk/parents-­caregivers
How to Talk So Teens Will Listen and Listen So Teens Will Talk by Adele Faber
& Elaine Mazlish (2006).
194 Chapter 13

Parenting after Divorce: Resolving Conflicts and Meeting Your Children’s Needs
by Philip Stahl (2007).

Discussion Questions
1. What were some of David’s unique experiences and needs from the overlap of
divorce and his father’s political extremism?
2. How did combining CBT and Expressive Arts facilitate the achievement of
David’s treatment goals? Give specific examples.
3. As a therapist, what beliefs, biases, and/or emotions would you need to
bracket to effectively work with David and his family?
4. What steps would you take to manage ethical and legal issues related to
David’s case and family? How would you respond if you received a subpoena
for custody dispute?

References
Anderson, L. R., Hemez, P. F., & Kreider, R. M. (2022). Living arrangements of
children: 2019. Household Economic Studies. www​.census​.gov/content/dam/
Census/library/publications/2022/demo/p70-174.pdf
Beck, A. T., & Weishaar, M. (2018). Cognitive therapy. In R. J. Corsini & D.
Wedding (Eds.), Current psychotherapies (11th ed., instr. ed., pp. 237–272).
Cengage.
Çaksen, H. (2022). The effects of parental divorce on children. Psychiatriki,
33(1), 81–82. https://doi.org/10.22365/jpsych.2021.040
Centers for Disease Control. (2022). Provisional number of marriages and mar-
riage rate: United States, 2000–2021. www​.cdc​​.gov/nchs/data/dvs/marriage​
-­divorce/national-­marriage​-­divorce​-­rates-00-21.pdf
Doxsee, C., Jones, S. G., Thompson, J., Halstead, K., & Hwang, G. (2022).
Pushed to extremes: Domestic terrorism amid polarization and protest.
Center for Strategic & International Studies. https://www​.csis​.org/analysis/
pushed-­extremes-­domestic​-­terror​ism​-­amid-­polarization-­and-­protest
Drewes, A. A. (2001). The gingerbread person feelings map. In C. E. Schaefer &
H. Kaduson (Eds.), 101 more play therapy techniques (pp. 92–97). Aronson.
Forrest-­Bank, S. S., Nicotera, N., Bassett, D. M., & Ferrarone, P. (2016). Effects
of an expressive art intervention with urban youth in low-­income neighbor-
hoods. Child & Adolescent Social Work Journal, 33(5), 429–441. https://doi​
.org/10.1007/s​10560-016-0439-3
Gujing, L., Hui, H., Xin, L., Lirong, Z., Yutong, Y., Guofeng, Y., Jing, L., Shulin,
Z., Lei, Y., Cheng, L., & Dezhong, Y. (2019). Increased insular connectivity
and enhanced empathic ability associated with dance/music training. Neural
Plasticity, 2019. https://doi​.org/10.1155/2019/9693109
Guzman, L. (2020). Essential art therapy exercises: Effective techniques to man-
age anxiety, depression, and PTSD. Rockridge Press.
 Divorce and Political Extremist Groups 195

Harold, G. T., & Sellers, R. (2018). Annual research review: Interparental con-
flict and youth psychopathology: An evidence review and practice focused
update. Journal of Child Psychology and Psychiatry, 59(4), 374–402. https://
doi​.org/10.1111/jcpp​.12893
Harpviken, A. N. (2020). Psychological vulnerabilities and extremism among
Western youth: A literature review. Adolescent Research Review, 5(1), 1–26.
https://doi​.org/10.1007/s40894​-019-00108-y
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2016). Acceptance and commit-
ment therapy: The process and practice of mindful change (2nd ed.). Guilford
Press.
Homeyer, L. E., & Sweeney, D. S. (2022). Sandtray therapy: A practical manual
(4th ed.). Routledge.
Lindsey, L., Robertson, P., & Lindsey, B. (2018). Expressive arts and mindful-
ness: Aiding adolescents in understanding and managing their stress. Jour-
nal of Creativity in Mental Health, 13(3), 288–297. https://doi.org/10.1080/​
15401383​.2018.1427167
Linehan, M. M. (2014). DBT Skills Training Manual. Guilford Press.
Lowenstein, L. (2006). Creative interventions for children of divorce. Champion
Press.
Malchiodi, C. A. (2005). Expressive therapies: History, theory, and practice. In
C. A. Malchiodi (Ed.), Expressive therapies (pp. 1–15). Guilford Press.
Miller, C., & Rivas, R. C. (2022). The year in hate and extremism: 2021. South-
ern Poverty Law Center. https://www​.splcenter​.org/year-­hate-­extremism-2021
O’Connor, K. J., Schaefer, C. E., & Braverman, L. D. (2015). Handbook of play
therapy (2nd ed.). Wiley.
Phifer, L. W., Crowder, A. K., Elsenraat, T., & Hull, R. (2020). CBT toolbox for
children & adolescents. PESI.
Rathus, J. H., & Miller, A. L. (2014). DBT skills manual for adolescents. Guilford
Press.
Rousseau, C., & Hassan, G. (2019). Current challenges in addressing youth
mental health in the context of violent radicalization. Journal of the Ameri-
can Academy of Child & Adolescent Psychiatry, 58(8), 747–750. https://doi​
.org/10.1016/j​​.jaac​.2019​.03​.031
Rubin, J. A. (2011). The art of art therapy: What every art therapist needs to
know. Routledge/Taylor & Francis Group.
Sands, A., Thompson, E. J., & Gaysina, D. (2017). Long-­ term influences of
parental divorce on offspring affective disorders: A systematic review and
meta-­analysis. Journal of Affective Disorders, 218, 105–114. https://doi​
.org/10.1016/j​.jad.2017.04.015
Thoma, N., Pilecki, B., & McKay, D. (2015). Contemporary cognitive behavior
therapy: A review of theory, history, and evidence. Psychodynamic Psychiatry,
43(3), 423–462. https://doi​​.org/​10.1521/pdps.2015.43.3.423
196 Chapter 13

Tullius, J. M., De Kroon, M. L. A., Almansa, J., & Reijneveld, S. A. (2021). Adoles-
cents’ mental health problems increase after parental divorce, not before, and
persist until adulthood: A longitudinal trails study. European Child & Adoles-
cent Psychiatry, 31, 969–978. https://doi​.org/10.1007/s00787-020-01715-0
Turrell, S. L., & Bell, M. (2016). ACT for adolescents: Treating teens and adoles-
cents in individual and group therapy. Context Press.
Wong, D. W., Hall, K. R., & Wong Hernandez, L. (2020). Counseling individuals
through the lifespan (2nd ed.). Sage.
 CHAPT E R 1 4

Sexual Abuse
Trauma-­Focused Cognitive Behavior Therapy and Creative
Approaches with a Biracial Adolescent
Felicia R. Neubauer

Ava is a 16-year-­old biracial female who lives with her biological mother, Ms.
Johnson, and her 14-year-­old sister, Alexis. Ava sees her biological father on
weekends. He and her mother separated when Ava was 10. Ms. Johnson began
dating, and when the COVID-19 lockdown happened, she allowed her par-
amour to stay with them for financial reasons, as she was not working. During
the pandemic, Ava was not allowed to see her father for several months due to
his asthma, which was a risk factor for COVID-19. When Ms. Johnson became ill
with COVID-19, the paramour went into Ava’s room nightly and raped her. When
Ava began visiting her father again, she disclosed the child sexual abuse (CSA).
Ms. Johnson brought Ava for treatment because of continued anxiety, flashbacks,
nightmares, noncompliance, crying frequently, and isolating herself.

For this case study, consider:

1. How did the COVID-19 quarantine impact adolescents who experienced
CSA?
2. What should the therapist do if Ava avoids talking about the CSA and only
wants to talk about COVID-19?
3. What specific treatment strategies should be provided? What should psycho-
education address? What should the trauma narration focus on?

Child Sexual Abuse

Previous literature (Kendall-­Tackett, Williams, & Finkelhor, 1993) describes how
CSA has a significant impact on a child’s development and can persist into adult-
hood. Kendall-­Tackett et al.’s review of 45 studies on CSA revealed that sexu-
ally abused children had more symptoms than non-­abused children, with abuse
accounting for 15–45% of the variance. The most frequent symptoms of CSA
were fears, posttraumatic stress disorder, behavior problems, sexualized behav-
iors, and poor self-­esteem. Akinbode, Pedersen, and Lara-­Cinisomo (2020) found

197
198 Chapter 14

that women who experienced CSA during their adolescence had more perina-
tal depression and anxiety than women who did not experience CSA. Kendall-­
Tackett et al. (1993) also found that the degree of symptomatology was related to
specifics of the CSA, such as if there was penetration, the duration and frequency
of the abuse, force, the relationship of the perpetrator to the child, and maternal
support. de Arellano et al. (2014) found that the severity of trauma symptoms
after CSA can also be related to the child’s experience of other childhood trau-
mas, including medical trauma, exposure to domestic violence, terrorism, and
natural disasters. The severity and duration of trauma symptoms depend on how
quickly effective treatment such as Trauma-­Focused Cognitive Behavior Therapy
(TF-­CBT) is provided to the child (Cohen, Mannarino, & Deblinger, 2006).

CSA during COVID-19

When the COVID-19 lockdowns were initiated in March 2020, a concern was
that the combination of increased parental stress, lockdown restrictions that kept
family members from having typical breaks, and reduced time children spent with
mandated reporters would yield an increase in interpersonal traumas such as CSA.
At the same time, Child Protective Service (CPS) professionals were working vir-
tually most of the time due to safety concerns about being exposed to COVID-19.
In April 2020, CPS reported that home investigations, the court process, and in-­
home treatment were at a near standstill (Welch & Haskins, 2020). It was consid-
erably more difficult for the child welfare system to effectively check on the nearly
3.5 million children that they usually contacted (Welch & Haskins, 2020). Also in
April 2020, the Rape, Abuse, and Incest National Network (RAINN) reported a
22% increase in monthly calls from minors by the end of March 2020 with 67%
identifying their perpetrator as a family member and 79% currently living with
that perpetrator (Kamenetz, 2020). According to RAINN, the reports coming in
indicated that child sexual abuse was escalating in both frequency and severity.

Description of TF-­CBT
TF-­CBT (Cohen et al., 2006) is an evidence-­based treatment developed by Judith
Cohen, MD, Esther Deblinger, PhD, and Anthony Mannarino, PhD, and refined
over the past 25 years to help children and adolescents recover from trauma. The
TF-­CBT model was originally designed and found to be efficacious in treating
and reducing symptoms related to child sexual abuse. Later research indicated
that TF-­CBT was efficacious in treating and reducing symptoms for children who
had experienced other traumas as well, including domestic violence, terrorism,
and natural disasters (de Arrelano et al., 2014). Twenty-­one randomized con-
trolled trials conducted throughout the world document that TF-­CBT was supe-
rior for improving children’s trauma symptoms and responses (TF-­CBT, 2023).
TF-­CBT is a hierarchical treatment approach with several components
including psychoeducation, relaxation, cognitive coping, trauma narrative and
 Sexual Abuse 199

processing (i.e., gradual exposure), in-­vivo exposure, conjoint parent–child sessions,

and enhancing safety skills (Cohen et al., 2006). These components are organized
into three phases: stabilization, trauma narration, and integration/consolidation.

Stabilization Phase
The stabilization phase consists of psychoeducation, relaxation skills, affect mod-
ulation skills, and cognitive coping skills (PRAC) for adolescents. Caregivers
also receive this content as well as parenting skills to respond properly to the
trauma and behavioral difficulties. Beginning with psychoeducation, adolescents
and caregivers are separately provided information about the specific trauma(s)
the adolescent experienced and how TF-­CBT can help. They are reassured that
not every trauma they experienced will necessarily be a focus of the TF-­CBT
because the skills will generalize. During psychoeducation, the adolescent and
caregiver answer questions about what information they already know about the
specific type of trauma they endured. This helps the therapist be able to praise
involvement, identify accurate and inaccurate information, and discern possible
cognitive distortions. The therapist then adds information and corrects misinfor-
mation. This approach is engaging and works well for gradual exposure of the
trauma early in treatment.
In the stabilization phase, adolescents also learn and practice relaxation skills,
affect modulation skills (e.g., feelings identification, expression, and regulation),
and cognitive coping. These skills are taught so that adolescents and caregivers
can manage general symptoms as well as trauma symptoms rather than avoiding
them. Gradual exposure in which the adolescent and caregiver talk about the
CSA occurs in each session.
Parenting and behavior management also begin for the caregiver in this phase.
The therapist starts by praising caregivers for seeking services. The therapist gives
effective instructions on behavioral management such as exploring functional
analysis of behavior, explaining differential attention (e.g., reinforcement and
extinction of behaviors), giving 5-minute work chores as consequences for inap-
propriate behavior, providing positive attention, and demonstrating active listen-
ing. These skills are used throughout TF-­CBT and hopefully after treatment ends.
The therapist also assesses the caregivers’ coping skills as well as teaches
them relaxation skills, affect modulation skills, and cognitive coping skills. The
therapist encourages caregivers to practice the skills in the session and for home-
work in between. In contrast to the adolescent’s sessions where cognitive coping
is addressed in the second phase, caregivers learn cognitive coping and restruc-
turing during the stabilization phase. This helps caregivers begin to change their
thoughts and feelings related to their adolescent’s trauma so caregivers can give
more helpful responses.
When using TF-­CBT with adolescents, it is helpful to use playful strategies
such as artwork, using the What Do You Know? card game for psychoeduca-
tion (Deblinger et al., 2019), and using the Triangle of Life online application for
200 Chapter 14

cognitive coping and processing (Mannarino & Cohen, 2014). Bibliotherapy and
relevant games can also make treatment more fun.

Trauma Narration Phase

In the trauma narration phase, it can be helpful to read a book related to CSA
such as the ones listed in the resources below. Then the therapist invites the ado-
lescent to create her own storybook. The therapist segues into the introduction of
the trauma narrative by asking the adolescent to describe herself, her strengths,
what she likes about herself and her family, and her interests. She also is asked to
name the trauma in some way in the introductory chapter. In subsequent sessions,
the adolescent is asked to write chapters on when she disclosed the CSA; details
about her CSA; and her thoughts, feelings, and body sensations about it. Depend-
ing on how long the CSA occurred, and to what extent, there may be one chapter
or several. It can be helpful to develop a table of contents with the adolescent and
order the chapters from the least to most anxiety-­provoking to develop a gradual
exposure hierarchy. If multiple traumas are included, they are worked into the
same hierarchy.
A tentative hierarchy for Ava is described in the case example. As long as the
caregiver is at the same point in the TF-­CBT model, the therapist shares the chap-
ters with the caregivers, without the child present, so the caregiver can share and
process their thoughts and feelings about it. If the caregivers aren’t at the same
point, the caregivers complete the stabilization phase before the therapist shares
the chapters.
As the adolescent’s narrative concludes, the therapist begins to identify covert
and overt/hypothetical cognitive distortions to help the adolescent with cogni-
tive and affective reprocessing. The identification of cognitive distortions occurs
through strategies such as Socratic questioning, evidence gathering, the best
friend role-­play, and psychoeducation. The therapist helps the adolescent repro-
cess these cognitive distortions, separately from the caregiver. As the distortions
are reprocessed successfully, the adolescent adds new thoughts and feelings into
the narrative, usually at the end of each chapter. The reprocessed chapters are
shared again with the caregivers by the therapist, so there are no surprises. This
helps prepare the caregivers for when they attend conjoint sessions where the
adolescent shares the trauma narrative.

Integration/Consolidation Phase
The integration/consolidation phase focuses on the final components of TF-­CBT,
namely in vivo mastery (if needed), conjoint sessions, and enhancing safety skills.
(Note: If there are ongoing safety issues related to immediate environment, then
safety skills are addressed in the stabilization phase). The therapist helps the ado-
lescent identify concerns and locations for in vivo mastery. For example, if the
adolescent is afraid to go down into the basement because that was where the
 Sexual Abuse 201

CSA occurred, then an in vivo plan is developed to desensitize the adolescent to

be able to go into the basement and spend time there.
It can be very helpful to plan conjoint portions of sessions along the way. Con-
joint sessions set the stage so that the adolescent and caregiver are more comfort-
able by the time they share the adolescent’s trauma narrative. Conjoint sessions
also help them both practice stabilization skills. These conjoint sessions reinforce
psychoeducation, mutual praise, relaxation skills, sharing feelings, and so forth. It
is important that both the adolescent and caregiver prepare for conjoint sessions
ahead of time by practicing stabilization skills to prevent retraumatization and to
enhance the adolescent’s healing.
Regarding the sharing of the trauma narrative, the adolescent and the care-
giver should know which portions will be shared that day. If the adolescent has
any specifics about how the caregiver should or shouldn’t respond, the therapist
shares this with the caregiver ahead of time. The adolescent, rather than the thera-
pist, is encouraged to read the narrative to the caregiver. The therapist encourages
the caregiver to provide active listening and praise for the adolescent’s courage.
Afterward, the therapist processes the session with the adolescent and caregiver
separately.
Age-­appropriate provision of sex education should be discussed ahead of
time with the caregiver so that cultural/religious/family preferences are addressed.
Personal safety skills should be carefully introduced with the idea that what-
ever the child did to survive the trauma was the correct response, and the new
skills learned are tools for their future toolbox. This is important, so the child’s
response is not heard as problematic. The therapist can talk about other ways
adolescents normally keep themselves safe. The idea of “no-­go-­tell” is introduced
and can be compared to fire drills, which are also behavior rehearsals. It should
also be stressed that although it is the adolescent’s job to help with their own
safety, it is not their responsibility but, rather, the perpetrator’s not to carry out
the CSA in the first place. What-­if scenarios as well as role-­playing some of these
scenarios is done when the adolescent can regulate a heightened level of anxiety
or discomfort. When role-­playing, it is important not to touch the child and to
turn off the phone before practicing calling 911. The therapist emphasizes that if
abuse occurs in the future, the adolescent can immediately tell an adult and keep
telling until the adolescent gets protection and support. The therapist informs
the adolescent that this step of telling, in real life, can be difficult and anxiety-­
provoking, but she now has the courage and skills to persevere.

Case Study Application

Intake Assessment
An assessment was done with Ava and with Ms. Johnson. Standardized measures
were administered to assess Ava’s trauma symptoms. Ms. Johnson and Ava both
endorsed that Ava had significant symptoms of posttraumatic stress disorder
202 Chapter 14

(PTSD), with some symptoms of depression and anxiety. Ava’s PTSD symptoms
focused on the CSA by Ms. Johnson’s paramour. She did not endorse symptoms
related to racial trauma or microaggressions and felt that she had a solid support
network in this area. Ava had been a fairly compliant child who did well academ-
ically and behaviorally. Now, however, she was often quick to sass her parents
when they asked her to do something, and she was sometimes short with teach-
ers. The results of the behavior measure were within norms for her age, but her
mother was frustrated with the noncompliance and her negative attitude.
Ms. Johnson reported that she herself was having significant difficulties since
Ava disclosed the sexual abuse, although she was supportive and believing. Ms.
Johnson reported that she felt bad that Ava not only dealt with the repercus-
sions of their COVID-19 restrictions but was also sexually abused by the man
she trusted to take care of Ava while she was sick with COVID-19. She blamed
herself for not being aware, acknowledging that she was too sick to do more than
sleep for much of her illness. Ms. Johnson also blamed COVID-19 for creating
the groundwork for the sexual abuse to take place.

Treatment Goals
Treatment goals were as follows:
1. Increase Ava’s understanding about trauma and the CSA and its impact on
her.
2. Increase her coping skills through relaxation, affect modulation, and cogni-
tive coping.
3. Discuss and process thoughts and feelings related to the CSA to the point of
accurate understanding and restoration.
4. Increase her knowledge about age-­appropriate sex education and her per-
sonal safety skills.
5. Reduce her noncompliance.

Initial Phase of Treatment: Stabilization and Skill Building

First, I met with Ava and Ms. Johnson to go over the results of the assessment
measures and to explain Ava’s diagnosis of PTSD. I was careful to explain that
TF-­CBT has been shown in research studies to reduce PTSD symptoms signifi-
cantly, so there was every reason to believe Ava’s symptoms would be much better
at the end of the treatment process. I also discussed the likely length of treatment,
instilled hope, and talked about how Ms. Johnson’s belief in and support of her
daughter were the best predictors of outcome for Ava. Her support combined
with evidence-­based treatment gave them a lot to be positive about.
I spent the rest of that session and part of the next doing psychoeducation
about child sexual abuse and the potential impact of the COVID-19 pandemic on
adolescents. This was done with Ava and Ms. Johnson separately. Related to child
sexual abuse, the What Do You Know card game was used, because including fun
 Sexual Abuse 203

TABLE 14.1. AVA: INITIAL PHASE

Transcript Analysis
T: “Ava, how do you think other kids felt when Checking to see how well she can identify the
they were sexually abused?” different feelings kids may have when they
A: “I guess sad. Mad.” experienced CSA. Then provided gradual
T: “Absolutely they may feel sad or mad. How else exposure (GE) for her own emotions.
might they feel?”
A: “Um. Scared.”
T: “Yes. They may feel scared. What else?”
A: “I don’t know.”
T: “Good job! Let me add some others. Kids may
feel depressed, betrayed, confused, anxious, even
brave, because they got through it and told about
it. All feelings about the CSA are okay. How did
you feel about it?”
A: “Sad. Angry. Confused. Why would he do that This is a good place to try to link the CSA and
when my mom was so sick with COVID?” pandemic lockdown and see if she’ll tell me her
T: “Why do you think he did that?” underlying thoughts.
A: “Because Mom had to stay away from us.” That’s accurate.
T: “Yes. CSA usually happens in secret, so the
perpetrator doesn’t get in trouble. Since back
then with COVID-19, your mom had to be
quarantined for ten days, it made keeping it a
secret more likely. Good job, Ava!”

activities increases engagement of adolescents (Deblinger et al., 2019). With Ava,

the activity was done by going from the general to the specific (gradual exposure),
asking her what she knew, and praising her. I provided additional and/or missing
information and listened for cognitive distortions. This is described as follows:
In subsequent sessions, I taught Ava relaxation skills of diaphragmatic breath-
ing, square breathing, mindfulness, guided imagery, and progressive muscle relax-
ation. I helped her identify the skills she enjoyed and encouraged her to use them
to manage trauma symptoms in and between sessions. Ava demonstrated to her
mother the skill of guided imagery about being at the beach. In a separate session,
I taught Ms. Johnson the same skills. I encouraged her to use them for herself as
well as help Ava practice them if she needed help.
Building on this, I talked to them separately about affect modulation, includ-
ing feelings identification, expression, and modulation skills. Ava did not have
significant difficulties with affect modulation, and this was all she needed. How-
ever, it should be noted that some adolescents do have significant difficulties and
need to spend more time in this component. I checked in with Ava about affect
modulation skills in subsequent sessions and worked on this component with Ms.
Johnson.
I also talked with Ava and Ms. Johnson separately about cognitive coping and
taught them the cognitive triangle (triad). This was done slightly differently for
the adolescent and caregiver, as previously noted. They learned common types of
cognitive distortions and practiced cognitive processing of general thoughts and
examples. I elicited thoughts, feelings, and reactions from Ms. Johnson about the
204 Chapter 14

CSA of her daughter, and used strategies such as Socratic questioning, evidence
gathering, and psychoeducation for her to learn to reprocess.

Middle Phase of Treatment: Trauma Narration

and Cognitive Processing
In the middle phase of treatment, I talked about trauma narration and normal-
ized anticipatory anxiety about it. I stated that many adolescents reported how
helpful it was to talk about their traumatic experiences in detail and to process
them. I read a book (i.e., Please Tell) with Ava about CSA, noting that it was a
bit young for her age. Then I worked on a table of contents with Ava for her own
book of traumatic experiences. I started with the introduction and ended with the
conclusion. We ordered the traumatic experiences from easiest to most anxiety-­
provoking. Ava, with input from me, included chapters on her disclosure of sex-
ual abuse; when her mother became ill with the virus and had to isolate, which
led to the paramour being in more of a caretaking role; and the first, last, and
most difficult time he sexually abused her. Ava chose to draw pictures for each of
the chapters.
As discussed above, if Ava wanted to talk only about the pandemic and avoid
talking about the CSA, I would need to segue to the CSA anyway and not collude
with Ava’s avoidance. I would need to reinforce relaxation, affect modulation,
and cognitive coping (PRAC) skills. I would ensure that the trauma narration
includes the quarantine but would focus on the CSA.

Figure 14.1. “Before I Told” Drawing courtesy of Felicia Neubauer, based on client(s)’
representations.
 Sexual Abuse 205

In preparation for this phase, I talked to Ms. Johnson to remind her that this
is the part of treatment that increases anxiety, and we needed to work together
to help Ava not avoid treatment and to discuss her own avoidance if it arose. I
also continued to work with Ms. Johnson on her own skills and behavior man-
agement. Once trauma narration began, I met with Ava first to review homework,
including skill practice, and elicit the trauma narrative chapter for the session.
First, I elicited an introduction; I wrote down everything Ava said and then read
it back to her for additional gradual exposure and clarification to make any cor-
rections. Then I shared the chapter with Ms. Johnson, without Ava present, so
that Ms. Johnson could process it.
In the following session, I elicited a chapter that was identified by Ava as eas-
iest, which was when her mother became ill, followed by the disclosure and first
experience of CSA. These and the remaining chapters were elicited in the order
described above. After each chapter was written, I shared it with Ms. Johnson by
herself so she could process the information.
Once the trauma narration was completely elicited, I worked with Ava to use
strategies including psychoeducation, evidence gathering, and Socratic questioning
to process her current and previous thoughts. I helped Ava facilitate more appro-
priate thinking and better feeling about the trauma experiences. This is shown as
follows:

TABLE 14.2. AVA: MIDDLE PHASE

Transcript Analysis
T: “Let’s look at some of the thoughts you have There is some validity to that possibility or at least
identified in here. You said if the pandemic didn’t the timing. Let’s see if we can go deeper.
happen and your mom didn’t get sick, the CSA
wouldn’t have happened.”
A: “Yes. If COVID didn’t happen, he wouldn’t have
been living with us, my mom wouldn’t have been
ill, and he wouldn’t have gotten to me to sexually
abuse me.”
T: “That sounds like it could be true. However, do
you think all kids quarantined during the pandemic
were sexually abused?”
A: “Probably not.” Let’s see if she can use logic to dispute and
T: “Yes. So, what do you think made the reprocess her own cognitive distortion.
difference?”
A: “I guess most people wouldn’t think about
doing CSA, so it didn’t happen to the kids around
them.”
T: “Exactly right, Ava. Great job. So, what made
the CSA happen then?”
A: “The circumstances were caused by COVID, Awesome job, Ava! Praising the cognitive
but it was because he thought about it and acted restructuring, this is a much more accurate
on it that the CSA happened.” thought; cognitive processing is working.
206 Chapter 14

As the chapters were reprocessed, I shared them with Ms. Johnson again.
When the entire trauma narration was reprocessed, it was put in order, and then
I worked with Ava and Ms. Johnson to prepare them for the conjoint sessions
where Ava would share the trauma narration directly with her mother. This
included having them identify which coping strategies they would use if needed,
having Ava give input into how she wanted her mother to respond, and having
Ms. Johnson practice her responses. The conjoint sessions were then held to pre-
pare them, share the narration, and talk with each to process the experience.
The remaining components of the TF-­CBT, such as age-­appropriate sex edu-
cation, were completed in subsequent sessions. I spoke with Ms. Johnson to dis-
cuss the subject matter with her and to encourage her to do the sex education
with Ava herself, so she knew exactly what was being said and so she could share
her values and beliefs. In preparation for the sex education discussion with Ava,
I gave Ms. Johnson a book (What’s Happening to My Body: Book for Girls,
Madaras, 2007) to review and use. Although many caregivers prefer that the
therapist discuss the sex education directly with their adolescent, Ms. Johnson
did talk with Ava herself. Ava did not need to do in vivo exposure, so that is not
included here.
In the final component, which overlapped with conjoint sessions, I explained
to Ava that everything she did during the trauma was the right thing, because she
survived it, and the skills she learned are additional tools for her toolbox. This
is important so Ava did not feel that I thought she responded “wrongly” at the
time. Then what-­if situations were discussed and role plays were done where she
practiced the concepts of personal safety skills, including yelling no, getting away,
telling an adult, and continuing to tell until someone believes and helps her.

Ending Treatment
During the final session, Ava and Ms. Johnson completed the same standard-
ized measures for posttreatment results, which showed that Ava had significantly
fewer trauma symptoms and no longer met full criteria for a posttraumatic stress
diagnosis. These results were shared with Ava and her mother. I gave Ava her
certificate of completion. We shared cupcakes together and discussed the impor-
tance of continuing to use her treatment skills. I stressed that if Ava has thoughts
or feelings about her traumatic experiences, she should continue to talk to her
mother about it, and they could call for booster sessions if needed.

Ethical and Cultural Considerations

For racially and ethnically diverse clients, the therapist needs to assess for racial
trauma in addition to the CSA. Ava, as a biracial adolescent, felt like she was not
exactly like her African American father or her Caucasian mother. However, she
had support from her father and community to process racism, so Ava reported
that racial trauma was not a concern for her.
 Sexual Abuse 207

The therapist also needs to assess whether adolescents have significant trauma
symptoms related to the impact of COVID-19. TF-­CBT skills can generalize to
manage many traumas. Ava processed her COVID-­ related concerns with the
skills she learned in TF-­CBT.
In cases of abuse, the therapist needs to ensure that abuse was reported to
authorities and obtain the report number for case records. If the abuse was not
properly reported, then the therapist needs to contact police and/or their local
Child Protective Services. Finally, therapists need to be aware that they may be
called into court to testify. Therefore, every effort needs to be made to keep accu-
rate and timely records as well as review state rules and regulations. In cases
of divorce, therapists need to read the most recent divorce decree to determine
which person has rights to obtain mental health services. The therapist needs to
inform all parents or caregivers of the treatment being provided and offer to meet
with them as needed.

Parent Consultations
As described above, I provided parent consultation and guidance throughout TF-­
CBT to Ava’s mother, Ms. Johnson. I invited Ava’s father to join the process. He
declined to do so on a regular basis due to distance and time constraints. How-
ever, he was willing to engage in a few telehealth sessions in which I informed
him of treatment goals and strategies, common symptoms of CSA, Ava’s progress,
and parenting strategies to facilitate her coping skills. Although Ava’s father expe-
rienced intense guilt and anger regarding her CSA, he declined to seek his own
counseling mostly due to stigma. Therefore, I normalized his feelings, coached
him on the same coping skills I was teaching Ava, and provided him parenting
resources as shown below.

Conclusion
Ava and her mother appeared to benefit from TF-­CBT. Standardized measures,
anecdotal information, as well as my observations, showed significant treatment
progress and symptom reduction. The willingness of Ava and Ms. Johnson to
work on and implement the components was instrumental in Ava’s symptom
reduction. Implementation of behavior management reduced Ava’s noncompli-
ance. Ava was able to process the CSA and the impact of her mother’s illness.
Ms. Johnson was able to reduce her self-­blame and to be instrumental in her
daughter’s symptom reduction. Both Ava and Ms. Johnson learned how resil-
ient they are. Despite being guardedly confident in the beginning of treatment
during COVID-19, I learned that the TF-­CBT worked well related to the impact
of COVID-19.
208 Chapter 14

Sample Case Notes

Session 1
Ava was accompanied to the individual treatment session by her mother. Met
with Ms. Johnson, who reported a better week and that Ava was less stressed.
Relaxation homework was reviewed with each separately, and both reported
using them and found them helpful. Ms. Johnson learned the cognitive triangle,
and homework was assigned for her to practice during the week. The cogni-
tive triangle was introduced to Ava, and read and discussed part of a storybook
about changing negative thinking to positive thinking. Ava was given homework
to continue to practice relaxation skills and to use the cognitive coping skills
related to some peer difficulties.

Resources

For Professionals
Helping the Traumatized Child: A Workbook for Therapists (Helpful Materials
to Support Therapists Using TFCBT: Trauma-­Focused Cognitive Behavioral
Therapy) by George Sachs (2015).
NCTSN. Secondary Traumatic Stress in Professionals Treating Child Sexual Abuse,
https://www​.nctsn​ .org/resources/​ secondary-­traumatic-­stress-­professionals​
-­treating​-­child​-­sexual-­abuse
TF-­CBT Web 2.0: A course for Trauma-­Focused Cognitive Behavioral Therapy,
https://tfcbt2.musc​.edu/

For Children and Adolescents

Hush: Moving from Silence to Healing after Childhood Sexual Abuse by Nicole
Braddock Bromley (2007).
The Hyena Who Lost Her Laugh: A Story about Changing Your Negative Think-
ing by Jessica Lamb-­Shapiro (2000).
It’s Not Your Fault by Lindsay Kreps (2020).
Please Tell: A Child’s Story about Sexual Abuse by Jessie (1991).
What’s Happening to My Body by Lynda Madaras (2007).

For Parents
Healing the Harm Done: A Parent’s Guide to Helping Your Child Overcome the
Effects of Sexual Abuse (English and Spanish edition) by Jennifer Y. Levy-­
Peck (2009).
NCTSN. Creating Supportive Environments When Scary Things Happen, https://
www​ . nctsn​ . org/resources/creating ​ - s­ upportive ​ - e­ nvironments ​ - w
­ hen- s­ cary​
-­things​-­happen
 Sexual Abuse 209

NCTSN. Teen Sexual Assault: Information for Parents, https://www​​.nctsn​.org/

resources/teen-­sexual-­assault-­information-­parents

Discussion Questions
1. What behaviors might be noticed in an adolescent that might concern a par-
ent about possible trauma?
2. If Ava had refused to go into detail in the trauma narrative, how could the
therapist have helped her work through avoidance?
3. If Ava’s father had also wanted to participate in the TF-­CBT, how might the
therapist work with separated parents?
4. How did the therapist work with Ava to identify a table of contents and sub-
sequent hierarchy for trauma narration?

References
Akinbode, T. D., Pedersen, C., & Lara-­Cinisomo, S. (2020). The price of pre-­
adolescent abuse: Effects of sexual abuse on perinatal depression and anxiety.
Maternal and Child Health Journal, 25, 1083–1093. https://doi​.org/10.1007/
s10995​-020-03088-x
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and trau-
matic grief in children and adolescents. Guilford Press.
de Arellano, M. A. R., Lyman, D. R., Jobe-­Shields, L., George, P., Dougherty, R.
H., Daniels, A. S., Ghose, S. S., Huang, L., & Delphin-­Rittmon, M. E. (2014).
Trauma-­focused cognitive​-b ­ ehavioral therapy for children and adolescents:
Assessing the evidence. Psychiatric Services, 65(5), 591–602. https://doi​.org/​
10​.1176/appi​.ps.201300255
Deblinger, E., Neubauer, F., Runyon, M., Baker, D., Sirois-­Geddie, A., Marquez,
Y. I., & Pollio, E. (2019). What do you know? A therapeutic card game about
childhood trauma, sex education, and personal safety (2nd ed.). CARES Insti-
tute, Rowan Medicine.
Kamenetz, A. (2020). Child sexual abuse reports are on the rise amid lock-
down orders. NPR. https://www​.npr​.org/sections/corona​virus-­live-­updates/​
2020/04/28/847251985/child-­sexual​-­abuse-­reports-­are-­on-­the-­rise-­amid-­lock
down-­orders
Kendall-­Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual
abuse on children: A review and synthesis of recent empirical studies. Psycholog-
ical Bulletin, 113(1), 164–180. https://doi​.org/10.1037/0033-2909.113.1.164
Mannarino, A., & Cohen, J. (2014). TF-­CBT triangle of life app. https://tfcbt​.org/
tf​-­cbt​-­triangle-­of-­life/
TF-­CBT. (2023). About trauma-­focused cognitive behavior therapy (TF-­CBT).
http://Tfcbt​.org
210 Chapter 14

Welch, M., & Haskins, R. (2020, April 30). What COVID-19 means for Amer-
ica’s child welfare system. Brookings. https://www​.brookings​.edu/articles/
what-­covid​-19-means-­for​-­americas-­child-­welfare-­system/
 CHAPT E R 1 5

Self-­Harm
Dialectical Behavior Therapy with an
African American Adolescent
Anelie Etienne and Domonique Messing

Ashly Johnson is a 14-year-­old African American female. Ashly lives with her
mother, Amber Johnson, a 34-year-­ old African American woman, and three
younger half siblings, James Johnson, 10, Kevin Johnson, 7, and Nicole Miller,
5. Ashly’s mother’s boyfriend, Robert Miller, is a 39-year-­old Caucasian man and
is the father of Nicole, and he resides in the home. Ashly’s father, Levi Smith, is a
35-year-­old African American man who lives three towns over with his girlfriend,
Sarah King, who is African American, and Ashly’s half sister Leah Smith, who is
6. Ashly and her father have a strained relationship, in part because he is unable
to consistently spend time with Ashly. Mr. Smith works a factory job with no paid
time off and relies on his girlfriend for transportation. Ashley’s mother and her boy-
friend (Mr. Miller) have a contentious relationship, often having verbal arguments
and one reported physical fight occurring during Ms. Johnson’s pregnancy with
Nicole. Ashly frequently stayed with a friend, who lived up the street, to escape
the tension and fights at home. Until recently, the family lived in a predominantly
African American neighborhood.
Mr. Miller recently won a lawsuit against his former construction employer and
decided to move the family to a more affluent, predominantly Caucasian neigh-
borhood. As a result, Ashly changed schools and struggled to make new friends.
Ashly reports that “the neighbors are mean, and I feel like an outsider at school.”
Ashly shared that at school “a group of girls called me nig—and monkey.” Ashly
is ostracized by her peers, and her grades have begun to decline. Ashly has told
her mother, “I feel sad all the time.” Ashly wants to move back to her old neighbor-
hood and frequently shares this with her mother. However, Ms. Johnson is unable
to afford rent without Mr. Miller. Ashly’s father expressed that he is unable to care
for her financially and that she must stay with her mother. Ms. Johnson recently
noticed cuts on Ashly’s right arm. Ms. Johnson is seeking counseling services for
Ashly due to her cutting, experience of racism, isolation, and declining grades.

211
212 Chapter 15

For this case study, consider:

1. What are the common concerns for African American adolescents who expe-
rience hate speech? What has contributed to Ashly’s behavior of self-­harm?
2. What is the rationale for using Dialectical Behavior Therapy (DBT) with
Ashly?
3. What ethical guidelines need to be considered?

Hate Speech: A Form of Bullying

For this case study, we will consider hate speech as a form of bullying and will
evaluate the prevalence of self-­injurious behaviors in adolescents who experience
symptoms resulting from hate speech. This information will help us understand
the impact of racially motivated behaviors, particularly in adolescents, and the
methodology to treat the symptoms effectively.
Many people believe teasing is a common aspect of the coming-­of-­age pro-
cess that most children face. However, some believe there is a threshold between
harmless teasing and behavior that seems more sinister. With racial tensions
rising, hate speech is becoming more common and its impacts more apparent.
Kansok-­Dusche and colleagues’ (2022) study noted that an exclusive definition
did not exist for hate speech. However, it was generally described as an aggressive
or violent interaction rooted in prejudice, based on nationality, race, ethnicity, or
sexual orientation with malicious intent (Kansok-­Dusche et al., 2022).
Although the literature reveals gaps in the research about hate speech, the
experience of African American youth and the impact of race-­related trauma are
undeniable. African American girls simultaneously manage the physiological,
psychological, and psychosocial challenges of adolescence, race, and gender. They
may also face other uncontrollable components such as family income. Socio-
economic status is a major factor in the prevalence of hate speech, with lower-­
income families being more likely to experience hate speech when compared to
their more affluent counterparts (Kansok-­Dusche et al., 2022).
The experience of hate speech during an African American girl’s journey
through her developmental stages can pose additional strains on her mental
health, as well as negatively impact her behavior and school performance (Evans,
2019). Children lack the emotional intelligence to cope with the trauma imposed
on them when they experience race-­related stress, and consequently maladaptive
behaviors form (Kansok-­Dusche et al., 2022). Unfortunately, studies have shown
that when challenging behaviors occur in school, African American girls receive
harsher discipline compared to their White counterparts (Evans, 2019). Often,
this form of systemic racism is one of many examples of the intersectionality of
race and institutions that they may encounter on their path through life as an
African American girl.
According to a longitudinal study over 10 years, the Centers for Disease Con-
trol and Prevention (2023) reported that three out of five high school–age girls
 Self-­Harm 213

experience chronic feelings of sadness and hopelessness, with a record high in

2021. Although sadness and hopelessness may increase for all female high-­school
students, African Americans were more likely to have attempted suicide and more
likely to miss school because they felt unsafe (Centers for Disease Control and
Prevention, 2023). More than 90% of African American youth over the age of
8 years old will be exposed to racial discrimination, which will have an adverse
impact on their self-­esteem, disposition, and interpersonal skills, and significantly
reduce their ability to perform academically (Williams, 2020).

Non-­Suicidal Self-­Injury
Non-­suicidal self-­injury (NSSI) is defined as “purposeful, self-­inflicted destruction
of one’s own body that is neither socially endorsed (e.g., piercing, tattooing, scar-
ification) nor deliberately intended to lead to death” (Rojas-­Velasquez, Pluhar,
Burns, & Burton, 2021, p. 368). The rate of self-­injurious behaviors among ado-
lescents is between 17 and 60% (Rojas-­Velasquez et al., 2021). Of those who
engage in these behaviors, 90% of them use it to cope with difficult and unpleas-
ant feelings (Rojas-­Velasquez et al., 2021). Literature on NSSI has been domi-
nated by studies primarily focused on middle- to upper-­class young Caucasian
women. African Americans and other ethnic communities are underrepresented
in the NSSI literature (Rojas-­Velasquez et al., 2021). This gap in the literature
may lead practitioners to believe that fewer disparities exist across different eth-
nicities; however, African American youth experience race-­related stressors that
create significant long-­lasting mental health outcomes (Williams, 2020). Risk fac-
tors for African American youth include emotional dysregulation, difficult social
and familial relationship, poor coping skills, and coexisting mental health condi-
tions (Rojas-­Velasquez et al., 2021).
Studies have established that people who engage in self-­injurious behaviors
are much more likely to attempt suicide, especially female adolescents (Koth-
gassner et al., 2021). The number of African American female adolescents who
engage in self-­injurious behaviors or attempted suicide has recently increased
(Centers for Disease Control and Prevention, 2023). This increase is understand-
able given that many African American female adolescents may have experienced
hate speech and have lacked the tools to manage the distressing emotions. Afri-
can American girls who engaged in self-­injurious behaviors within the context of
hate speech need an evidence-­based intervention to recover.

Dialectical Behavioral Therapy

Dialectical Behavior Therapy (DBT), created by Marsha Linehan (2015), was ini-
tially designed for the treatment of borderline personality disorder. It was later
adapted to address a variety of mental health concerns (Lenz, Del Conte, Hollen-
baugh, & Callendar, 2016). DBT has skills that can assist a client in managing
intense and overwhelming emotions. Dialectic philosophy has three core beliefs:
214 Chapter 15

everything is interconnected, change is constant and inevitable, and opposites can

be integrated to get closer to the truth (Lenz et al., 2016).
DBT uses four skill sets to assist clients in overcoming their current mental
health struggles: mindfulness, distress tolerance, interpersonal effectiveness, and
emotional regulation. The mindfulness models were adapted from Eastern med-
itation practices. This technique teaches a client to become more aware of the
present moment (Lenz et al., 2016). The client learns to focus on a single thing
without judgment of self or others. The distress tolerance model teaches clients to
accept things over which they do not have control, as well as problem solve and
improve their mood. Distress tolerance teaches clients to tolerate uncertainty in
life and manage the painful feelings that result. Interpersonal effectiveness teaches
self-­advocacy, boundaries, and the ability to say no. Emotional regulation will
help them understand that emotions are not permanent, and feelings can be fleet-
ing (Lenz et al., 2016).
DBT treatment procedures and strategies that will be helpful to Ashly with
self-­harm and bullying are mindfulness, distress tolerance, interpersonal effective-
ness, and emotional regulation. Given Ashly’s developmental level, she will bene-
fit from DBT and has the developmental capacity to understand, learn, and apply
the skills of DBT. Ashly has entered Piaget’s formal operations stage; she is able
to engage in abstract and hypothetical reasoning. In this stage of development,
Ashly will be able to review her progress, continually reevaluate her goals, and
understand and apply metaphors to her current life circumstances (Miller, 2011).
Distress tolerance skills will teach Ashly to tolerate her strong emotions
without using the maladaptive coping skill of self-­harming. Self-­harming by cut-
ting is an impulsive behavior based on strong emotions. Interpersonal effective-
ness will focus on building Ashly’s interpersonal communication skills so she
can express her needs instead of burying them. Self-­injury often occurs because
a youth struggles with communication. Ashly resorts to self-­injury instead of
talking about what she is going through. She will develop control over her emo-
tions and, through emotional regulation, eliminate the impulse to react with a
negative coping skill whenever strong emotions come up. Mindfulness will aid
Ashly in recognizing her thoughts and feelings while accepting them without
judgment. Learning mindfulness will assist Ashly in interrupting her strong emo-
tions and allow her to pause long enough to implement positive coping skills
instead of acting on the impulse to cut.
According to Erikson (1950), peers and academic success greatly influence
Ashly’s self-­esteem. Connecting with peers is extremely important in this stage
of Ashly’s life. The lack of positive peer connection, academic failure, and race-­
related stress lead to low self-­esteem and maladaptive behaviors (Miller, 2011).
Ashly’s depression, race-­related stress, and self-­harm require a treatment modal-
ity that helps her develop practical cognitive and behavioral coping skills. DBT
provides a therapeutic approach that will assist Ashly in moving from a dysregu-
lated to a regulated mind.
 Self-­Harm 215

Case Study Application

In considering the different factors that make up Ashly’s case, I (DM) decided to
use two models to help guide my understanding of Ashly: DBT and the RESPECT-
FUL model of counseling. The RESPECTFUL acronym refers to Religious/spiri-
tual identity; Economic class; Sexual identity; Psychological maturity; Ethnic/
racial identity; Chronological/developmental challenges; Traumatic experiences;
Family background; Unique physical characteristics; and Location of residence
and language (D’Andrea & Daniels, 2001). As previously stated, DBT provides
technical skills that teach clients how to replace maladaptive behaviors and man-
age difficult emotions. This modality has been effective for adolescents engaging
in self-­harm and suicidal ideations (Kothgassner et al., 2021). The success was
attributed to the holistic approach of integrating the family into the treatment
process (Kothgassner et al., 2021).
The RESPECTFUL model helps me consider Ashly’s multidimensional back-
ground to guide the therapeutic intervention. First, I consider Ashly’s spiritual
and religious background. Ashly and her mother both report they are of Christian
faith. However, they do not attend church regularly. Ashly has reported concerns
about “disappointing God because I cut.” Next, I consider Ashly’s economic class
and background (LeBeauf, Smaby, & Maddux, 2009). Ashly is of a lower socio-
economic status. The family’s socioeconomic status has impacted the resources
to which they have access. Ashly’s mom reports housing insecurity without the
support of her boyfriend. It is possible that Ashly, her siblings, and her mother are
also dependent on her mom’s boyfriend for other basic needs such as food and
clothing (LeBeauf et al., 2009).
Ashly identifies as a cisgender heterosexual female. Ashly’s gender identity
does not significantly impact her life negatively or positively. Ashly is a 14-year-­
old African American female who feels increasingly isolated in her new predomi-
nantly White neighborhood and school. She believes she has no control over her
current living situation and must “deal because I have nowhere else to go.” Ashly
relates most to her mother’s side of the family. She reports having a stronger
sibling bond with her mother’s children than with her father’s daughter. Ashly is
very close to her extended family, particularly her first cousins.

Treatment Goals
Ashly’s treatment goals were developed with the family. The family and I explored
where we should begin. Ashly stated, “I don’t really know what depression is or
why I feel this way.” When developing treatment goals, I combine the client’s lan-
guage with my clinical understanding. Therefore, Ashly’s initial treatment goal is
“Ashly will be able to understand her depression better.” Ashly stated, “I want to
be able to know why I am feeling this way.” Ashly’s initial objective is “Ashly will
learn emotional vocabulary in individual weekly sessions to better describe what
she is feeling.”
216 Chapter 15

During the initial assessment, a safety plan was developed due to Ashly’s his-
tory of cutting. The family and I reviewed Ashly’s protective factors, which she
identified as “support from my cousins, going for walks, drawing, and sometimes
reading.” We identified her triggers, which she stated are “mom not listening, not
being able to see my cousins, and tension at home.” We also identified which
adults Ashly views as supportive. Ashly identified an art teacher (at her former
school), her older cousin, and sometimes her mother. We also reviewed 24-hour
emergency community resources when my therapy office is closed.

Treatment Process
My goal for the first session was to begin building rapport with Ashly, explore
confidentiality and its limits, and explain what DBT is and how I believe it could
help her overcome her current mental health struggles. I prepared my office by
turning off the overhead lights and turning on the lamp on my desk. I also put
fidgets out for Ashly to use if she became nervous or needed a distraction. After
introducing myself and giving Ashly three fun facts about me, I asked Ashly to
do the same. I then explained to Ashly what Dialectical Behavior Therapy is and
how I believed the different skills could help her. I recommended that we start
with distress tolerance skills. I invited Ashly to engage in a distress tolerance
activity called Pros and Cons to examine the pros and cons of having drama and
stress and not having it. See table 15.2 and figure 15.1, Activity from sessions 1
and 2 (Moonshine, 2008).

TABLE 15.1. DISTRESS TOLERANCE SKILLS: PROS AND CONS

Pros of Cutting Cons of Cutting
• Changes the pain from my heart to my body • Leaves marks and scratches/scars
• I’m in control. I say when it happens. • It makes my mom scared.
• My dad comes to see me when I cut. • Cutting doesn’t make dad come see me more.
Cons of Not Caring about School Pros of Not Caring about School
• All the attention from adults . . . annoying • I’m in therapy.
• I might fail ninth grade. • Summer school might be an option; also, it can
• I have to make up all the schoolwork I did not be less stressful than regular school.
do. • I’ve been given extra time to make up my
schoolwork.
TABLE 15.2. ASHLY: SESSION 1
Transcript Analysis
T: “As I said before, distress tolerance is about Reinforcing what distress tolerance is and how
learning to deal with frustration and being able it can help Ashly in her everyday life will assist in
to deal with stress, drama, and crisis in a healthy promoting a sense of self-­efficacy.
way.”
A: “Okay, yeah, I remember you saying that. Not Adolescents often feel unsure about learning new
really sure how to do that.” ways of doing things.
T: “We will build your skills by learning different Reassuring Ashly that I will be there to help her
strategies.” learn and build her new skills.
A: “So, you want me to do this work sheet? It Adolescents often try to make sense of new
seems stupid and a lot like schoolwork.” experiences by comparing them to places or
situations that seem similar.
T: “Yes, I would like you to complete the Normalizing and reassuring Ashly that her
worksheet. I know it seems like schoolwork, and I thoughts are common.
believe it will be helpful.”
A: “Can we do it together?” Partnering is an excellent way to help adolescents
overcome any worries or concerns they may have.
T: “Sure, you let me know when you would like my Giving adolescents a sense of control can help
help.” them feel secure and safe in new situations.

Figure 15.1. Activity. Figure courtesy of Domonique Messing based on client’s representation.
218 Chapter 15

My goal for Ashly’s second session was to continue exploring distress tol-
erance and build on the skills learned from the Pros and Cons work sheet. This
week I wanted to provide Ashly with a skill she can use outside of the session to
aid her during stressful or difficult situations. I explained to Ashly that observe
breathing is a breathing technique that would help ground her, keep her focused
on the present moment, and distract her from the stressful situation.

TABLE 15.3. ASHLY: SESSION 2

Transcript Analysis
T: “Ashly, I want to invite you to try a breathing Inviting Ashly instead of telling her, to give her
exercise that will help calm you when stressed or agency during our session time.
in difficult situations.”
A: “Ms., I don’t think breathing will help me when Adolescents are often skeptical of new skills and
I’m stressed.” information.
T: “I know it’s not something you would usually Validating that what I am asking Ashly to do is
use when stressed. Are you willing to see what it new and outside of her comfort zone, and again
is about?” inviting her to try the activity
A: “Ugh, I guess, Ms., but you have to do it too.” It’s often easier for adolescents to engage in a
new task if they have a partner.
T: “Inhale while counting to five slowly. Let the Guiding Ashly through the activity while fulfilling
breath out while counting to five slowly.” [Repeat her request to do it together. This helps Ashly feel
five times.] less awkward.
A: “Ms., I can’t just stop and do that when Expressing doubt and worry about her own ability
something is making me stressed.” to use observe breathing as a coping skill in
everyday life
T: “Right now, you see it as impractical. I believe Reflecting her perception. Adding hope that she
as we practice this together, it will eventually can learn. Asking for her willingness to engage in
become second nature. Are you willing to practice just one small step during session [I prompt her to
this with me in session when I prompt you?” practice it about every 10 minutes the rest of the
session and subsequent sessions].
 Self-­Harm 219

Ethical and Cultural Considerations

Race is a sensitive topic for many people. Therefore, when engaging in race-­
related conversations, feelings of discomfort may arise. However, in therapeutic
relationships, uncomfortable conversations are frequent and expected. A thera-
pist must be nonjudgmental; otherwise, it may impede treatment success. Thus,
maintaining self-­awareness and using supervision can be helpful.
As an African American therapist, it was ethically important for me to man-
age my own biases and experiences of microaggressions, especially when working
with a client who has similar life experiences. Supervision can be used to address
a therapist’s thoughts and feelings that arise when addressing sensitive topics.
A goal of supervision can be “confronting and exploring emotionally charged
subject matter while maintaining an atmosphere of compassion and empathy for
the anxiety, pain, ambivalence, and anger that can accompany topics of race”
(Harrell, 2014, p. 85). It is highly recommended that therapists use supervision
to explore race-­related experiences that may be unintentionally triggered while
counseling a client so that therapists can maintain a nonjudgmental attitude
toward everyone.

Parent Consultations
The first parent consultation meeting was with Ms. Johnson. Mr. Smith was
scheduled to join this session; however, he was unable to attend. Mr. Smith did
not provide a reason for his absence. I informed Ms. Johnson that parent consul-
tations are essential to the therapeutic process because they allow me to support
her while she supports Ashly. I explained that these meetings are an opportunity
for her to express her concerns, receive validation, and learn the strategies Ashly
was learning in her sessions. Ms. Johnson expressed concern, stating, “I don’t
know if I will always have time to make these meetings because I have other
kids with a lot going on.” Ms. Johnson explored other options for meeting with
me, including online virtual and phone sessions. During parent consultation, Ms.
Johnson and I reviewed and practiced the skills Ashly had been working on in the
session.

Conclusion
Throughout treatment, Ashly gained numerous DBT coping skills to assist her in
managing her depressive symptoms and self-­harm behavior. Ashly identified DBT
coping skills that could aid her in stressful situations, even though she reported
not implementing them consistently. Ashly and her family reported that she no
longer cut herself. Ashly identified one peer with whom she has become “good
friends.” Ashly continued to be open to learning more DBT skills to manage her
mental health symptoms better and remained in ongoing individual therapy as
needed.
220 Chapter 15

Sample Case Notes

Session 1
Subjective: The client expressed uncertainty about beginning the therapeutic
process, specifically using DBT. She expressed that the initial activity felt “like
schoolwork” and was hesitant to write down her thoughts. The client acknowl-
edged her depression symptoms; she stated, “Sometimes it’s too much, and I just
want to relieve the pain.”
Objective: At the start of the session, client was quiet and only engaged this ther-
apist when prompted. The client used fidgets during the session. The client visibly
relaxed when this therapist also agreed to complete a Pros and Cons work sheet.
This therapist and client explored how understanding the pros and cons of a
situation can assist the client in problem solving and finding ways to cope and
manage stress or drama.
Assessment: From a Dialectical Behavior Therapy perspective, Ashly appears to
be experiencing symptoms of depression and self-­harm due to stressors in the
home, experiencing hate speech at school, moving to a predominantly White
neighborhood, not experiencing validation, and lacking coping skills.
Plan: This therapist will teach concepts of DBT and use different worksheets and
activities to reinforce problem solving and effective ways for Ashly to cope with
current life stressors and crises.

Resources

For Professionals
Dialectical Behavior Therapy: Volume 1—The Therapist’s Guidebook, https://a​
.co/d/4MxCg7b
Dialectical Behavior Therapy: Volume 2—Companion Worksheets, spiral-­bound,
https://a​.co/d/57t4P2t

For Teens
The DBT Skills Workbook for Teens: A Fun Guide to Manage Anxiety and Stress,
Understand Your Emotions and Learn Effective Communication Skills (Life .
. . Health and Wellness Books for Teenagers), https://a​.co/d/6VJDH8c

For Parents
DBT Skills Workbook for Parents of Teens—A Proven Strategy for Understand-
ing and Parenting Adolescents Who Suffer from Intense Emotions, Anger, and
Anxiety, https://a​.co/d/0dlDJKI
 Self-­Harm 221

Discussion Questions
1. What contributing factors exacerbated Ashly’s depression symptoms?
2. As a therapist, how would you prepare to talk to your client about race or
racism?
3. As a therapist, how would you prepare yourself to deal with potential triggers
from the case that could create therapy-­interfering behaviors?

References
Centers for Disease Control and Prevention. (2023). CDC’s youth risk behavior
survey data summary & trends reports, 2011–2021.
D’Andrea, M., & Daniels, J. (2001). RESPECTFUL counseling: An integrative
model for counselors. In D. Pope-­Davis & H. Coleman (Eds.), The interface
of class, culture and gender in counseling (pp. 417–466). Sage.
Erikson, E. H. (1950). Childhood and society. Norton.
Evans, K. (2019). The invisibility of Black girls in education. Relational Child &
Youth Care Practice, 32(1), 77–90.
Harrell, S. (2014). Compassionate confrontation and empathic exploration: The
integration of race-­related narratives in clinical supervision. Multicultural-
ism and Diversity in Clinical Supervision: A Competency-­Based Approach,
83–110. http://dx​​.doi​.org/10.1037/14370-004
Kansok-­Dusche, J., Ballaschk, C., Krause, N., Zeißig, A., Seemann-­Herz, L., Wachs,
S., & Bilz, L. (2022). A systematic review on hate speech among children and
adolescents: definitions, prevalence, and overlap with related phenomena.
Trauma, Violence, & Abuse. https://doi​.org/10.1177_15248380221108070
Kothgassner, O. D., Goreis, A., Robinson, K., Huscsava, M. M., Schmahl, C., &
Plener, P. L. (2021). Efficacy of dialectical behavior therapy for adolescent self-­
harm and suicidal ideation: A systematic review and meta-­analysis. Psycholog-
ical Medicine, 51, 1057–1067. https://doi​.org/10.1017/S0033291721001355
LeBeauf, I., Smaby, M., & Maddux, C. (2009). Adapting counseling skills for
multicultural and diverse clients. In G. R. Walz, J. C., Bleuer, & R. K. Yep
(Eds.), Compelling counseling interventions: VISTAS 2009 (pp. 33–42).
American Counseling Association.
Lenz, S. A., Del Conte, G., Hollenbaugh, M. K., & Callendar, K. (2016). Emo-
tional regulation and interpersonal effectiveness as mechanisms of change
for treatment outcomes within a DBT program for adolescents. Counsel-
ing Outcome Research and Evaluation, 73–85. https://doi.org/​10​.1177/​
2150137816642439
Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). Guilford Press.
Miller, P. H. (2011). Theories of developmental psychology. Worth.
Moonshine, C. (2008). Acquiring competency and achieving proficiency with dia-
lectical behavior therapy. Pesi.
222 Chapter 15

Rojas-­Velasquez, D. A., Pluhar, E. I., Burns, P. A., & Burton, E. T. (2021). Non-
suicidal self-­injury among African American and Hispanic adolescents and
young adults: A systematic review. Prevention Science, 22, 367–377. https://
doi​.org/10.1007/s​11121​-020-01147-x
Williams, M. T. (2020). Microaggressions: Clarification, evidence, and impact.
Perspectives on Psychological Science, 15(1), 3–26. https://doi​.org/​10​.1177/​
1745691619827499
 CHAPT E R 1 6

Tourette Syndrome and Risk

of Exploitation
Equine Assisted Family Play Therapy
with a White Adolescent
Tracie Faa-­Thompson

Jenny is a 16-year-­old White adolescent female. She moved into our area of
England about a year before she and her family commenced therapy. She lives
with her mother and her younger sister. The family moved to be near their mater-
nal grandmother and her partner after Jenny experienced bullying due to her
Tourette syndrome. Jenny attended the local high school about 20 miles from
where she lived until the school closed due to the COVID-19 pandemic. When the
lockdown ended, she returned to school. Unfortunately, the stress of being back
in school was too much for her, and she was unable to control her Tourette syn-
drome of vocal and motor tics. Her Tourette syndrome presented as her running
down the school corridors past classrooms banging on doors and windows while
making threats. This was taken very seriously by school personnel, and she was
excluded from school with the caveat that she was not to return until she was
“better.” Since her mother’s parenting style was permissive, her mother struggled
to set boundaries or sanctions when Jenny’s behavior was unacceptable, which
put Jenny at risk for exploitation.

For this case study, consider:

1. How did the combination of Tourette’s, risk of exploitation, and the COVID-
19 pandemic impact Jenny and her family?
2. What were the benefits of using Equine Assisted Family Play Therapy™
(EAFPT) with Jenny?
3. What procedures in EAFPT were particularly helpful to Jenny?

Tourette Syndrome
Tourette syndrome (TS) is a complex neurological disorder characterized by
repetitive, sudden, uncontrolled (involuntary) movements and sounds called tics

223
224 Chapter 16

(Genetic and Rare Diseases Information Center, n.d.). TS is caused by a variety of

genetic and environmental factors. It is estimated that 1% of the population has
TS. It affects one schoolchild in every hundred and is more common among boys.
More than 300,000 children and adults are living with TS in the United Kingdom
(Tourettes Action, 2023) and 1.4 million in the United States (Centers for Disease
Control and Prevention [CDC], 2022).
The key features of TS are involuntary motor and/or vocal tics, which must
be present for at least 12 months to meet the diagnostic criteria. Motor tics are
movements of the body such as blinking, mouth or nose twitches, shrugging the
shoulders, or jerking an arm. Vocal tics are sounds that a person makes such as
humming, clearing the throat, sniffing, or yelling out a word or phrase, which
may include curse words. Simple tics involve just a few parts of the body whereas
complex tics involve several different parts of the body in a repeated pattern such
as bobbing the head while jerking an arm and then jumping up (CDC, 2022).
About 85% of people with TS will also experience co-­occurring conditions and
features, which might include Attention-­Deficit/Hyperactivity Disorder (ADHD),
Obsessive Compulsive Disorder (OCD), and Anxiety (Tourettes Action, 2023).

Risk of Sexual Exploitation

The World Health Organization (WHO, n.d.) defines sexual exploitation as
actual or attempted abuse of a position of vulnerability, power, or trust for sexual
purposes (WHO, n.d., p. 2). The prevalence of sexual exploitation ranges from 15
to 25% among females and 5 to 15% among males in the general US population
(Finkelhor, Turner, Shattuck, & Hamby, 2015). Adolescents with disabilities are
particularly vulnerable to sexual exploitation due to the social power differen-
tial and lack of knowledge about healthy sexual relationships (Treacy, Taylor, &
Abernathy, 2018).
Sexual exploitation disrupts adolescents’ emotional regulation as well as cog-
nitive and affect integration (Linde-­Krieger et al., 2021). Howe (2005) contended
that sexual exploitation impairs adolescents’ ability to regulate and make sense
of their emotions and levels of arousal. Sexually exploited adolescents often pres-
ent with pseudo mature behavior, meaning a false appearance of independence
and indiscriminate affection to any person who takes an interest (Martin & Bees-
ley, 1977). They may have inappropriate and heightened sexualized behavior
toward peers (Trickett, 1997). Consequently, their sexually labile behavior can
result in adolescents experiencing further exploitation, social confusion, and peer
rejection after engaging in sexual activity. Due to these dire consequences, adoles-
cents with disabilities need interventions to protect them from the risk of sexual
exploitation.

Needed Interventions
Play therapy is an intervention that gives children the needed space to come to
terms with the stress and multiple losses experienced by a child who has been
 Tourette Syndrome and Risk of Exploitation 225

bullied and at risk for sexual exploitation (Cattanach, 1992). Cattanach advised
that it is important to assist children to repossess their bodies and find an iden-
tity other than one bound up in their past. Adolescents who have been sexually
exploited may struggle with the idea of traditional play therapy and may feel it
is too “childish” for them. However, an outdoor setting for play therapy may
intrigue adolescents.
Beyond the four walls, being outdoors allows “the therapist to hold an inter-
nal psychological frame around the work with the client . . . trusting in their
own confidence and competence” (Jordan, 2015, p. 93). A sense of “competent
therapist self” is a key to feeling able to move away from the “geographical”
concept of walls and toward an understanding of “symbolic” walls, created by
the therapeutic relationship. Because feelings of psychological safety are depen-
dent on feelings of physical safety, Fearn (2014) suggested that in outdoor play
therapy “There is a balance to be struck between children’s vital need for risk and
challenge and adult concerns for their safety” (p. 117). Fearn goes on to note, “In
most cases, children can be trusted to learn to assess and take manageable risk
for themselves and it is vital for the development of self-­other awareness that
they do so” (p. 117).
Adolescents who have been bullied and sexually exploited need assistance
with body boundaries to identify safe and unsafe touch. They also need actual
experience with safe touch in which they are in control of touch and touching.
Horses are large, sensitive creatures that are also very touch sensitive and will let
their feelings be felt immediately if they are touched or approached in ways they
do not like. Horses can provide the safe touch and trusting relationship that ado-
lescents who experienced bullying and exploitation so desperately need. The lov-
ability conveyed from the horse to adolescents may help build their self-­esteem
(Gilligan, 2001). Therefore, combining horses with outdoor play therapy for ado-
lescents who experienced bullying and exploitation is a powerful intervention.

Animal-­Assisted Play Therapy

Animal Assisted Play Therapy™ (AAPT) is a multidisciplinary therapeutic
approach that includes interested animals, such as horses, in the practice of play
therapy and other therapeutic or educational interventions (VanFleet & Faa-­
Thompson, 2017). AAPT requires substantial training of the practitioners who
employ it. It can be appropriate for all ages of clients, and it can be used with
individuals, families, and groups. It also can be applied within a wide range of
therapy orientations and modalities, both nondirective and directive. AAPT
represents the full integration of the fields of play therapy, attachment and rela-
tionship theories, animal behavior, ethology, animal-­assisted interventions, and
animal welfare.
AAPT is defined as
the integrated involvement of animals in the context of play therapy, in which
appropriately trained therapists and animals engage with clients primarily
226 Chapter 16

through systematic playful interventions, with the goal of improving clients’

developmental and psychosocial health, while simultaneously ensuring the ani-
mals’ well-­being and voluntary engagement. Play and playfulness are essential
ingredients of the interactions and the relationship. (p. 17)

In AAPT, a strong emphasis is on animal welfare, in which the animal must enjoy
and not merely tolerate most interactions. The therapist-­animal relationship is a
metaphor for the therapeutic relationship between the therapist and client(s). The
focus of client-­animal relationship through play is in service of therapeutic goals
(Faa-­Thompson, 2022).

Case Study Application

Treatment Goals and Objectives

When thinking about treatment goals and objectives, it is useful to think about
whose goal is it and what’s the motivation. For Jenny’s school, their goal was to
“fix” her so that she would be able to return to school and resume her studies.
They wanted Jenny “fixed” but were unable to describe what “fixed” would look
like. For Jenny’s family, their goal was for her to stop presenting with challeng-
ing behaviors. What about Jenny? At the beginning of sessions, she was unsure,
confused, and believed it was all her fault. She was trying hard to meet everyone’s
expectations of what “fixed” looked like.
In our Equine Assisted Family Play Therapy (EAFPT) program, we have a
loose outline when discussing goals and expressed outcomes with the family and
other interested parties. Sometimes goals are very clear, and sometimes they can
be “softer” outcomes. However, it’s important that we do not follow a set for-
mula. In the 30+ years I have been working in the field of Equine Assisted Psy-
chotherapy, I have read many treatment manuals of varying numbers of sessions
in set programs that outline what should be included in each session. Although
some of the activities may be useful to include in sessions, in my experience it is
important to have the confidence, expertise, and knowledge to be flexible in our
approach. As we work outdoors on grass in the horse’s natural environment and
live in Northern England, sometimes we can have all four seasons in one session
because the natural environment plays a big part in which activities we choose.
Session content also depends on the mood of the horses, if they choose to attend
the sessions, and the moods of the clients when they arrive. We must work with
what presents to us on that given day from all those included in the process.
With respect to Jenny and her family’s goals, we agreed on the outcomes of
Jenny feeling and being safe (two different things), more family cohesion, clear
communications, and boundary setting. The stated goal of getting Jenny back to
school was just too far when we started and probably would have set her up to
fail. Without the feeling of safety and family support, Jenny could not even begin
to think about what a return to school would look like. Often in our work, clients
 Tourette Syndrome and Risk of Exploitation 227

and referrers are set on outcomes that are unachievable and miss too many steps.
We tend to strip everything back, take small steps, and build strong foundations
that we can revert to when challenges are too difficult.
The treatment plan focused on the fun that the family was having together
while not ignoring the issues they were facing. We looked at goals for the family as
well as Jenny, so that Jenny was not viewed as “the problem needing to be fixed.”
We found common ground. We did this by emphasizing that like horse herds,
“Families come in all shapes and sizes”; “Families are all unique”; and “You can
choose your friends, but you cannot choose your family.”

The Treatment Process

In our EAFPT program, we follow the diamond model comprising one equine
expert, the horses, therapist, and clients. We use the Equine Assisted Growth and
Learning Association (EAGALA, 2018) model, which we feel is the safest and
most ethical model because it includes a horse expert to observe and keep the
horses safe and a human therapist who is qualified and professionally registered
to work with the client group. (Note: In the United States, this will be termed
licensed counselor, social worker, or psychologist.) It’s very difficult if you are a
lone therapist to split your attention between horse and human, making the pro-
cess potentially unsafe for all.
The horses at Turn About Pegasus (TAP), my Equine Assisted Family Play
Therapy program, consist of a small band of mixed-breed horses who live
together in large fields of 20+ acres. The horses are playful and work at liberty.
This setting is also our home, so the horses are not brought to sessions. When cli-
ents arrive, we open the field gate, and we invite the horses to join us in sessions
if they choose. At TAP, most of our family work is with blended and adopted
families as well as kinship carers (foster families), so our focus is on attachment,
relationship, and resilience.

Overview and Beginning Sessions

We provided a total of ten 90-minute sessions of EAFPT with Jenny, her mother
and grandmother, and however many of the horses wished to be involved. In
the beginning sessions, we provided psychoeducation about equine behavior and
communication in herds. Boundaries and clear communication were the overrid-
ing theme. We focused on relationships and what worked well rather than what
was not working.
A fundamental goal was assisting Jenny to keep herself safe, so we empha-
sized “safe touch” with the horses. At the end of every session, we said thank you
to the horses by grooming them in ways they liked to be groomed, observing the
invites to groom from the horses and responding to invites. We call this “listen
with your eyes” to the horses. They are loose and are not switched off or resigned
to being touched by humans with little choice. Rather, they will invite and gesture
with their nose the parts of their bodies they like to be touched. They are very
228 Chapter 16

expressive about parts of their body that they do not like to be touched. Jenny
learned to “listen with her eyes” and to notice when her grooming was plea-
surable for the horses or not. We used these grooming opportunities to discuss
human-­to-­human touch and consent. We encouraged Jenny to think of how she
could respond in the future to unwanted human touch.

Sessions 5 through 7—Barriers Activity

In session 5, we began the barriers activity. We invited the family to use the equip-
ment in the arena to build themselves a fortress to keep themselves safe from out-
side influences that could cause them harm. Before we did this, we invited them
to label the horses (metaphorically, not actually put labels on them) as things that
erode your good self-­esteem. An issue that often comes up after a few sessions
is that clients make a connection with the horses, and they do not want to label
them as anything negative. This is to be celebrated as they develop a positive rela-
tionship and empathy for the horses. However, for the purposes of this activity,
the family was able to label the three horses present as Bullies, Put Downs, and
Abusers.
The family worked at building their first barrier, but there was little commu-
nication or planning between them. They made a barrier without much thought
or effort right in the middle of the field instead of using a natural wall as a bar-
rier. Once ensconced in their fortress, we gave them each a bucket of horse treats
that represented their self-­esteem. We asked them to hold onto it for 5 minutes (5
minutes is our maximum time to avoid the horses getting frustrated). The horses
on seeing the food broke through their fortress in less than a minute to get to the
treats. We rescued the treats and debriefed them. Everyone was laughing.
We asked Jenny’s family what had happened. They said their fortress was not
strong enough and that it might work better if they worked together. They tried
again, this time trying to make it stronger by adding more to it but with no real
plan. They ran out of time so had to dismantle the fort and begin again in the
next session. The same thing happened at the next session, but it took more time
for the fort to be breached. During these times I was reflecting on what was hap-
pening and stating things such as, “Oh no, the bully is getting under the barrier.
What can you do?” and “Here comes the abuser. He’s trying to break through at
the side. Who is going to protect your self-­esteem?” I kept the narrative coming in
an upbeat voice, and the whole family was laughing. Jenny and mum and grand-
mother put their self-­esteem together and took turns protecting their fortress. The
second time they managed 4 minutes and realized that if they worked together
and helped each other, they were stronger together.
In session 7, mum took charge of the fortress, and the whole family dis-
cussed how they were going to build it stronger by learning from their first three
attempts. Mum directed how it would look and gave rationales for why in discus-
sion with her own mum and Jenny. They spent a long time getting everything just
 Tourette Syndrome and Risk of Exploitation 229

right and even made seats for each other to sit on. They sat close to one another
in a triangle with their backs resting against each other and rested their “self-­
esteem” on their laps. This fortress had an inner and outer ring that was much
larger than the two before, so the horses couldn’t reach over as it was more inter-
woven. This time the barrier held strong.
We debriefed with the family about what they had learned in the sessions.
They were able to say that when they worked together and stopped trying to
control everything, things worked out well. Mum stated that she felt proud
of herself that she could take charge as she was always the one to back down.
Grandmother was able to state that she felt relieved that she didn’t have to be the
one always coming up with solutions. Jenny stated that she was pleased that her
mother could keep her safe. We do not go into long debriefs in EAFPT as then it
would become a talking therapy and defeat the whole purpose.

Session 8
Below is a short transcript of the beginning of session 8. Mum, grandmother, and
Jenny had arrived, and all three are smiling broadly.
A check-­ in, as described above, is important at the start of each session
because it reveals the processing that has occurred in the family between sessions.

TABLE 16.1. JENNY: SESSION 8

Transcript Analysis
T F-­T: “Good morning. I’m noticing three smiling Role-­modeling the power of tuning into and
faces. I’m wondering if there is any particular stating observed facial expressions. Rather than
reason for the smiling faces?” requiring a response, I invite a response with “I’m
[Jenny and mum share a glance.] wondering.”
J: “Yes, Mum confiscated my phone last night, Mum had set a boundary and clearly
and I won’t get it back for a week, and I’m communicated the consequences.
grounded.”
T F-­T: “Wow, your mum took your phone from I was genuinely astonished, as I never expected
you, and you are grounded, and you are happy those words from a teenage girl. Expressing
about that?” genuineness facilitates safety and a strong
therapeutic bond.
J: “Yes, because now I know she can keep me Jenny’s verbalization reinforces the positive
safe. Before she would always give in. Now she change she experiences in her mom and herself.
doesn’t. I now know I am loved by my mum.”
T F-­T: “Mum, hearing what Jenny has just said, I Inviting mum’s verbalization provides confirmation,
wonder how you might be feeling?” role-­models communication, and facilitates
connection.
Mum: “Proud and confident and relieved that I can Mum’s verbalization reinforces her experiences
keep Jenny safe.” and reveals achievement of one of the overall
goals for therapy, Jenny’s safety.
(continued)
230 Chapter 16

TABLE 16.1. (CONTINUED)

Transcript Analysis
T F-­T: “So you feel proud you can keep Jenny My response and humor help me celebrate
safe, and Jenny feels safe. That must be so with them. This reaffirms the strength of our
fantastic for you both to feel like that. I am therapeutic relationship. Intentionally addressing
astonished, though, as I never ever thought I grandmother honors her role in the family.
would hear those words from a teenage girl
in relation to her phone or being grounded.”
[Laughter all around. Two weeks prior,
grandmother had a breast cancer scare, so I
turned to her next.] “Grandmother, hearing all this,
I’m wondering what your thoughts are?”
Grandmother: “Relief that no matter what Affirmation from grandmother to mother
happens to me, I know that Jenny will be kept strengthened their bond and increased mother’s
safe by her mother and that her mother is now confidence even more. Hugs from the entire
so much more confident, which fills me with joy.” therapy team role-­modeled safe touch, which
[Spontaneous family hug and a misty eye all became Jenny’s internal working model of safe
around, including therapy team] relationships.

Ending Sessions and Learnings

The last two sessions were focused on strengthening that trust and bond within
the family. Jenny came to our sessions initially because she was told to, and the
goal was to get her back into school. She felt like it was all her fault and was ter-
rified of her Tourette’s. She had little interest in horses. However, Jenny quickly
found a connection with the horses and wanted to learn about equine ethology
and behavior as well as the human-­animal bond, which were gently weaved into
and integral to all our sessions. Jenny and her family decided that she wouldn’t be
going back to school. (Although the school wouldn’t have her back, Jenny’s deci-
sion illustrated her self-­determination.) Instead, Jenny was accepted at the local
equine college. After three years, Jenny successfully completed her higher-­level
diploma in equine studies.
Her relationship with her mother and grandmother continued to be strong
with the grandmother taking on the role of grandmother and not having to step
in and mother maintaining her authoritative parenting style. Jenny no longer was
a victim of unequal relationships and made many friends of all genders.
Interestingly for us, during Jenny’s EAFPT sessions, even when sessions
were tough for her, she never displayed any motor or vocal tics. Of course, her
Tourette’s had not disappeared but, rather, there was something about the inter-
action with the horses and the therapy team that did not set off her Tourette’s. We
noticed this but did not draw attention to this fact so as not to cause stress, which
could have made her tics more likely. Not drawing attention to her lack of tics
was especially important because Jenny had been accused by others of putting it
on despite having had a Tourette’s diagnosis since she was 5. Whether to draw
attention to or leave something out that has happened or not during EAFPT ses-
sions is always a choice for the therapy team. This therapeutic choice emphasizes
the importance of extensively qualified therapy team members who can provide
a valid rationale for their modality of intervention in each session. A manualized
 Tourette Syndrome and Risk of Exploitation 231

formulaic approach relies on the manual’s guidance rather than the expertise of
the therapists.

Ethical and Cultural Considerations

To date, the whole industry of Equine Assisted Therapy is unregulated, which
means that anyone can call themselves an equine-­assisted therapist and indeed
some do. The internet is liberally littered with impressive websites offering a
whole range of animal-­assisted therapies with myriad client groups. On closer
inspection and wading through the list of trainings, you might find that the “ther-
apists” are not trained in working with the client population they are engaging
with, nor do they have any equine credentials.
It is important to follow EAGALA ethics and have advanced training in
equine-­assisted therapy. Both my co-­therapist and I are qualified human thera-
pists and equine specialists at the MA/MSc level. At the heart of our work is
animal sentience and enjoyment. If the animals do not feel safe and do not enjoy
the interactions, then we are replicating what had been done to Jenny during the
times she was being sexually exploited. For example, in her previous experiences
with boys, she thought she was in a relationship, but the relationship was what
was in it for the boys and not what was in it for her. In our work, reciprocal rela-
tionships between horses and humans are fundamental to the process, with the
horses having free choices to leave if they are not enjoying the interaction. If that
were to happen (it hasn’t happened yet), we as therapists are qualified to work
with the family without the equines being present and to use that experience of
free choice and self-­efficacy to help clients think about reciprocity in relation-
ships. If animals were not given choices and if they were expected to remain in
situations where the human needs are paramount, then we would be perpetuating
the metaphor of helplessness and force. This ill approach would convey to our
clients that one sentient being’s feelings, wishes, and needs are more important
than another’s.
To show respect to the horses, we are careful to keep the barrier activity ses-
sion of denying horses their treats to 5 minutes only so that the horses don’t
get frustrated at not getting to the treats. At the end of the session the horses
get to eat all the treats, which are then no longer labeled self-­esteem. This is an
important part of the session as it keeps the animals in mind as sentient beings.
All clients love to feed the horses and offer them praise for their participation.
This positive interaction helps clients integrate their own self-­determination in
relationships.

Conclusion
EAFPT can be incredibly effective by enhancing the development of empathy,
efficacy, confidence, relationship, and much more. This work is far more complex
than individual work, however, and requires considerably more training and skill
232 Chapter 16

than many assume. With that said, simple activities in nature with animals who
have both voice and choice alongside well-­qualified and experienced group ther-
apists have the potential to make significant differences in short periods of time.
By being in the moment and working within safe therapeutic space with animals
who are free to be themselves, clients discover their own freedom to let down
their guard and be themselves as well. Working with families is totally different
from working individually and needs a heightened skill set. Therapists in this field
need to be:
• skilled and trained in systemic family therapy;
• fluent in equine ethology and behavior;
• skilled in knowing when to use humor as a defuser, and adaptable and able
to switch the session plan immediately depending on what the family present,
the animals present, and the wider environment presents;
• skilled in splitting attention—if you have found it difficult to split attention
between one person and one animal, it’s magnified with a group of people
and animals; and
• able to work as part of a good human therapy team. There is no room for
therapists’ egos in EAFPT.

Resources
EAGALA, https://www​.eagala​.org/
IIAAPT, https://iiaapt​.org/
https://www​.tourettes-­action​.org​.uk/
http://www​.turnaboutpegasus​.co​.uk/

Discussion Questions
1. What does the human therapist need to be adept in when doing Equine
Assisted Family Play Therapy™?
2. What else is important when undertaking group work?
3. In your opinion, would this intervention have been as effective if the horses
were not free to choose whether to attend sessions?
4. What else might have helped this family?

References
Almon, J. (2013). Adventure: The value of risk in children’s play. Alliance for
Childhood.
Cattanach, A. (1992). Play therapy with abused children. Jessica Kingsley
Publishers.
Centers for Disease Control and Prevention. (2022). Data and statistics on
Tourette syndrome. https://www​.cdc​.gov/ncbddd/tourette/data​.html​#:~:text​
=About%201.4%20million%20people%20in%20the%20U.S.
 Tourette Syndrome and Risk of Exploitation 233

Equine Assisted Growth and Learning Association. (2018). EAGALA model.

https://www​.eagala​.org/model
Faa-­Thompson, T. (2022). Horse play and canine capers: The importance of play
to facilitate learning and healing. In M. Kirby (Ed.), Nourished: Horses, ani-
mals and nature in counselling and psychotherapy & mental health (pp. 213–
228). Australia Aware Publishing.
Fearn, M. (2014). Working therapeutically in the outdoors. In E. Prendiville & J.
Howard (Eds.), Play therapy today: Contemporary practice with individuals,
groups and carers. Routledge.
Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2015). Prevalence of
childhood exposure to violence, crime, and abuse: Results from the national
survey of children’s exposure to violence. JAMA Pediatrics, 169(8), 746–754.
https://doi​.org/​10.1001/jamapediatrics.2015.0676
Genetic and Rare Diseases Information Center (n.d.). Tourette syndrome. https://
rarediseases​.info​.nih​.gov/diseases/7783/tourette​-­syndrome
Gilligan, R. (2001). Promoting resilience: A resource guide on working with chil-
dren in the care system. BAAF.
Howe, D. (2005). Child abuse and neglect: Attachment, development and inter-
vention. Palgrave Macmillan.
Jordan, M. (2015). Nature and therapy: Understanding counselling and psycho-
therapy in outdoor spaces. Routledge/Taylor & Francis Group.
Linde-­Krieger, L. B., Moon, C. M., & Yates, T. M. (2021). The implications of
self-­definitions of child sexual abuse for understanding socioemotional adap-
tation in young adulthood. Journal of Child Sexual Abuse: Research, Treat-
ment, & Program Innovations for Victims, Survivors, & Offenders, 30(1),
80–101. https://doi​.org/10.1080/10538712.2020.1841352
Martin, H., & Beesley, P. (1977). Behavioural observations of abused children.
Developmental Medicine and Child Neurology, 19, 373–387.
Tourettes Action. (2023). Information and resources for health professionals
about Tourette syndrome. https://www​.tourettes​-­action​​.org​.uk/
Treacy, A. C., Taylor, S. S., & Abernathy, T. V. (2018). Sexual health education for
individuals with disabilities: A call to action. American Journal of Sexuality
Education, 13(1), 65–93. https://doi​.org/10.1080/15546128.2017.1399492
Trickett, P. (1997). Sexual and physical abuse and the development of social com-
petence. In S. Luthar, J. Burack, D. Ciccetti, & J. Weisz (Eds.), Developmental
pathology: Perspectives on adjustment, risk and disorder (pp. 67–92). Cam-
bridge University Press.
VanFleet, R., & Faa-­Thompson, T. (2017). Animal assisted play therapy. Profes-
sional Resource Press.
VanFleet, R., & Faa-­Thompson. T. (2019). Animal assisted play therapy tech-
niques manual. Play Therapy Press.
World Health Organization. (n.d.). Sexual exploitation and abuse. www​.who​
.int/docs/default-­s ource/documents/ethics/sexual​-­e xploitation-­a nd-­a buse​
-­pamphlet​-­en​.pdf?sfvrsn=409b4d89_2
 CHAPT E R 1 7

Eating Disorders
Enhanced Cognitive Behavior Therapy with
a Mexican American Adolescent
Sara Cantu

Claudia is a 14-year-­old, third-­generation Mexican American girl who lives with

her mother, father, and younger brother. She enjoys school, plays in the band,
and plays on the school tennis team. Her mother works in the office of Clau-
dia’s school, and her father manages a branch of a bank. During the COVID-19
pandemic, Claudia had a difficult time adjusting to virtual school, feeling discon-
nected from friends and not being able to enjoy her activities. Claudia’s mother
also noticed changes in the way Claudia was eating and was concerned that
she was frequently throwing up. Her mother brought her concerns to their family
doctor, and the doctor recommended making an appointment with a therapist.

When working with Claudia, it is important to consider:

1. What are the symptoms and diagnostic criteria for bulimia? How do these
symptoms apply to Claudia’s diagnosis?
2. What is the focus of Enhanced Cognitive Behavior Therapy (CBT-­E)? How
is a CBT-­E treatment plan formulated for Claudia? Given Claudia’s specific
eating disorder, what are the treatment goals?
3. What ethical and cultural considerations should be made when working with
Claudia and her family?

Eating Disorders
Eating disorders are a group of psychological disorders related to eating behav-
iors that result in a lower quality of life and social functioning (Qian et al., 2022).
Eating disorders include anorexia nervosa (AN), characterized by restrictive eat-
ing; binge-­eating, characterized by overeating to the point of pain; and bulimia
nervosa (BN), characterized by attempts to control weight through use of com-
pensatory behaviors (e.g., vomiting, laxatives, extreme exercise, or fasting) (NIH,

235
236 Chapter 17

2021). Eating disorders can cause serious damage to the heart, kidneys, intestines,
throat, and teeth.
The median age of onset for BN and AN is 18 years old and for binge eating is
21 years old (NIH, 2021). The prevalence of eating disorders in the United States
is 1.2% for binge eating disorder with a lifetime prevalence of 2.8%; .3% for BN
with a lifetime prevalence of 1%; and .6% for AN (NIH, 2021). Overall, the life-
time prevalence of an eating disorder diagnosis is .91%, with a 12-month prev-
alence rate of .43% (Qian et al., 2022). However, US adolescents who develop
an eating disorder between the ages of 13 and 18 have a lifetime prevalence of
2.7%, which is 33.7% higher than if the onset were 21 years or older. The fre-
quency of anorexia in Hispanics/Latinos is lower compared to the non-­Hispanic
White population, whereas the frequency of binge eating disorder and bulimia is
comparable to the non-­Hispanic White population (Perezet al., 2016).

Enhanced Cognitive Behavioral Therapy

In 1981, C. G. Fairburn developed a manual for Cognitive Behavioral Therapy
Bulimia Nervosa (CBT-­BN). Since this first edition, the manual has been revised
to include a more transdiagnostic approach to treating eating disorders and was
renamed Enhanced Cognitive Behavioral Therapy (CBT-­E) (Fairburn, 2008). The
CBT-­E transdiagnostic approach focuses on the similarities found between differ-
ent eating disorder diagnoses (Fairburn, 2008).
Current research (Atwood & Friedman, 2019; Dalhenburg, Gleaves, &
Hutchinson, 2019; Groff, 2015; Linardon, 2018) reflects that CBT-­E is more
effective in decreasing eating disorder behaviors when compared to other treat-
ment models as well as nontreatment control groups. Atwood and Friedman
(2019) found that treatment participants experienced a decrease in eating disor-
der behaviors more quickly using CBT-­E when compared with other treatment
models. Dahlenburg et al.’s (2019) systematic review concluded that the benefits
of CBT-­E are maintained to a significant degree after treatment and that some
participants continue to experience increased benefits over time. The decrease in
eating disorder behavior was found across the spectrum of eating disorder diag-
noses, supporting CBT-­E’s transdiagnostic perspective (Linardon, 2018).
Although researchers have found reasons to support the use of CBT-­ E,
there are limitations to current research proving the efficacy of CBT-­E with spe-
cific populations. To date, studies applying CBT-­E have not included men, the
LGBTQ+ community, diversity of races and ethnicities, and use with younger
participants and families. The current body of research is also missing a greater
depth of understanding of the impact of CBT-­ E on specific eating disorder
behaviors known to significantly impact recidivism, including subjective binge-
ing, driven exercise, eating disorder behavior marginally below the diagnostic
threshold, and lack of systemic support.
Although studies supporting the use of CBT-­E have concluded that partic-
ipants experienced significantly decreased eating disorder behavior, participant
 Eating Disorders 237

symptoms remained above the threshold needed for diagnosis (Atwood & Fried-
man, 2019). In addition, a significant portion of current research supporting the
use of CBT-­E has been conducted in connection with Fairburn, CBT-­E’s creator,
creating concern for the possibility of allegiance effect influencing outcomes
(Groff, 2015). It is important for counselors to keep these limitations in mind
when considering the implementation of CBT-­E. For Claudia, I carefully consid-
ered these limitations as well as benefits and decided that CBT-­E was the best
treatment approach for her, as will be described below.

CBT-­E Overview and Stages

CBT-­E treatment strategies focus on cognitive distortions that reinforce the eating
disorder: overemphasis placed on body shape and weight as well as the control
that the person has over body shape and weight. A person diagnosed with an eat-
ing disorder might behave in different ways, even changing behavior over time, in
response to these cognitive distortions, but the psychopathology that maintains
the eating disorder remains the same.
The overall treatment goals for CBT-­E are to (a) disrupt the maintaining
mechanism composed of cognitive distortions and disordered eating behav-
iors and (b) develop healthy cognitions about eating and healthy routine eating
behaviors. These goals are accomplished in four stages within a typical 20-week
CBT-­E treatment protocol (Fairburn, 2008). In week one of stage one, the ini-
tial assessment takes place. In the following three weeks of stage one, the clini-
cian meets with the client two times per week, sessions 2–7. During the intense
first four weeks of stage one, the goal is to align with the client by focusing on
treatment and change, create a personalized formulation, provide education, and
introduce the importance of in-­session weighing and regular eating. In stage two,
weeks 5 and 6, sessions 8 and 9, the client and clinician assess progress made,
identify challenges or barriers to progress, and adjust the formulation if needed.
In stage three, weeks 7 through 14, weekly appointments address the primary
maintaining mechanisms of the eating disorder in an individualized way, provid-
ing strategies and alternatives to behaviors and thinking. In stage four, sessions
18, 19, and 20 are held every other week, and focus is on maintaining changes
made and minimizing risk of relapse. A final appointment is held 20 weeks after
the end of stage four to review progress.

CBT-­E Stage 1
In the initial assessment, the client will begin to engage in treatment, will be pro-
vided information related to their eating disorder, create a formulation with the
help of the clinician, discuss expectations of treatment, plan for real-time self-­
assessment, discuss homework, and confirm the next appointment (Fairburn,
2008). To better understand the client’s eating disorder, clinicians gather informa-
tion related to current disordered eating behavior, current concerns related to the
eating disorder, development and history of the eating disorder, coexisting mental
238 Chapter 17

health or medical concerns, personal and family history related to health and
mental health, a quick personal history, current life circumstances, and the client’s
attitudes toward treatment. In addition, height and weight are taken at the con-
clusion of the first session. The initial assessment typically can be conducted in a
longer first session, no longer than an hour and a half.
It is important that the clinician consider medical concerns and the possible
need for medical oversight during treatment. The clinician should gather medical
information in the initial assessment including recent blood work results, recent
EKG and bone density results if available, risk of suicide or self-­harming behav-
ior, current significant mental health concerns, current substance use, as well as
a release to work with other medical providers supporting the client. Potentially,
significant medical concerns, suicidality, or substance use could preclude a client
from participating in CBT-­E before addressing outstanding risks.
During the first session, the clinician collaboratively creates with the client
a formulation, a tool to conceptualize the eating disorder with the client used
throughout treatment. A formulation is a visual diagram of cognitive distortions
that represent overemphasis on body shape, weight, and control over body shape
and weight; subsequent behavior; and reactions that perpetuate the cognitive dis-
tortion and behavior that keep the client in her eating disorder. The formula-
tion is created using the client’s words and focuses on the pattern that maintains
the eating disorder. Common maintaining mechanisms include overevaluation of
shape and weight, overevaluation of control, dietary restriction, dietary restraint,
being underweight, and changes in eating triggered by situations. The client is
given a copy of the formulation to review. The formulation will be at the center
of treatment planning.
The clinician explains to the client what to expect in treatment, with empha-
sis placed on the importance of completing each step of treatment such as ses-
sions, self-­assessment, homework, and in-­ session weights. In-­session weights
are an opportunity for the client to be responsible as well as face reality; this
happens through weighing during sessions only, speaking the number out loud,
graphing weights showing trends, and addressing concerns with the clinician.
The remaining sessions in stage one, each 50 minutes in length, follow a pat-
tern: weight once a week, review records for quality, discuss attitude and patterns,
determine and follow agenda with client, summarize, and discuss homework. The
goals of these sessions are to provide education related to eating disorder diagno-
sis, establish a regular eating pattern, and arrange for family support. A regular
eating pattern focuses first on routine rather than changing what a client is eating.
The client is asked to eat breakfast, lunch, snack, dinner, snack, and sometimes a
snack before lunch. Fairburn (2008) emphasizes, “Implementing the regular eat-
ing intervention is a skill that all CBT-­E therapists need to acquire. It involves
conveying the rationale well, being persuasive, tackling objections and obstacles,
and praising all signs of progress” (p. 81). Involvement of family is based on their
family’s ability to support change and limited by family’s contribution to the dif-
ficulty of creating change.
 Eating Disorders 239

CBT-­E Stage 2
During stage two, the clinician and client review progress using informal assess-
ment or formal assessment completed outside of session, identify barriers, review
formulation to gain a deeper understanding, and design stage three, prioritizing
the most pressing maintaining mechanisms. During stage two, it is determined
whether a longer version of CBT-­E over 40 weeks rather than 20 would be most
appropriate, based on the client’s needs and health.

CBT-­E Stage 3
Stage three includes the same components as stages one and two, as well as tar-
geting maintaining mechanisms in individualized ways. Depending on the client,
stage three can include identifying overevaluation; creating greater importance
in other domains; addressing shape checking, avoidance, and the idea of feeling
fat; historical review; managing mind-­set; education on dieting; dietary restric-
tion; mood intolerance; addressing dietary rules; learning problem-­ solving
skills; and functional mood modulatory behavior.

CBT-­E Stage 4
Finally, stage four follows the same structure as sessions in stage three. The dif-
ference in stage four compared to stage three is that sessions become increas-
ingly more future focused and less focused on the present. It is recommended
that treatment concludes once maintaining mechanisms have been disrupted and
the client has begun to change patterns. It is not expected that all symptoms or
behavior of the eating disorder have completely ceased. A final session is held 20
weeks following the last session of stage four. In the final session, the clinician
and client determine whether there is a need for additional treatment based on
significance of eating disorder symptoms.

Case Study
Given the evidence-­based research, I implemented CBT-­E to treat Claudia’s eating
disorder. I believed CBT-­E would help disrupt the maintaining mechanisms of her
eating disorder and begin to alleviate her eating disorder symptoms quickly. Her
parents and health care providers were willing to be part of her treatment by sup-
porting her change in behavior.
Goals for Claudia’s first session included building rapport, gathering infor-
mation about Claudia’s current eating disorder symptoms, providing information
related to eating disorders, creating a formulation together, discussing expectations
of treatment, planning for real-­time self-­assessment, discussing homework, and
confirming the next appointment. Once I introduced myself, I discussed confiden-
tiality and Claudia’s current eating disorder symptoms and provided some basic
information to Claudia about eating disorders and the idea of a formulation, I
encouraged Claudia to work with me to create a formulation of her eating disorder.
240 Chapter 17

TABLE 17.1. CLAUDIA: TRANSCRIPT/ANALYSIS

Transcript Analysis
T: “You and I are going to work together to draw a Using the diagram of a formulation helps someone
picture of how your eating disorder works. We will to understand the steps that reinforce the
call it a formulation. Here is a picture of how some behavior of an eating disorder.
eating disorders work.”
C: “What does overevaluation mean?” Overevaluation and other terms used in a
formulation may not be familiar to an adolescent;
these words can be personalized by therapist and
adolescent.
T: “Overevaluation means giving something a Personalizing the formulation makes the process
lot of importance. What word would you use to more meaningful and clearly identifies the steps
describe this? How would you describe the things in the formulation that must be taken to create
you do to try to control your weight or the shape change in the eating disorder.
of your body?”
C: “I think I would call it highlighting instead of Claudia’s words will be added to the formulation;
overevaluation. I tell myself I am taking care of my the formulation is a working document and will
food when I throw up.” be updated as Claudia and her therapist work
together.

After introducing the idea of the formulation and beginning to personalize

it using Claudia’s input, I gave Claudia a copy of the formulation to take home
with her so she could continue to think about it between sessions. During the
first session, Claudia and I also talked about the importance of real-­time self-­
assessment, homework, and establishing a regular eating pattern. Real-­time self-­
assessment involved Claudia keeping a detailed record of her eating patterns and
eating disorder behavior that were reviewed during each session (see My Mon-
itoring Record work sheet from Credo Oxford, https://www​.credo-­oxford​.com/
pdfs/F5.3_Blank_monitoring_record​.pdf). At first, I emphasized eating at regular
intervals, rather than focusing on what was eaten. I addressed concerns Claudia
had about implementing a regular routine for eating. After Claudia and I created
a formulation and plan for a regular eating routine, she will share it with her
family. In a later session, I encouraged her to share it with both of her parents.
During stage two of treatment, Claudia and I continued talking about her for-
mulation and examined the maintaining mechanism more closely. By creating the
formulation with Claudia, we identified that Claudia’s maintaining mechanism
in her eating disorder was an overevaluation of her appearance. The heightened
value she placed on her appearance resulted in Claudia wanting to control her
body through eating disorder behaviors. Helping Claudia to see the pattern that
she was in, and its consequences, was an important step in changing the behavior.
I made this process developmentally appropriate for Claudia by integrating in art
activities.
 Eating Disorders 241

TABLE 17.2. CLAUDIA: TRANSCRIPT/ANALYSIS

Transcript Analysis
T: “I am asking you to begin to eat breakfast, This routine allows for Claudia to feel both hungry
lunch, and dinner, with a snack between breakfast and satisfied at regular intervals throughout the
and lunch, and a snack between lunch and day. She will avoid feeling overly hungry or overly
dinner.” full if she maintains this routine.
C: “I don’t have time to eat that many times; Claudia could be fearful of the change in routine
no one eats that often. I can’t eat dinner on the that could result in a change in herself or a change
nights I have tennis.” in the control she feels.
T: “This will take some planning, and I understand I will be patient and empathetic when responding
that it will be a change for you. A lot of people to her concerns. Normalizing a new routine will
have this routine; I know you can do it. Let’s make help Claudia to feel like the change is possible.
a plan together to help you be successful.”
C: “I don’t usually eat breakfast before school; I It is reasonable that this change will require
am always running late.” adjustments that need to be discussed.
T: “Okay, let’s think of something that will be easy Initially, emphasis is placed on the routine and not
for you to do in the morning.” what Claudia will be eating.

TABLE 17.3. CLAUDIA: TRANSCRIPT/ANALYSIS

Transcript Analysis
T: “Today I would like you to create a picture that Providing a variety of materials and flexibility
shows me the importance you give to different for Claudia to depict her self-­evaluation gives
parts of who you are. We are going to use her freedom and control to express herself in a
these art supplies to help us. [Provides paper, developmentally appropriate way.
markers, glue, assorted materials including glitter,
construction paper, yarn, pipe cleaners] Let’s start
by making a large circle.”
C: Agreeably drew a large circle using markers.
T: “Let’s name important parts of you together.” This could be difficult for someone with an eating
disorder, who places a lot of value on a few
domains of themselves, to do without support.
C: “How I look is important, being a friend is
important, helping around the house is important
. . .”
T: “Now that you have named valuable parts of I will provide Claudia with an example. I will
who you are, use the circle you drew and any of be careful not to indicate a right or wrong way
our materials to show me how much you value to complete this activity, giving Claudia the
each part. Like this one I drew.” opportunity to create something unique.
C: [Worked silently while I waited. When she was
done, she looked up, indicating that she was
finished.]
T: “I notice there are some parts of your circle that Reflecting with Claudia on what it would be like if
are larger and some that are smaller. What do you the representation of herself is changed will help
think it would be like if this small piece were gone? her to see the impact that this thinking has on her
Or this big piece were even bigger?” and her behavior.
242 Chapter 17

After Claudia and I identified and gained an understanding of how her

overevaluation of her appearance impacted her, she and I began to define a plan
to create greater importance in other domains of her self-­evaluation. Together
Claudia and I identified new activities that Claudia was interested in becoming
involved in. These new activities provided her with new or strengthened domains
from which her evaluation of self was created. Ideas for new activities often come
from activities that the client was previously interested in, activities they have
been curious about, or interests they saw friends and family involved in. It was
important to agree on one to two new activities that Claudia was willing to start.
Creating specific goals that were related to activities was important because gen-
eral goals were difficult to achieve, and setting too large a goal would have pro-
hibited her from reaching the goal. Claudia and I agreed on a way to ensure that
she started her new activity of playing 10 minutes with her dog three times a
week and agreed that this goal would be reviewed during each session.
In the remaining sessions, Claudia and I continued to examine and adjust her
formulation and explored what changes could be made to disrupt the maintaining
mechanisms of her eating disorder. Sessions involved reviewing self-­assessments
and weekly goals to better understand the formulation as well as establishing
goals for the following weeks. Claudia was ready to conclude her counseling
when her eating disorder’s maintaining mechanism had been disrupted, as evident
by changes in her behavior related to body and eating behavior.

Ethical and Cultural Considerations

When working with a client who has been diagnosed with an eating disorder, it is
very important to be aware of health and safety concerns that could be affecting
the client. By regularly communicating with other professionals working with
a client, clinicians can ensure that potentially life-­threatening health and safety
concerns are managed appropriately.
Family involvement is also vital to the treatment process when working with
an adolescent diagnosed with an eating disorder. Family members are an import-
ant part of supporting change. They are also largely responsible for shopping for
and preparing food, which is important to forming a regular eating routine.
Clinicians should be thoughtful of the client’s cultural relationship with food
and cultural expectations for body image when treating an eating disorder. Treat-
ment is influenced by culturally appropriate food, traditions around food, and
cultural differences related to the idea of an ideal body. The degree of assimilation
or acculturation that a client experiences also impacts cultural aspects of treat-
ment. For example, the degree to which Claudia identifies as Mexican American,
Mexican, or American impacts her body satisfaction. Culture influences body-­
related values important for body image perception (Çakıcı, Mercan, & Denizci
Nazlıgül, 2021). Claudia’s maintaining mechanism may have been rooted in the
thin ideal portrayed by Western culture and her overevaluation of the importance
of her appearance.
 Eating Disorders 243

Parent Consultations
Parents or other family members are an integral part of treatment when work-
ing with adolescents who have been diagnosed with an eating disorder. Family
plays an important part in supporting the client to log real-­time self-­assessments
and providing the opportunity for the client to establish regular eating patterns.
Family members are often included in sessions to make them aware of the specific
nature of the client’s eating disorder, the nature of treatment, and how they can
play a supportive role.

Conclusion
Through the course of CBT-­E, Claudia learned about the maintaining mecha-
nisms of her eating disorder, how her thoughts and behavior were reinforcing the
importance of the maintaining mechanisms, and how she can disrupt this pat-
tern and create new healthier patterns for herself. Claudia and her family worked
together to create a routine of regular eating supporting Claudia’s new outlook.
Working with Claudia, I learned the importance of collaborating with Claudia to
regularly revise and fine-­tune her formulation. These updates ensured that Clau-
dia’s sessions were specific to her needs and relevant to her progress each session.

Sample Case Notes

Session 1
Subjective: Client was hesitant to describe eating disorder behavior; she attempted
to justify her behavior and focused on decrease in eating disorder behavior
after parents become concerned; she expressed lack of motivation when talking
about creating a regular eating routine. Client stated, “It’s really not a problem
anymore.”
Objective: Client sat with arms and legs close to body, hands in lap, she made
direct eye contact when spoken to. Client spoke clearly and thoughtfully. When
working together to create formulation, the client was cooperative and careful to
follow directions.
Assessment: Reflected in the client’s formulation, she is involved in thinking
errors and behavior related to her body and weight that perpetuate the pattern of
the eating disorder.
Plan: Counselor will follow prescribed steps in CBT-­E manual; the remaining ses-
sions of stage one will emphasize pattern and attitude of self-­assessment, and
establish a regular eating pattern.

Session 8
Subjective: Client was smiling and cooperative. Client was engaged with craft
materials, expressive and thoughtful in the way that she chose to use them. Client
244 Chapter 17

adjusted what she created as she thought about different parts of herself, demon-
strating reflectiveness.
Objective: Client was relaxed, sitting with relaxed posture, making direct eye
contact throughout the session. She was actively engaged in creating a visual rep-
resentation of herself, adding new ideas and details as she worked.
Assessment: Client demonstrated an overevaluation of her appearance through
discussion and visual representation that she created. She can identify other areas
of herself that are important and recognize the impact that placing significant
emphasis on her appearance has on other areas of her life.
Plan: Client and I will work together to enhance the importance of other domains
for self-­evaluation by identifying activities that she will become involved in and
creating a specific plan for her to begin these activities.

Resources

For Professionals
Eating Disorders: A Guide to Medical Care, https://higherlogic​down​load​.s3.
amazonaws ​ . com/AEDWEB/ ​ 2 7a3b69a-8aae ​ - 45b2 ​ - a04c-2a078d02145d/
UploadedImages/Publications​_Slider/2120_AED_Medical_Care_4th_Ed_
FINAL.pdf
Instructions for Self-­Monitoring, https://www​.cbte​.co/download/t5-1-instructions​
-­for-­self-­monitoring/?wpdmdl=2298&master​key=5f4cd05c9f8e6
Topics to Cover When Assessing the Eating Problem, https://www​.cbte​.co/site/
download/t5-1-topics-­to-­cover-­when-­assessing​-­the-­eating-­problem/?wpdmdl
=654&masterkey=5c6fc29ef10b9

For Adolescents
Individuals 10 Actions, https://higherlogicdownload​.s3.amazonaws​.com/​AED​
WEB/27a3b69a-8aae-45b2-a04c-2a078d02145d/UploadedImages/Publi​ca​
tions​_Slider/ExE_Individuals_10​_Actions​.pdf
National Association of Anorexia Nervosa and Associated Disorders, https://
anad​.org/
National Eating Disorders Association, https://www​.national​eating​disorders​.org/

For Parents
Cognitive Behavior Therapy for Eating Disorders in Young People: A Parent’s
Guide by Riccardo Dalle Grace and Carine el Khazen (2021).
Nine Truths about Eating Disorders, https://www​ .aedweb​.org/publications/
nine-­truths
Your Child’s Weight: Helping without Harming Birth through Adolescence by
Ellyn Satter (2005).
 Eating Disorders 245

Discussion Questions
1. What health-­related information would you gather to ensure that Claudia is
ready for CBT-­E?
2. What are the benefits of creating a formulation in collaboration with Claudia?
3. What ethical considerations are important to consider when working with
Claudia and her family?
4. When working with Claudia, or another adolescent diagnosed with an eating
disorder, what personal beliefs or opinions about food and body would you
need to be aware of?

References
Atwood, M. E., & Friedman, A. (2019). A systematic review of enhanced cogni-
tive behavioral therapy (CBT‐E) for eating disorders. International Journal of
Eating Disorders, 53(3), 311–330. https://doi​.org/10.1002/eat.23206
Çakıcı, K., Mercan, Z., & Denizci Nazlıgül, M. (2021). A systematic review of
body image and related psychological concepts: Does ethnicity matter? Psiki-
yatride Güncel Yaklas˛ımlar, 13(4), 707–725.
Dahlenburg, S. C., Gleaves, D. H., & Hutchinson, A. D. (2019). Treatment out-
come research of enhanced cognitive behaviour therapy for eating disorders:
A systematic review with narrative and meta-­analytic synthesis. Eating Disor-
ders, 27(5), 482–502. https://doi​.org/10.1080/10640266.2018.1560240
Fairburn, C. G. (1981). A cognitive behavioural approach to the treatment of
bulimia. Psychological Medicine, 11(4), 707–711. https://doi​ .org/10.1017/
S0033291700041209
Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford
Press.
Groff, S. E. (2015). Is enhanced cognitive behavioral therapy an effective inter-
vention in eating disorders? A review. Journal of Evidence-­Informed Social
Work, 12(3), 272–288. https://doi​.org/​10.1080/15433714.2013.835756
Linardon, J. (2018). Meta-­analysis of the effects of cognitive-­behavioral therapy
on the core eating disorder maintaining mechanisms: Implications for mech-
anisms of therapeutic change. Cognitive Behaviour Therapy, 47(2), 107–125.
https://doi​.org/10.1080/16506073.2018.1427785
National Institutes of Health. (2021). Eating disorders. https://medlineplus​.gov/
eatingdisorders​.html
Perez, M., Ohrt, T. K., & Hoek, H. W. (2016). Prevalence and treatment of eat-
ing disorders among Hispanics/Latino Americans in the United States. Cur-
rent Opinion in Psychiatry, 29(6), 378–382. https://doi​ .org/10.1097/YCO​
.0000000000000277
246 Chapter 17

Qian, J., Wu, Y., Liu, F., Zhu, Y., Jin, H., Zhang, H., Wan, Y., Li, C., & Yu, D.
(2022). An update on the prevalence of eating disorders in the general pop-
ulation: A systematic review and meta-­analysis. Eating and Weight Disor-
ders—Studies on Anorexia, Bulimia and Obesity, 27(2), 415–428. https://doi​​
.org/​10.1007/s40519-021-01162-z

TABLE 17.4. MY MONITORING RECORD

Day________________________________ Date_______________________
Time Foods and drink consumed Place V/L/E* Context and comments

*V = vomiting, L = laxative misuse, E = exercise

Note: From “F5.3—Blank monitoring record,” Online Training Program in CBT-­E, CREDO, Oxford, 2017. https://www​
.cbte​.co/for-­professionals/cbt-­e-resources-­and-­handouts/
 CHAPT E R 18

Substance Use Disorder

Motivational Interviewing and Creative Approaches
with an African American Adolescent
Allison Crowe and Jason O. Perry

Robby is a 17-year-­old African American high school cisgender male who lives
with his grandparents in a small town in North Carolina. His mother intermittently
stayed with them for extended periods but would leave due to her struggles with
illicit substances. Robby’s father left his mother and him when he was 8 years
old, and the father later remarried. Throughout his school years, Robby had man-
aged to stay out of any sort of legal trouble. However, recently he was arrested
for breaking and entering into a store and stealing a vaping device and a small
package of synthetic THC. As part of his sentence, Robby was court ordered
to receive a mental health assessment and treatment. He was diagnosed with
depression and substance use disorder.

For the case of Robby, please consider the following:

1. For teenagers such as Robby, what are common considerations for counselors
when working with mental health and substance use disorders?
2. How can Motivational Interviewing be especially impactful for this age
group, and why is it a useful theory to draw from?
3. How can creative techniques enhance more traditional frameworks when
working with teenage clients? What benefits and challenges should counsel-
ors consider with creative approaches?

Depression
The Substance Abuse and Mental Health Services Administration (SAMHSA,
2020) estimates that 21 million adults (8.4%) in the United States had at least
one major depressive episode in 2020. This was highest among individuals ages
18–25 (17.0%). Among adolescents (ages 12–17), it is estimated that 4.1 mil-
lion adolescents (17%) in the United States had at least one major depressive
episode in 2020. In 2020, an estimated 41.6% of US adolescents with a major
depressive episode received treatment. Depression in adolescents can look like the

247
248 Chapter 18

following—feelings of sadness, anxiousness, worthlessness, or emptiness. Also,

the teen might lose interest in activities he used to enjoy. Feelings of irritability,
frustration, or anger are frequently experienced. In addition, there might be with-
drawal from family and friends, a drop in grades, changes in eating and sleeping
habits. Fatigue or memory loss, as well as harming oneself or thoughts of suicide,
are other symptoms of depression (National Institute of Mental Health, NIMH,
2022).

Substance Use Disorders

It is well known that substance use disorders (SUDs) often co-­occur with mental
health concerns and vice versa. Although they commonly co-­occur, they don’t
“cause” each other. Three possibilities have been established as to why they are
seen together (NIMH, 2021). First, the same risk factors can contribute to both
mental health struggles and substance use disorders. Environmental factors such
as trauma, experiences of discrimination and racism, or poverty impact both.
When experiencing a mental health concern such as depression or anxiety, a per-
son self-­medicates or seeks a way to cope with the symptoms through substances,
which can lead to a substance use disorder. Finally, substances or a substance use
disorder can contribute to the development of other mental health concerns due
to changes in the brain (NIMH, 2021).
Among adolescents in the United States, substance usage is a public health
concern, with at least one in eight teenagers abusing an illicit substance in the past
year (National Center for Drug Abuse Statistics, 2023). Specifically, substance use
increased by 61% among eighth graders between 2016 and 2020. Sixty-­two per-
cent of twelfth graders have abused alcohol, and 50% of teenagers have misused
a substance at least once.

Motivational Interviewing
For the case of Robby, we draw from the major tenets of Motivational Inter-
viewing (MI). MI is a counseling approach for eliciting change with a particular
emphasis on helping clients explore and resolve ambivalence, defined as a struggle
to articulate conflicting values that work against positive change (Miller, 1995;
Miller & Rollnick, 2002, 2004, 2009). This emphasis on resolving ambivalence
is essential because ambivalence often creates stumbling blocks along a client’s
road to living a healthier, more fulfilling lifestyle (Miller & Rollnick, 2002; Roll-
nick & Miller, 1995). MI is a client-­centered approach in which the counselor
accepts people as they are by viewing clients’ own values, motivations, abilities,
and resources as important and valuable. MI is based on the Rogerian funda-
mental principle of empathic understanding (Rogers, 1951), although MI differs
from traditional Person-­Centered theory, as it is more focused and goal-­directed
toward resolving client ambivalence (Miller & Rollnick, 2002, 2009). It is a col-
laborative approach, supported by the belief that every person has the motivation
 Substance Use Disorder 249

and resourcefulness to change. Clients who are ambivalent may not have had the
opportunity to feel understood (Miller & Rollnick, 2002).
MI encourages counselors to assist the client with examining and resolving
ambivalence, because ambivalence is understood as the main obstacle to over-
come when attempting to change. As the counselor, we must remember that moti-
vation must originate from the client. The counselor relies on the client’s intrinsic
goals and values to create change. The counselor works with the client to express
all feelings related to changing a behavior to resolve ambivalence. Readiness
for change is understood as a product of interpersonal communication, and the
counselor should remain open and responsive to a client’s motivational signals.
For example, resistance from the client could mean that treatment is moving too
fast. A counselor can notice this and adjust his or her motivational strategies to
remain flexible with the client. Finally, the counseling process is supported by a
collaborative relationship.

Four MI Principles
Miller and Rollnick (2002) share four key principles that are central to MI. The
first, expressing empathy, focuses on the importance of seeing the world through
the eyes of the client. This is critical, because when a client feels understood, an
open expression of thoughts and feelings is possible. Reflective listening is an
important part of expressing empathy, as well as normalizing ambivalence about
change (Miller & Rollnick, 2002). This reflection and normalization of ambiva-
lence not only helps the client to feel understood, but also helps to reduce defen-
siveness and resistance.
The second principle, developing discrepancy, describes how exploring dis-
crepancies can facilitate change. When the client can see that there is a difference
(or discrepancy) between behavior and goals, or values and goals, they may be
more likely to make changes. Rolling with resistance refers to avoiding arguments
for change. When a counselor notices opposition from the client, they should not
oppose it directly. Instead, resistance is the client signaling for the counselor to
adjust their approach. By inviting new perspectives without imposing, the coun-
selor maintains a supportive stance, affirming clients’ autonomy and ability to
solve problems with their own insight (Miller & Rollnick, 2002).
The final principle, supporting self-­efficacy, describes a self-­fulfilling proph-
ecy that occurs from a counselor’s belief in the client’s capacity to lead their own
change. Operating under this principle, a counselor acknowledges that his or her
own expectations have a profound impact on client outcomes. By understanding
that the power to choose is inherent within the client, not the counselor, a coun-
selor can advocate for change through expressing belief in the client’s abilities,
personal responsibility, and by offering to help, but not create, the process of
change.
Since the original approach, authors have applied MI to different types of
clients and presenting concerns. We encourage readers to consult literature on MI
250 Chapter 18

and adolescents (e.g., Naar & Suarez, 2021) to ensure that it is tailored to devel-
opmental needs of the age group. In the following case study, we offer the case of
Robby through the eyes of Motivational Interviewing principles. In addition, we
apply a creative approach taken from an earlier article on creative approaches to
Motivational Interviewing (Crowe & Parmenter, 2012). This is just one activity
from the article, and readers are encouraged to consult the full article to see more
creative approaches that align with each of the MI principles.

Case Study Application

Seventeen-­year-­old Robby Denton spent most of his childhood living in the
home of his maternal grandparents, in a small rural town in northeastern North
Carolina. By all outside appearances, Robby had a good life, as his grandparents
were held in high regard by members of the community. Though their home was
modest, he lived in a desirable neighborhood and had a few friends close to his
age. His mother sometimes stayed at the home for extended periods of time,
but she seemed to slip in and out of her son’s life, and her level of involvement
in Robby’s development proved to be inconsistent at best. This was mainly due
to her struggles with illicit substances and unemployment. Robby’s father had
moved out of the state for employment purposes when Robby was in elementary
school and remarried soon after, when Robby was about 8 years old. His father’s
and stepmother’s relationship resulted in producing two siblings, both boys,
now ages 6 and 7, respectively. He heard from his dad and stepmom from time
to time, but his grandparents were the most constant “family” to Robby. He
struggled with adjusting to his parents’ lack of involvement in his life. Although
his grandparents were aware that the familial situation caused him to become
irritable and angry, they avoided seeking counseling services for Robby and did
not talk about the problems at home.
When two law enforcement officers knocked on the front door asking to
speak to Robby one afternoon, his grandparents were in shock. This was the first
time Robby had ever been in any sort of potential trouble. The officers explained
that Robby was a suspect in a recent breaking and entering and robbery at a local
tobacco store. When the officers searched his room, Robby was found to have
a vaping device and a small package of synthetic THC in his backpack match-
ing the description of the items stolen from the store. He was arrested and was
released to his grandfather, who paid the $300 cash bail, and a court date was
set to take place in four weeks. The attorney, who was appointed by the court,
strongly advocated on Robby’s behalf and asked the judge to take into account
his client’s age and the fact that he had no prior record. The judge, who was
known for being creative and progressive, ordered Robby to comply with super-
vised probation for a period of one year and entered a deferred prosecution judg-
ment, which meant that the case would be dismissed once all conditions were met.
As special conditions of Robby’s probation, the judge ordered him to obtain an
assessment from a clinical mental health provider and follow any recommended
 Substance Use Disorder 251

treatment. The judge also ordered Robby to pay restitution, in the amount of
$350, to replace the window he broke when he entered the tobacco store, and to
participate in victim-­offender conferencing, a practice consistent with the princi-
ples of Restorative Justice (Karp, 2019).
Although Robby was happy to not be in jail, he was angry that he got caught
and was resistant to change. He was not one to talk about and share his feelings
and was upset about having to meet with a mental health counselor. From Rob-
by’s perspective, he was managing his life well enough and wished he could can-
cel the appointment with the counselor, avoiding it. Although Robby recognized
that he had been unhappy for quite some time, he was not interested in seeking
help or making changes in his life.

Treatment Goals and Objectives

The treatment aim was to work according to MI principles, particularly express-
ing empathy, rolling with any resistance, and developing a discrepancy with
Robby. The objective was to allow Robby to be the one to decide that something
needs to change and be the driver of this change.

First Sessions
Prior to the first appointment, at the urging of his grandmother, Robby reviewed
my (second author’s) counseling website. The website mentioned that I was
skilled in using the method of Motivational Interviewing. Robby was slightly
interested in knowing more about what to expect, especially because this would
be his first visit with a mental health counselor. He was less than excited when he
entered my counseling office for his first appointment, but by the end of the ses-
sion Robby was surprised that he had talked more than he thought he would. In
fact, he noticed that he felt like a big weight had been lifted after that initial visit.
As his counselor, I did not judge him, even when he admitted that when he felt
down, he used his vape to smoke THC to take his mind off things. And when he
told the story of why he’d broken into the convenience store, Robby was relieved
that he did not feel judged.
When Robby realized that he was about to enter his third session, he was sur-
prised to find himself not experiencing feelings of dread. As the alliance between
Robby and me continued to develop, grow, and strengthen, he felt more com-
fortable sharing his thoughts and feelings related to his life. As he could safely
talk about and share how he was feeling, details about his parents and the deep
depression that used to remain beneath the surface began to bubble up to the
top. Robby spoke of feeling confused, especially when he was little, why his mom
would come back and then leave again, and why his grandparents never wanted
to talk about it.
Keeping true to the spirit of MI (Rollnick & Miller, 1995), I worked to build
a partnership, working together in a collaborative way, and I avoided the role of
the expert. Robby noticed feelings of being valued and accepted as I demonstrated
252 Chapter 18

respect for his ability to make decisions for himself and be autonomous. Robby
also sensed that I was compassionate and caring, most especially because, on sev-
eral occasions, I discussed the importance of us working to understand what was
in his best interest. Lastly, the concept of evocation was quite evident, as I encour-
aged Robby to generate ideas during our sessions.

River of Life Activity

In the third session I introduced the River of Life activity (Crowe & Parmenter,
2012), which involved having Robby draw a large river, and then map out major
life events, people, places, and things that have influenced him along the way.
The principle that we consider most in this session is expressing empathy. Robby
needed to feel that I had empathy for him and his experiences in his river of life.
According to MI and the stages of change, when the client can sense this from the
counselor, the likelihood is greater that the client feels understood, and the ther-
apeutic relationship can strengthen. The goal of the session was for me to accept
Robby “as is” and to convey this back to Robby. By using visual art, I worked
with Robby to draw his river so that I could see the world through his eyes. This
principle is critical, because when a client feels as though he or she is understood,
an open expression of thoughts and feelings is possible. If we accept the client as
is and communicate this to the client, the possibility for change increases. Below
we list materials, instructions, and a part of the transcript between Robby and me
as the counselor.
Materials: Large piece of paper, such as butcher-­block paper. Smaller pieces of
paper can also be used if the counselor does not have butcher block paper.
Instructions:
1. Instruct client to create their “river of life” by drawing an image of a river
that represents events, activities, and important milestones that the client has
faced before coming to counseling. This gives the counselor an opportunity to
learn more about the client and their river of life or personal story.
2. After drawing their river image and sharing this with the counselor, the coun-
selor and client together discuss the themes, events, and other important
information.
3. The counselor is to focus on acceptance of the client as they are and convey-
ing this to the client. This is done using person-­centered skills such as uncon-
ditional positive regard and communication of empathy using reflection of
content, feeling, and meaning.
Later in the session, Robby shared about the first time he tried vaping with
THC with a friend from school. It helped him forget about some of the pain and
anger that he had with his parents, and it felt good to “numb out” the loneli-
ness he felt when he looked back on his dad’s leaving and his mom’s inconsistent
relationship. It also helped him forget his resentment toward his grandparents
for never talking to him about his parents or letting him ask questions. He also
admitted to me that a big part of him did not want to stop vaping. Why should
 Substance Use Disorder 253

TABLE 18.1. ROBBY: SESSION 3

Transcript Analysis
C: “Robby, you will notice this large piece of paper By understanding more about Robby, the
I have today. I would like you to draw what I call counselor can express empathy for Robby.
your river of life that has major events, activities,
and milestones that you have been through before
coming into counseling.”
R: “Umm, okay, I guess I can do that. Isn’t this Adolescents often feel awkward in general and are
drawing stuff for little kids though?” sometimes surprised by expressive arts.
C: “The arts can be for everyone, regardless of The counselor develops a small discrepancy by
age. You do not have to be good at drawing to pointing out that Robby has been willing to try a
do this. Would you be willing to try it? I know you few new things just by coming into counseling as
have done a lot of new things with me so far, so I a willing participant.
wonder if you would do the same today.”
R: “Sure. I guess my first rock in the river was Robby had talked about his dad’s leaving and
when my dad left. I did not understand what what it meant to him, but this was the first time
was going on and why he and my mom were he had really considered it as a major upsetting
not happy. He left North Carolina without any event, or “rock” in his river. This creative activity
explanation.” helped Robby more fully understand the
significant impact this had on him at an early age.
C: “I can imagine how confusing that must have More expression of empathy.
been for you.”
R: “Yes, it was. And my mom—she was not much Robby shares further pain and confusion with
better. She would live with us for a while and greater depth than he had before.
things would be great. I would be happy again.
But then something would happen, and the next
morning, she would be gone. My grandparents
would just tell me it was ‘for the best’ and that I
would understand when I was older.”
C: “So, how about we draw this as your next rock The counselor continues to draw out the events of
. . . when your mom first moved out.” Robby’s River of Life and express empathy.
R: “I would be so upset and confused when she Robby is gaining insight into his own patterns of
left, but then feel excited when she would call, up-­and-­down feelings.
saying that she was coming back.”
C: “So, on one hand it was hurtful that she would The counselor begins to implement the technique
leave with no warning, but at the same time when of developing a discrepancy.
she had come back it felt good.”

he? It does not impact his grades at school or anything else. What was the big
deal? I heard this ambivalence and planned to highlight this in a future session,
instead still focusing on expressing empathy to continue to build the therapeutic
alliance. In a future session, I began to plant the seed that there might be ways
for Robby to cope with his feelings other than using substances, and that Robby’s
legal trouble might indicate that something needs to change.

Case Discussion
The River of Life activity was a creative exercise coupled with Motivational Inter-
viewing techniques that helped Robby see more deeply the impact of his parents’
leaving when he was young. Although he had some knowledge of this impact,
the visual arts allowed him to conceptualize this as a rock in his river. As the
254 Chapter 18

counselor, I drew out pain and unhappiness from Robby’s childhood based on
these events and his grandparents’ tendencies to bottle up their own thoughts and
feelings related to this. In addition, I continued to work with Robby to see the
connection between the THC vaping and how this was a negative coping behavior
for the pain he felt. As sessions continued, I used additional creative techniques
and MI principles to change Robby’s behavior so that he replaced his substance
use with other, more positive, healthy coping strategies.

Ethical and Cultural Considerations

According to Sullivan et al. (2017), nearly 17% of Americans live in rural areas,
including some of the poorest and most underserved areas of the nation (Sulli-
van et al., 2017). In addition, African Americans are like other rural residents in
that they hold rural values (i.e., close relationships with family, strong ties to reli-
gion, independence, and stoicism) but have endured decades of discrimination and
poverty and have legitimate reasons to mistrust the health-­care system (Sullivan
et al., 2017). Although African Americans experience mental disorders (such as
depression and anxiety) at rates similar to Whites, they are significantly less likely
to receive treatment (Sullivan et al., 2017). Individuals who delay entering treat-
ment may sometimes wait until a higher level of care is needed, such as in-­patient
hospitalization. Consequently, avoiding treatment can result in marked functional
impairment (Sullivan et al., 2017).
MI can be used with culturally diverse clients such as Robby. Lee and col-
leagues (2013) suggest that counselors expand their scope beyond the individ-
ual to the family and community and acknowledge discrimination and racism
as causes of distress rather than factors that impact levels of distress. Counselors
using MI with diverse clients must also be aware of their own implicit cultural
bias to avoid microaggressions that will do more damage to the client. In addi-
tion, to deliver culturally competent MI, the counselor should bring up culture,
cultural norms, and cultural communities to gain a full understanding of the
client.

Parent and Teacher Consultations

Because Robby’s grandparents were his legal guardians, I provided biweekly
feedback to whichever grandparent drove him to the counseling appointment.
To maintain trust with Robby, I always asked him if I could tell his grandpar-
ent something general about our session, without disclosing anything private,
by inviting his grandparent to the last five minutes of the session. I informed
Robby that usually adults will “stay off your back” if they know you are mak-
ing progress. Robby was agreeable to this and would decide which sessions he
wanted to invite in his grandparent. I would tell the grandparent something
general, such as,
 Substance Use Disorder 255

Today, we discussed difficult events in Robby’s life, that I will keep private, and
I provided empathy without judgment by statements such as “You felt confused
and hurt.” I believe doing this without giving advice is helping Robby develop his
own motivation to move toward his goals of living a better life. Grandpa, one
thing that might be helpful for you to try is to ask Robby during dinner to share
one positive and one negative about his day, without giving advice. Then, you
share one positive and one negative about your own day.

I also invited his grandparents and mother to feel free to schedule a consul-
tation session with me. I made it clear that I would keep Robby’s privacy but
would help them understand MI principles and interactions with Robby that may
be helpful. If Robby had difficulties with teachers at school, I would ask Robby’s
permission to send his teachers and school counselors an email with brief sugges-
tions on how to help him (i.e., say “I know you want to do well in this class. You
seem down today. What’s going on? How can I help?”).

Conclusion
Robby made considerable progress through MI. The immediate empathy he expe-
rienced substantially decreased his resistance to counseling to the point of not
just seeing it as a meaningless obligation forced on him by the judge but, rather,
seeing it as a valuable experience to help him achieve his own goals. Robby was
able to explore the discrepancies between his substance use and his desire to one
day be a respectable father. He developed a new perspective of self-­efficacy in tak-
ing steps toward managing his depression now and in the future; using healthy
coping strategies; setting realistic expectations and boundaries with his parents;
and building reputable relationships so that he could become an engaged and
respectable father one day.
Seeing Robby’s progress confirmed our belief that creative techniques coupled
with MI principles can add dimension, especially when working with young peo-
ple experiencing depression and substance use.

Sample Case Notes

Session 1
Subjective: Client entered session due to court mandate and appeared reluctant
to share.
Objective: Mandated counseling due to legal issues, THC use, and recent behav-
ior changes at home. Lives with grandparents and charged with breaking and
entering.
Assessment: Client will benefit from counseling using Motivational Interviewing
with a focus on empowering himself to be the motivator of change. Will focus on
expressing empathy to build alliance.
256 Chapter 18

Plan: Use MI principles to begin to build the therapeutic relationship, roll with
resistance to change, develop discrepancies. Consider creative techniques to illus-
trate life events and take pressure off talk therapy alone.

Session 3
Subjective: Client appeared more comfortable and willing to share with this
counselor. Started processing feelings related to parents’ departures, grandpar-
ents’ unwillingness to communicate, and the role THC played in coping with this.
Objective: Engaged in River of Life activity that encouraged client to use visual
art to create his own river that depicted major life events that impact him today.
Used MI techniques to continue the relationship and begin to develop discrepan-
cies and roll with resistance.
Assessment: Client understood impact of parents’ departures and grandparents’
lack of communication in a deeper sense. Began to understand and explore THC
and its relationship to coping.
Plan: Will continue to use creative applications of MI with client to reinforce
change.

Resources
For Professionals
Crowe, A., & Parmenter, A. (2012). Creative approaches to Motivational Inter-
viewing: Addressing the principles. Journal of Creativity in Mental Health, 7,
124–140, doi: 10​.1080/​15401383.2012.684662
Holt, E., & Kaiser, D. H. (2009). The first step series: Art therapy for early sub-
stance abuse treatment. Arts in Psychotherapy, 36, 245–250. doi: 10.1016/j​
.aip​.2009.05.004
Horay, B. J. (2006). Moving towards gray: Art therapy and ambivalence in sub-
stance abuse treatment. Art Therapy: Journal of the American Art Therapy
Association, 23(1), 14–22. doi: 10​.1080/​07421656.2006.10129528
Miller, W. R. (1995). Motivational enhancement therapy with drug abusers. Uni-
versity of New Mexico. http://motivationalinterview​​ .org/​
Documents/MET​
Drug​Abuse.PDF
Naar, S., & Suarez, M. (2021). Motivational interviewing with adolescents and
young adults (2nd ed.). Guilford Press.

For Adolescents
Wood, A. (2020). The motivational interviewing workbook: Exercises to decide
what you want and how to get there. Rockridge Press.
 Substance Use Disorder 257

Discussion Questions
1. Based on the case study of Robby as presented in this chapter, what would
you do next in session if you were the counselor working with Robby?
2. As the counselor working with Robby, you pick up on some defensiveness
and resistance from Robby in session 6. Use MI language to describe how
you would conceptualize this and outline your “next steps” for treatment.
3. What other creative techniques could you imagine using with Robby? How
would you use these in combination with MI?

References
Carroll, K., Ball, S., Nich, C., Martino, S., Frankforter, T., Farentinos, C., Woody,
& G., Kunkle, L. E. (2006). Motivational interviewing to improve treatment
engagement and outcome in individuals seeking treatment for substance
abuse: A multisite effectiveness study. Drug and Alcohol Dependence, 81(3),
301–312.
Crowe, A., & Parmenter, A. (2012). Creative approaches to Motivational Inter-
viewing: Addressing the principles. Journal of Creativity in Mental Health, 7,
124–140. doi: 10​.1080/​15401383.2012.684662
Karp, D. R. (2019). The little book of restorative justice for colleges and universi-
ties: Repairing harm and rebuilding trust in response to student misconduct.
Good Books.
Lee, C. S., López, S. R., Colby, S. M., Rohsenow, D., Hernández, L., Borrelli,
B., & Caetano, R. Culturally adapted motivational interviewing for Latino
heavy drinkers: Results from a randomized clinical trial. Journal of Ethnic
Substance Abuse, 12 (4): 356–373. doi: 10.1080/15332640.2013.836730
Miller, W. R. (1995). Motivational enhancement therapy with drug abusers. Uni-
versity of New Mexico. http://motivationalinterview​ .org/Documents/MET​
Drug​Abuse​.PDF
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people
for change (2nd ed.). Guilford Press.
Miller, W. R., & Rollnick, S. (2004). Talking oneself into change: Motivational
interviewing, stages of change, and therapeutic process. Journal of Cognitive
Psychotherapy: An International Quarterly, 18(4), 299–308. doi: 110.1891/​
088983904780944306
Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is
not. Behavioural and Cognitive Psychotherapy, 37, 129–140. doi: 10.1017/
S1352465809005128
Naar, S., & Suarez, M. (2021). Motivational interviewing with adolescents and
young adults (2nd ed.). Guilford Press.
National Center for Drug Abuse Statistics. (2023). Illicit drug use. from https://
www​.cdc​.gov/nchs/fastats/drug-­use-­illicit​.htm
258 Chapter 18

National Institute of Mental Health. (2021). Depression. https://www​.nimh​.nih​

.gov/health/topics/depression
NIMH. (2022). Substance use and co-­occurring mental disorders. Retrieved April
3, 2023, from https://www​.nimh​.nih​.gov/health/topics/substance​-­use​-­and​
-­mental-­health
Papp, J., Campbell, C., Onifade, E., Anderson, V., Davidson, W., & Foster, D.
(2016). Youth drug offenders: An examination of criminogenic risk and juve-
nile recidivism. Corrections: Policy, Practice and Research, 1(4), 229–245.
doi: 10.1080/23774657.2016.1218804
Rogers, C. (1951). Client-­centered therapy: Its current practice, implications and
theory. Constable.
Rollnick, S., & Miller, W. (1995). What is motivational interviewing?
Behavioural and Cognitive Psychotherapy, 23(4), 325–334. doi: 10.1017/
S135246580001643X
Substance Abuse and Mental Health Services Administration. (2020). Key sub-
stance use and mental health indicators in the United States: Results from
the 2020 national survey on drug use and health. https://www​​.samhsa​
.gov/data/sites/default/files/reports/rpt35325/NSDUHF ​ F RPDFWHTML-
Files2020/2020NSDUHFFR102121.htm
Sullivan, G., Cheney, A., Olson, M., Haynes, T., Bryant, K., Cottoms, N., & Cur-
ran, G. (2017). Rural African Americans’ perspectives on mental health: Com-
paring focus groups and deliberative democracy forums. Journal of Health
Care for the Poor and Underserved, 28(1), 548–565. doi: 10.1353/hpu​.2017​
.0039
Timko, C., Booth, B. M., Han, X., Schultz, N. R., Blonigen, D. M., Wong, J. J.,
& Cucciare, M. A. (2017). Criminogenic needs, substance use, and offend-
ing among rural stimulant users. Rural Mental Health, 41(2), 110–122. doi:
10.1037/rmh0000065
 CHAPT E R 1 9

LGBTQ
Gestalt Therapy and Liberatory Approaches with a
Dominican American Adolescent
Ana Guadalupe Reyes

Jose Luis identifies as a 16-year-­ old queer nonbinary person of Dominican

descent. They live with their parents, two younger siblings, and paternal grand-
parents in a three-­bedroom house. Their parents and grandparents are devout
Catholics who attend mass every Sunday. Jose Luis recently came out as queer
and nonbinary to some of their best friends and swore them to secrecy because
they are afraid of how their parents will respond. Jose Luis was referred to coun-
seling by their school counselor due to their experience of anxiety, increased bul-
lying at school, and exploration of their gender identity and sexuality. Jose Luis’s
parents were reluctant to seek counseling until the school counselor provided
additional information regarding the counseling process. Their parents, Rosie
and Carlos, accompanied Jose Luis to the intake session. Jose Luis’s parents
reported concerns about the client’s grades, lack of communication with family,
anxiety, isolation, clothing style, and bullying at school. Josie Luis appeared quiet
and anxious as their parents shared their concerns.

For this case study, consider the following:

1. What are some of the most common concerns queer adolescents may experi-
ence during the coming-­out process?
2. What may be underneath the parents’ reluctance to seek counseling?
3. How can we build trust and rapport with the parents and client? How can we
work collaboratively with the parents to support Jose Luis?
4. What are some cultural considerations we need to be aware of?

LGBTQ People
According to the National Alliance on Mental Illness (NAMI, 2023), lesbian,
gay, bisexual, transgender, and queer (LGBTQ) people are at greater risk for
poor mental health across all developmental stages, highlighting the importance
of culturally responsive mental health services across the life span. Some of the
issues most commonly reported among LGBTQ youth are depression, anxiety,

259
260 Chapter 19

substance abuse, suicidality, self-­harm, internalized homophobia, biphobia, or

transphobia, and comorbid mental health disorders (Batejan, Jarvi, & Swenson,
2015; Hunt, Vennatt, & Waters, 2018; Mustanski, Newcomb, & Garofalo, 2011;
Trevor Project, 2022). In addition, LGBTQ youth often report feelings of isola-
tion, shame, guilt, and internalized oppression; history of traumatic events such
as physical, emotional, or sexual abuse; and familial rejection and lack of social
support (Hunt et al., 2018). Based on what we know about Jose Luis thus far, it is
essential to remember that they may be experiencing feelings of shame, isolation,
and fear as they continue coming out and exploring their gender identity. As I
work with Jose Luis, I will continuously assess how they’ve internalized oppres-
sion and work with them to heal from internalized oppression. Further, I will
work with Jose Luis’s parents through parent consultation and potentially refer
them to an LGBTQ Latin parent support group.
Multiple researchers have found correlations between experiences of dis-
crimination and increased levels of depression, anxiety, and internalized neg-
ativity about one’s sexual identity (Meyer, 2003; Mustanski et al., 2011). One
of the factors contributing to increased mental health concerns experienced by
LGBTQ youth is minority stress (Meyer, 2003). Minority stress is the compound-
ing effect of the intersecting stressors LGBTQ youth experience from ongoing
institutional, systemic, and individual discrimination, stigmatization, and harass-
ment, such as racism, homophobia, biphobia, transphobia, cisgenderism, sexism,
and heterosexism due to their race/ethnicity, sexual identity, gender identity, and/
or gender expression (Hunt et al., 2018; Meyer, 2003). Further, LGBTQ youth
experience disproportionate physical and mental health disparities in the United
States (Hafeez, Zeshan, Tahir, Jahan, & Naveed, 2017; Hunt et al., 2018). Jose
Luis may experience various forms of discrimination as a queer nonbinary person
of Dominican descent. Thus, it is crucial to explore Jose Luis’s social and cul-
tural identities, what their identities mean to them, and assess their experiences of
oppression.
Mental health professionals must understand the experiences of LGBTQ
youth as multidimensional and interdependent with other salient personal, racial/
ethnic, cultural, and social identities (Paradies et al., 2015). From an intersec-
tional lens, it is essential to acknowledge that LGBTQ youth may experience dis-
crimination, oppression, and victimization based on the intersections of systemic
and structural oppression that target people based on their racial/ethnic identity
(e.g., racism), gender identity (e.g., cisgenderism, transphobia), gender expression
(e.g., heterosexism, cisgenderism, transphobia), sexual identity (e.g., heterosex-
ism, homophobia, biphobia), socioeconomic status (e.g., classism), religion, spir-
ituality, country of origin (e.g., nationalism), documentation status, and ability
status (Paradies et al., 2015), creating a unique experience of power, privilege,
and oppression based on their social locations. For example, as a queer nonbinary
Latine adolescent, Jose Luis may experience racism, heterosexism, cisgender­ism,
homophobia, transphobia, and xenophobia in various forms daily.
 LGBTQ 261

The intersection of various target identities has been linked directly to

increased susceptibility to discrimination, oppression, and victimization (Collins
& Blige, 2016; Crenshaw, 1989), compounding the psychological and physio-
logical effects of discrimination. For example, transgender adolescents of color
are vulnerable to increased violence, harassment, and discrimination resulting
from the intersection of heterosexism, cisgenderism, homophobia, and transpho-
bia. In 2017, the National Coalition of Anti-Violence Programs (NCAVP; 2018)
gathered data on 52 anti-­LGBTQ homicides in the United States and found that
LGBTQ people of color (POC) accounted for 71% of the reported anti-­LGBTQ
homicides (n = 31). Twenty-­four out of the 31 LGBTQ POC killed in anti-­queer
violence were transgender womxn of color (NCAVP, 2018). The introduction of
anti-­LGTBQ legislation across the United States significantly impacts the mental
health of LGBTQ people, including youth. For example, “93% of transgender
and nonbinary youth said that they have worried about transgender people being
denied access to gender-­affirming medical care due to state or local laws” (Trevor
Project, 2022, p. 14). Thus, I will explore Jose Luis’s experiences of anti-­LGBTQ
legislation and how current legislation may directly or indirectly affect them. Jose
Luis may be hypervigilant and afraid of how their life could be impacted by anti-­
trans legislation. In addition, I will explore their interest in gender-­affirming med-
ical care and connect them to resources as needed.

Guiding Theory and Frameworks

I will tailor my approach to meet Jose Luis’s needs as they arise. Thus, I will
be using Gestalt therapy as my guiding theory and intersectionality theory as a
framework to honor Jose Luis’s cultural wisdom and to guide my clinical work
with Jose Luis and their family. I will also integrate expressive arts to assist Jose
Luis in exploring their identity as a queer nonbinary Latine adolescent, including
their experience of anxiety, bullying, and gender and sexuality.

Gestalt Therapy
Gestalt theory is a holistic, phenomenological, experiential, process-­ oriented,
and relational approach to counseling (Perls, Hefferline, & Goodman, 1951;
Yontef, 1993). Gestalt therapy focuses on the totality of living organisms (i.e.,
emotions, senses, bodily sensations, and thoughts) to increase clients’ moment-­
to-­moment awareness, thus increasing their ability to live fully, make choices,
and accept responsibility (Perls et al., 1951; Yontef, 1993). The therapeutic rela-
tionship is considered an opportunity for authentic encounters between the cli-
ent and counselor, with moment-­to-­moment experiments co-­created by the client
and counselor. Experiments provide opportunities for the client to fully engage in
exploration, growth, and self-­acceptance while being in a relationship with the
counselor and experiencing the relationship, and exploring their intrapersonal
process (i.e., physical sensations, emotions, thoughts) in the here and now (Perls
et al., 1951; Yontef, 1993).
262 Chapter 19

Gestalt therapy will benefit Jose Luis because our initial focus will be build-
ing a therapeutic relationship where Jose Luis can authentically experience them-
selves and me. Being in a caring and authentic relationship with a counselor who
shares some social and cultural identities (i.e., queer, nonbinary, Latine) may also
support Jose Luis in exploring and accepting their intrapersonal experience. The
experiential nature of Gestalt therapy will also provide opportunities for Jose
Luis and me to co-­create different experiments to help them further explore dif-
ferent ways of being and to experience themselves differently.

Intersectionality Theory
Intersectionality theory aims to explore and understand people’s social locations,
power relations, and the impact of systemic and structural oppression on those
with marginalized identities (Collins & Blige, 2016; Crenshaw, 1989). Conse-
quently, intersectionality theory demands the understanding and interrogation
of our historical and current social, political, and ideological context “to bring
the often-­hidden dynamics forward in order to transform them” (Carbado, Cren-
shaw, Mays, & Tomlinson, 2013, p. 312) through reflexivity, practice, scholarship,
research, and activism (Collins & Blige, 2016). In counseling, intersectionality
theory can be used as a lens or framework to explore clients’ social and cultural
identities, the impact of systemic and structural oppression on their overall well-­
being and create comprehensive treatment plans that include advocacy inside and
outside of the counseling room.
Using intersectionality theory as a framework with Jose Luis will help me
explore their social and cultural identities, such as their race, ethnicity, sexuality,
gender identity, language(s) spoken, ability status, and religion/spirituality during
the initial phases of our work together, so that I can engage in ongoing reflec-
tion and exploration of their experiences of oppression outside of sessions and
in sessions with Jose Luis. Further, I will engage in reflection and exploration of
ways to dismantle the power structures present in our work (i.e., moving from
power over the client to practicing power sharing with the client) and the power
structures present in the client’s life (i.e., at school, at home, and within their
community).

Expressive Arts
Expressive arts, also called “creative interventions,” are creative, nonverbal thera-
peutic modalities used to facilitate clients’ connections to implicit experiences and
deeper feelings that may otherwise be absent from conscious awareness (Purswell
& Stulmaker, 2015). Expressive arts in counseling offer opportunities for creative
expression, catharsis, and the development of insight and awareness. Examples
of expressive arts techniques include bibliotherapy, poetry, film, music, music vid-
eos, drawing, painting, puppet shows, clay, role-­play, and sand tray (Purswell &
Stulmaker, 2015; Riley, 1997). Integrating expressive arts into clinical work with
 LGBTQ 263

adolescents is a developmentally appropriate intervention as it allows adolescents

to explore potentially distressing material in nonthreatening and abstract ways
to help them explore what may be forbidden for them to verbalize (Riley, 1997).
In addition, expressive arts may teach adolescents different ways to express their
inner experiences inside and outside counseling (Riley, 1997).
Integrating sand tray and other creative interventions that resonate with Jose
Luis may provide another way for them to explore their inner world and express
their experiences in session, especially during the initial stages of our work
together. Depending on Jose Luis and their parents’ receptivity, I may integrate
creative interventions into family sessions to support them in communicating
with each other.

Case Study Application

As a Gestalt therapist, I conceptualize Jose Luis as a courageous, creative, and
dynamic adolescent doing their best to explore who they are and how they can
honor who they are in the face of ongoing oppression and discrimination. Jose
Luis’s experience of anxiety is a typical response to discrimination, bullying,
and oppression. Their school climate is a microcosm of the larger sociopolitical
climate in the United States, directly impacting Jose Luis’s experience of safety,
acceptance, and belonging. Thus, Jose Luis is experiencing inner conflict as they
explore their safety, who they are, and who they want to be. To cope with the
increase of bullying and anti-­LGBTQ legislation, Jose Luis engages in deflection
(i.e., shifting their attention away from distressing aspects of their experience)
and introject (i.e., internalizing beliefs, values, attitudes, and cultural norms with-
out examination).
Jose Luis withdraws from their family and others because they are terrified
of rejection. To protect themselves, they’ve learned to disconnect from others
(e.g., isolating from friends and family, sharing minimal information with family,
being selective regarding who they come out to as queer and/or nonbinary) and,
at times, to disconnect from parts of themselves (e.g., queer identity, nonbinary
identity, desire to dress more “feminine”).
I believe their parents are also courageous, creative, and dynamic people try-
ing to meet their needs as they arise while meeting Jose Luis’s needs. Although
Jose Luis’s parents are not my clients, I need to partner with them as I work
with Jose Luis because they are from a collectivist culture and are skeptical about
the counseling process. Building a collaborative and compassionate relationship
with Jose Luis’s parents helps me to build trust, increase their willingness to con-
tinue seeking mental health services, and ultimately explore ways we can support
Jose Luis. Familial and parental acceptance and support are protective factors for
LGBTQ youth mental health (Trevor Project, 2022); thus, I must provide ongo-
ing support to Jose Luis’s parents as they process and accept their child’s sexual-
ity and gender identity.
264 Chapter 19

As I approached my work with Jose Luis and their parents, I kept in mind
that LGBTQ youth, particularly youth of color, experience significant disparities
in mental and physical health concerns due to ideological, institutional, interper-
sonal, and internalized oppression. Yet, a deficit-­based view of LGTBQ youth
of color is limiting and can promote harmful narratives. Thus, I explored ways
to honor the strengths, resilience, and resistance of Jose Luis. During my initial
sessions with Jose Luis and in parent consultations, I explored Jose Luis’s Com-
munity Cultural Wealth (CCW; Yosso, 2005) to help inform Jose Luis’s treatment
plan, including the clinical interventions implemented. The CCW model helped
me recognize and honor the different forms of capital (i.e., aspirational capital,
linguistic capital, familial capital, social capital, navigational capital, and resis-
tant capital) that helped Jose Luis “survive and resist racism,” cisgenderism, het-
erosexism, and linguicism (Yosso, 2005, p. 154). I encourage you to learn more
about Yosso’s (2005) CCW model. Unfortunately, an in-­depth overview of the
CCW model is outside this chapter’s scope.

Intake Session
My goals for the intake session were to develop rapport with Jose Luis and their
parents, obtain informed consent from the parents, and informed assent from
Jose Luis. Further, I aim to complete an initial assessment of family dynamics and
explore Jose Luis’s presenting concerns from their and their parents’ perspectives.

Session 1
My goals for the first session were to develop rapport, assess Jose Luis’s CCW,
start exploring their social and cultural identities, and delve into what brought
them to counseling from their perspective. After reintroducing myself, I invited
Jose Luis to ask me any questions they had for me to shift the power dynamic
between us and start building a collaborative therapeutic relationship.
At the end of the first session, I thanked Jose Luis for trusting me enough to
share their sexuality and gender identity and experiences coming out to friends. I
reminded them that we will start exploring their treatment goals during our next
session. See Sample Case Note for a summary.
 LGBTQ 265

TABLE 19.1. JOSE LUIS: SESSION 1

Transcript Analysis
Jose Luis: “I remember you saying that you speak Jose Luis was trying to understand what
Spanish and English. Can we use Spanish in our language(s) were acceptable during their sessions.
session?” As a student, they are used to being in English-­
dominant spaces unless they are home with their
family. Their first language is Spanish, yet due to
linguicism, they’ve internalized the message that
English is the preferred language. Thus, they are
exploring what parts of themselves they can share
with me and how receptive I will be.
Ana: “Of course, we can speak en español y Communicating acceptance and sharing that in
también podemos mezclarlo un poco y agregar this space we speak multiple languages
algo de Spanglish [translation: in Spanish and
we can also remix it a bit and throw in some
Spanglish.] Whatever you are most comfortable
with. How does that sound?”
Jose Luis: “I guess that is cool. I didn’t know we Jose Luis was trying to make sense of my
could do that . . .” response.
Ana: “This is your space. Sometimes we will do I took the opportunity to provide some
things that may seem a bit weird at first to help psychoeducation regarding our sessions to
you explore how you feel and what is going on for remind Jose Luis that they have the autonomy to
you. However, you get to decide what you want to decide what and how they share.
share and do in here. Our time together is for you
to explore what is going on for you in ways that
help you.”
Jose Luis: “Okay . . . I’ve been telling my parents Jose Luis starts opening up and exploring what
that I need help for a few months. Pero no brings them to counseling.
entienden por qué no saben que me identifico
como una persona queer y no binaria. [translation:
But they don’t understand because they don’t
know that I identify as queer and nonbinary.] They
just think I am a little weird because most of my
friends are also queer, but my parents don’t know
that. They just think we dress and act weird.”

Session 2
My goal for the second session was to continue facilitating Jose Luis’s expression
of their feelings, thoughts, and experiences and identify their treatment goals.
After exploring Jose Luis’s feelings and thoughts, I invited them to write down
three things they wanted to accomplish during our sessions. We agreed to work
on the following:
Treatment Goal #1: Increase self-­awareness and integration of various aspects of
self as evidenced by Jose Luis’s self-­report.
Objectives:
1. Engage in self-­ reflection exercises such as journaling or guided reflection
prompts to help them explore thoughts, emotions, and experiences.
2. Identify and explore core beliefs and values.
3. Foster self-­acceptance and self-­compassion.
4. Practice mindfulness and present-­moment awareness.
5. Encourage exploration of different aspects of self.
266 Chapter 19

Treatment Goal #2: Increase Jose Luis’s acceptance of emotions as they arise, as
evidenced by Jose Luis’s ability to label, express, and experience their emotions.
Objectives:
1. Develop emotional awareness by encouraging them to identify and label dif-
ferent emotions as they arise and explore their physical sensations and accom-
panying thoughts.
2. Normalize the experience of emotions.
3. Identify triggers and patterns.
4. Explore the functions of their emotions.
Treatment Goal #3: Increase ability to communicate needs as they arise to others
as evidenced by Jose Luis’s ability to verbalize their needs in the counseling ses-
sions, their parents’ report, and Jose Luis’s self-­report.
Objectives:
1. Identify and clarify personal needs.
2. Explore barriers to communication.
3. Develop communication skills.
4. Practice expressing needs in counseling sessions.
5. Collaborate with Jose Luis’s parents/family to support and reinforce their
progress in communicating needs.
Jose Luis and I agreed to periodically assess their progress and revise their treat-
ment goals.

Later Sessions
As we enter the working phase of our time together, I aim to explore Jose Luis’s
contact boundary disturbances (i.e., how they make and break contact with
themselves, me, and others) in session to co-­create experiments with them that
help them achieve their treatment goals. For example, we will practice mindful-
ness and present-­moment awareness in sessions to help Jose Luis connect with
their inner experience. In later sessions, we will continue shifting the treatment
plan and approach to meet the emerging needs of Jose Luis (e.g., referrals to
support groups and gender-­affirming medical care). Further, Jose Luis and I will
continue exploring ways to integrate their parents and family members into their
counseling sessions, as needed, especially as they continue exploring their desire
to come out to their parents.

Session 4
Now that we’ve developed more trust and established a sense of safety in our
therapeutic relationship, I aimed to support Jose Luis in exploring their somatic
experience of anxiety through an expressive art intervention in the fourth session.
On the following page is a short transcript of our session.
TABLE 19.2. JOSE LUIS: SESSION 4
Transcript Analysis
Ana: “Gently close your eyes and simply become I facilitated a grounding practice to help Jose Luis
aware of your breath. There is no need to change connect to their somatic experience in preparation
it—simply notice the natural rhythm of your breath for the expressive arts intervention.
[pause]. Allow your body to move with each
inhale and exhale [pause]. Now, gently shift your
awareness to any part of your body where you feel
anxiety and notice what you feel or sense [pause].
Now, gently shift your awareness back to your
breath and notice your breathing—again, there is
no need to change anything. Just become aware
of your breathing [pause]. Now slowly start wiggling
your toes and moving your arms. When you are
ready, open your eyes.”
[Jose Luis opens their eyes.]
“Now, I want you to draw how you experience your
anxiety.”
Jose Luis: “Okay, this should be interesting [smiles].” Jose Luis appeared both excited and nervous
about the expressive arts. Yet, they were willing to
draw their experience of anxiety.
Ana: “First, you are going to draw the outline of your I described the expressive arts activity and
body—think of it as drawing a gingerbread person allowed space for Jose Luis to ask any clarifying
(Drewes, 2001). Then you are going to draw/write questions.
how you experience your anxiety inside your body
(the gingerbread person) or anywhere on the page.
You can use any of the materials here.”
Jose Luis: “Can I play some music as I draw?” Jose Luis expressed a desire to play music and is
still asking for permission to bring themselves into
our clinical work.
Ana: “Of course, you will have about 15 minutes There are several pros and cons regarding
to draw; if you need more time we can adjust as whether we play music during an expressive arts
needed. How does that sound?” activity because music is evocative. However,
it seems important for Jose Luis to play music,
and the music they choose to play is something
we can explore at the end of the expressive arts
intervention while we process their drawing.
Jose Luis: “Sounds good. But I don’t think it will
take me that long at all.”
[starts playing music]
Ana: “It sounds like you have a sense of what you
are going to draw.
Jose Luis: “Yup.”
Ana: You have fifteen minutes starting now.”
Ana: “You have five minutes left.”
Ana: “You have about one minute left.”
Jose Luis: “Ya casi [translation: Almost ready].”
Jose Luis: “Ya termine [translation: I am done].” See Figure 19.1 for sample artwork.
[showing Ana their drawing]
Ana: “Estabas enfocade mientras dibujabas
[translation: You were focused while you drew].”
Jose Luis: “No pensé que me iba a conectar de esa Jose Luis found this expressive arts intervention
manera. Pero cuando comencé a dibujar puedo helpful, allowing them to connect with their
conectar más [translation: I didn’t think I was going experience in ways they hadn’t before.
to connect that way. But when I started drawing, I
was able to connect more] with my anxiety and how
it feels like in my body . . . you know. I am surprised
by what I drew.”
268 Chapter 19

Figure 19.1. La Tormenta Adentro [translation: The Storm Within]

Figure courtesy of Ana Guadalupe Reyes, based on client(s)’ representations.

For the remainder of the session, we processed Jose Luis’s experience of the
expressive arts intervention, what the drawing presents to them, and their expe-
rience of anxiety. Jose Luis was able to vocalize how their experience of anxiety
feels like a storm within that leaves them feeling trapped and stuck.
In the following sessions, Jose Luis’s ability to experience and express their
emotions increased as they explored and integrated previously disowned parts of
themselves. In addition, Jose Luis started identifying environmental triggers such
as experiences of discrimination, bullying, and tension within their family system,
which increased their anxiety.

Ethical and Cultural Considerations

No relevant ethical considerations, beyond the standard informed consent, came
up during my work with Jose Luis. However, many cultural considerations were
crucial in providing trans and queer affirming and linguistically and culturally
responsive services when working with Jose Luis and their parents. My aware-
ness of the Multicultural and Social Justice Competencies (Ratts, Singh, Nassar-­
McMillan, Butler, & McCullough, 2016) helped me explore counseling and
 LGBTQ 269

advocacy interventions that benefited Jose Luis. For example, during parent con-
sultations, I provided psychoeducation regarding adolescents and mental health.
I also consulted with the school counselor and principal regarding school policies
that were negatively impacting the client and engaged in advocacy against anti-­
LGBTQ legislation. I also reviewed the Competencies for Counseling with Trans-
gender Clients (ACA, 2009) to support my work with Jose Luis.

Parent Consultations
The language I spoke when I provided mental health services was an ongoing cul-
tural consideration because Jose Luis’s parents are monolingual Spanish speakers.
Thus, during the intake session, I spoke primarily in Spanish, especially when
speaking to the parents, and at times talked to Jose Luis in English and would
translate what Jose Luis or I said into Spanish to ensure that the parents under-
stood what was being said. Another important cultural aspect was ensuring that
the parents felt a sense of respeto and personalismo during the first few sessions.
Therefore, I met with them often for parent consultations and offered brief par-
ent consultations over the phone as needed. During parent consultations, I only
spoke Spanish and ensured that all resources and referrals provided offered cul-
turally and linguistically responsive services.

Conclusion
Throughout our work together, Jose Luis met all the treatment goals they estab-
lished, and they came out to their parents, who at first struggled with support-
ing the client as they explored what this meant for them as parents. Jose Luis’s
parents attended a local group for parents of LGBTQ youth, learned ways to
support Jose Luis, and started using nonbinary and inclusive language in Spanish.
With their increased self-­awareness and self-­acceptance, Jose Luis started explor-
ing their experiences of internalized oppression and became playful with their
gender expression.
As a therapist, I remembered the power of self-­acceptance and family of ori-
gin and creation. As Jose Luis grew in their self-­awareness and self-­acceptance,
they became more creative and playful in session and outside of session, which
served as a reminder of the importance of healing from internalized oppression to
experience a sense of liberation and empowerment.
270 Chapter 19

Sample Case Note

TABLE 19.3. CASE NOTE: DATA/ASSESSMENT
Client Name: Jose Luis Del Carmen Case Number: 20230517
Session #: 1 Session Date: 5/20/2023
Data: The client explored their experiences as a queer nonbinary person within their family system.
The client explored their experiences coming out to their friends. The client reported that most of their
friends have been supportive except for a couple who seemed to be uncomfortable after the client
shared identifying as nonbinary. The client and counselor explore the client’s desire to come out to
their family. The client expressed fear that their parents would “disown” them due to their religious and
cultural values. The client reported feeling “trapped” and “isolated.”
Assessment: The client appears self-­aware, as evidenced by their ability to recognize their need for
additional support and willingness to advocate for themselves. The client appears highly motivated and
engaged in counseling, as evidenced by their participation and open responses. The client seemed
anxious as they discussed their coming-­out process, especially as they explored their desire to come
out to their parents. The client fidgeted with their hands and fidget toy throughout the session. The
client’s fidgeting increased when they discussed their coming-­out process. The client maintained eye
contact and seemed to maintain psychological contact with the counselor throughout the session.
Plan: The counselor and client will start developing the client’s treatment plan. The client will continue
attending weekly individual counseling sessions with this counselor.
Counselor Signature: ________________________________ Date: _______________
Next Appointment: _______________________

Resources
For Professionals
Gay, Lesbian and Straight Supporters Network (for teachers and students),
https://www​.glsen​.org/about-­us
Erasure and Resilience: The Experiences of LGBTQ Students of Color Report,
https://www​.glsen​.org/research/latinx​-­lgbtq​-­students
National LGBTQIA+ Health Education Center, https://www​.lgbtqiahealth​educa​
tion​.org/

For Clients
National Queer Trans Therapists of Color Network (NQTTCN)—Mental Health
Fund, https://nqttcn​.com/en/mental-­health-­fund/
• The NQTTCN Mental Health Fund provides financial support of up to $100
per session for up to eight sessions with a mental health professional.
GLBT National Youth Talkline: (800) 246-7743
National Coalition of Anti-­
Violence Programs: (212) 714-1141 (English and
Spanish)
Trevor Project:
• Webchat: https://www​.thetrevorproject​.org/get-­help/
• Crisis Line: (866) 488-7386
• Text: Texting “START” to 678-678
 LGBTQ 271

For Parents
Somos Familia—resources for families who have a child who identifies with the
LGBTQ+ community, in English and Spanish, https://www​.somosfamiliabay​
.org/resources/
Family Acceptance Project, https://lgbtqfamilyacceptance​.org/

Discussion Questions
1. How may your social location impact your work with Jose Luis and their
parents?
2. How would you work to dismantle the power structures present in our work
with Jose Luis and their parents?
3. How would you engage in advocacy to dismantle the power structures pres-
ent in Jose Luis’s life?
4. How would you approach your work with Jose Luis after reading this
chapter?
5. Moving forward, how can you approach your work with queer adolescents
in ways that are affirming and liberating?

References
American Counseling Association. (2009). Competencies for counseling with
transgender clients.
Batejan, K. L., Jarvi, S. M., & Swenson, L. P. (2015). Sexual orientation and non-­
suicidal self-­injury: A meta-­analytic review. Archives of Suicide Research, 19,
131–150. doi: 10​.1080/​13811118.2014.957450
Carbado, D. W., Crenshaw, K. W., Mays, V. M., & Tomlinson, B. (2013). Intersec-
tionality: Mapping the movements of a theory. Du Bois Review, 10, 303–312.
doi: 10.1017/S1742058X13000349
Collins, P. H., & Bilge, S. (2016). Intersectionality. Polity Press.
Crenshaw, K. W. (1989). Demarginalizing the intersection of race and sex: A
Black feminist critique of antidiscrimination doctrine, feminist theory, and
antiracist politics. University of Chicago Legal Forum, 139–167.
Drewes, A. A. (2001). The gingerbread person feelings map. In C. E. Schaefer &
H. Kaduson (Eds.), 101 more play therapy techniques (pp. 92–97). Aronson.
Hafeez, H., Zeshan, M., Tahir, M. A., Jahan, N., & Naveed, S. (2017). Health
care disparities among lesbian, gay, bisexual, and transgender youth: A litera-
ture review. Cureus, 9(4), 2–7. doi: 10.7759/cureus.1184
Hunt, L., Vennatt, M., & Waters, J. H. (2018). Health and wellness for LGBTQ.
Advances in Pediatrics, 65(1). https://doi​.org/​10​.1016/j​.yapd.2018.04.002
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay,
bisexual, populations: Conceptual issues and research evidence. Psychologi-
cal Bulletin, 129, 674–697. doi: 10​.1037/0033-2909.129.5.674
272 Chapter 19

Mustanski, B., Newcomb, M., & Garofalo, R. (2011). Mental health of lesbian, gay,
and bisexual youth: A developmental resiliency respective. Journal of Gay and
Lesbian Social Services, 23, 204–225. doi: 10.1080/10538720.2011.561474
National Alliance on Mental Illness (NAMI). (2023). LGBTQI. https://www​
.nami​.org/Your-­Journey/Identity-­and​-­Cultural​-­Dimensions/LGBTQI
Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A.,
Kelaher, M., & Gee, G. (2015). Racism as a determinant of health: A sys-
tematic review and meta-­analysis. PLoS One, 10(9). doi: 10.1371/journal​
.pone.0138511
Perls, F., Hefferline, E. R., & Goodman, P. (1951). Gestalt therapy: Excitement
and growth in the human personality. Gestalt Journal Press.
Purswell, K. E., & Stulmaker, H. L. (2015). Expressive arts in supervision: Choos-
ing developmentally appropriate interventions. International Journal of Play
Therapy, 24(2), 103–117. doi: 10​.1037/a0039134
Ratts, M. J., Singh, A. A., Nassar-­McMillan, S., Butler, S. K., & McCullough, J. R.
(2016). Multicultural and social justice counseling competencies: Guidelines
for the counseling profession. Journal of Multicultural Counseling and Devel-
opment, 44, (1), 28–48.
Riley, S. (1997). Contemporary art therapy with adolescents. Jessica Kingsley
Publishers.
Trevor Project. (2022). 2022 National Survey on LGBTQ Youth Mental Health.
https://www​.thetrevorproject​.org/survey-2022/
Yontef, G. (1993). Awareness, dialogue and process: Essays on Gestalt therapy.
Gestalt Journal Press.
Yosso, J. T. (2005). Whose culture has capital? A critical race theory discussion of
community cultural wealth. Race Ethnicity and Education, 8(1), 69–91.
 CHAPT E R 20

Gender
Narrative Therapy with Parents of a Nonbinary
Transgender Korean American Adolescent
Brooks Bull

Lisa, a White, 50-year-­old mother, called me for help with her 12-year-­old child,
Alex. According to Lisa, Alex had recently come out as a nonbinary transgender
person (they/them pronouns), and the family needed help “figuring out what to do.”
The family consisted of Lisa, Charlie (Lisa’s partner of 10 years); and Alex, who Lisa
adopted at age 8 months from Korea. Alex, who was assigned female at birth, had
typical development until age 9 when “things started to go off course socially.” Lisa
explained that Alex has always been extremely socially isolated, has a hard time
making friends, and is overall quite depressed and lonely. Lisa’s hope was that ther-
apy could provide the emotional support for Alex to “figure out the gender stuff and
get back on track.” She explained that Alex’s disclosure had created a lot of new
tension and conflict between Charlie and her, a new dynamic in their relationship.

This case illustrates how work with transgender adolescents and their parents
must address both the cultural and familial level of meaning making. On the soci-
etal level, oppressive, pathologizing discourses are everywhere (on the internet,
around the watercooler, and on the playground). On the family level, individuals
are trying to make sense of gender and the emergent unfolding of identity devel-
opment and creating their own idiosyncratic meanings and stories. Caregivers
play a vital role in providing a safer space where the transgender child can be
themselves and go through the evolving process of adolescent identity develop-
ment. In this way, both cultural and familial context are a major part of the diag-
nostic and treatment planning picture.

For this case study, consider:

1. How does the cultural context of anti-­transgender discourse impact the case
conceptualization?
2. What is the rationale for a narrative approach with clients such as this?
3. What historical, political, and social knowledge do practitioners need to have
to treat transgender families ethically?

273
274 Chapter 20

Transgender Environmental Context

We are living through a particularly virulent moment of anti-­transgender pub-
lic discourse in the United States, and the impact can be felt in all corners of
transgender communities. At this time, more than 30 states have proposed leg-
islation banning gender-­affirming care for minors, some states going so far as
to define supporting children to socially and/or hormonally transition as child
abuse. There is no underestimating the pervasive and oppressive force this type of
political discourse exerts on families with transgender members. As this review of
the literature shows, minority stress powerfully impacts the well-­being of trans-
gender and nonbinary youth. On the other hand, parental support is also shown
to be a very real and powerful protective factor.
Johns and colleagues (2019) found that “compared with cisgender males and
females, transgender students were more likely to report violence victimization,
substance use, and suicide risk” (p. 67). In addition, nonbinary and genderqueer
individuals are at even greater risk. Lefevor, Boyd-­Rogers, Sprague, and Janis
(2019) showed that these individuals experience significantly more adverse health
outcomes compared to both their cisgender and binary transgender counterparts.
This highlights just how powerful the cultural value on gender conformity is.
Transgender people who do not express their gender identity in strictly masculine
or feminine ways are targets of discrimination, leaving them vulnerable to vio-
lence and mental health problems including suicidality.
Family acceptance is the most potent balm we have against cultural oppres-
sion. Indeed, having even one supportive caregiver can make an enormous positive
impact on the well-­being of transgender and nonbinary children (Andrzejewski,
Pampati, Steiner, Boyce, & Johns, 2021; Ryan, Russell, Huebner, Diaz, & Sanchez,
2010). The strong relationship between familial support and child well-­being was
confirmed by Kuvalanka, Weiner, Munroe, Goldberg, and Gardner (2017). Olson,
Durwood, DeMeules, and McLaughlin (2016) found that transgender children
who were supported in their identities showed comparable low levels of depres-
sion and anxiety compared to control groups. Both Olson and colleagues (2016)
and Kuvalanka and colleagues (2017) provide evidence that when children are
supported in their gender identities early in life, they show lower levels of depres-
sion and anxiety, and report higher levels of satisfaction overall. The clear evidence
of both increased risk for transgender and nonbinary youth coupled with the pow-
erful role parental acceptance plays in improving outcomes makes a strong case
for direct therapeutic work with parents whenever possible.

Narrative Therapy
Narrative therapy is one of the few family therapy theories that overtly addresses
societal and cultural discourses in its view of problem formation and resolution.
White and Epston (1990) revolutionized therapy by highlighting the need to sep-
arate people from problems, or as Winslade and Monk (2008) later put it, “the
 Gender 275

problem is the problem. The person is not the problem” (p. 2). Nowhere is this
simple intervention, externalizing, more obviously important than in therapy
with families with transgender and nonbinary children. By separating the child’s
gender identity from “the problem,” the therapist opens up space to identify the
actual sources of distress—dominant cultural discourses that oppress members of
the family, and the intrapsychic and interpersonal meanings that support those
oppressive discourses.

Re-­Storying as an Overall Goal

Narrative therapists are keen to identify the problem-­saturated stories and work
with clients to reshape those stories into ones in which the problem itself plays
the main role while the client is secondary, or even a victim of the problem’s
nefarious influence. For example, rather than endorsing a client’s story that they
are depressed, a narrative therapist would ask questions to externalize depression
from the client and then facilitate conversation to describe how depression as its
own entity impacts the client and their family. From this framework, the narrative
therapist collaboratively maps the origins, effects, and prognosis of the problem
with the client’s help. These questions create more and more daylight between the
client as a person and the problem, and oftentimes clients will soon begin to talk
about “it,” the problem, rather than themselves as a flawed person.

Dominant versus Alternative and Local Discourses

Narrative therapists do not hesitate to name the oppressive role of cultural dis-
courses in a client’s presenting problem. As a reminder, dominant discourses are
simply the bundle of meanings people from a dominant group culturally ascribe
to how a person should be, live, relate, and behave. In terms of gender, the domi-
nant discourse is that there are only two “real” genders, and that they hew closely
to biological sex. For anyone whose lived experience does not fit this binary con-
struction, the result is to feel othered, wrong, incomplete, or somehow less than.
Local and alternative discourses are real-­life people and families whose stories do
not fit the mold that the dominant discourses would like to pretend is singular.
For example, the fact that there have always been people who do not live within
the gender binary, in all cultures and in all eras, is a major challenge to the dom-
inant discourse. However, proponents of the “there are only two real genders”
position skillfully deploy a strategy of ahistorical discourse to combat the rich,
multitudinous history of gender diversity throughout time. Narrative therapists
bring this historical and discursive challenge into the room by naming the power-
ful oppressive force of cisgender privilege, binary thinking, and the strategic era-
sure of transgender history. They then provide alternative, local discourses about
actual transgender people and families currently living in our communities as
well as historical figures from near and distant past as an antidote to the silenc-
ing, oppressive dominant discourse our culture offers to transgender children.
276 Chapter 20

Remembering
In narrative practice, therapists ask questions to populate a client’s narrative with
allies and witnesses, and if possible, bring other supportive people into the con-
versations (White & Epston, 1990). Connecting parents and transgender children
with other families like theirs is of paramount importance. The therapy conversa-
tion must extend outside the confines of the session room to adequately address
the role of oppression. In fact, therapy with transgender families that exists solely
within the therapeutic system further reifies the notion that to have a transgender
child is a private problem only to be addressed within a mental health setting.
Part of a narrative therapist’s job is to puncture the pathologizing conception that
produces this insular system and connect transgender children and their parents
with the mirroring and growth that only come from and within community.
Parallel to connecting client families to other trans families, another form
of remembering can come in the form of filling in history. Dominant discourse
would have us pretend transgenderism is a new thing, something that has caught
on due to the internet or some other venue of social contagion. In contrast, learn-
ing about transgender history provides a tapestry of human experience into which
the clients can weave themselves. Giving clients books to read and films to watch
that provide allies, elders, and ancestors where previously there was a void can be
a powerful intervention. No longer is having a transgender child just a modern
thing, or a fad, but just another example of a long history of human diversity that
has always been present in all cultures including our own.

Case Study Application

Alex is a nonbinary transgender 12-year-­old in need of a supportive family envi-
ronment in which to continue their exploration and development of identity.
Lisa and Charlie are engaged, caring parents in need of support and education
to show up for Alex in this process. The family is living many stories at once—
the cultural story that transgenderism is a fad, an idea spread through social
networks and the media that has swooped in to invalidate Alex’s disclosure.
Alongside that dominant story, the family is also living out their stated values of
“everyone being who they are.” Lisa and Charlie have both articulated a desire
to allow Alex to choose whatever path in life they feel is right for them; how-
ever, the fear and panic they feel around gender identity is getting in the way of
fully living that value. Therapy for Lisa and Charlie can be a space to flesh out
more of the stories that live alongside the dominant discourse that questions the
validity of nonbinary transgender identities and pathologizes supportive parents.
For Alex, this therapy can be a space of relative safety to continue their articula-
tion of who they are and learn new skills for self-­advocacy. All members of this
family will benefit from being connected to more community of families with
transgender members.
 Gender 277

Regarding the role of clinician, assessment of Alex’s gender identity is not the
primary task of the clinician (Chang, Singh, & Dickey, 2018). On the contrary,
helping parents understand how to support their child on a journey of identity
exploration is the therapist’s primary job. An awareness of oppressive discourses
including adultism (the idea that children cannot know themselves due to their
age) as well as binarism (the idea that there are only two valid gender identities
and that they correspond strictly to biological sex) are key guiding principles.
The overall treatment goal is to increase parental support for Alex’s nonbi-
nary transgender identity. The objectives are as follows:
1. Develop a strong working relationship with parents and child.
a. Meet parents and child apart from the problem.
b. Engage family with hope and optimism about having a transgender ­family
member.
c. Clearly articulate therapist’s position and beliefs on gender identity.
2. Assess both family-­level and societal dynamics.
a. Identify dominant discourses impacting parents’ current understanding of
Alex’s gender identity.
b. Externalize this oppressive cultural force as The Problem.
c. Map the effects of The Problem for each member.
3. Replace problem-­ saturated narrative with alternative and local narratives
that support Alex.
a. Identify unique outcomes and exceptions (times when Lisa and Charlie are
not swayed by oppressive binary discourses).
b. Thicken alternative narratives with new language, experiences both from
within the family and from new allies (remembering).
4. Connect Alex and parents with community of other transgender families.

Treatment Process
Most of the work with this family happened with just Lisa and Charlie. Alex
was more of a visitor to this therapy who could redirect and deepen the parents’
work. The first session was devoted to letting Lisa talk about how she had previ-
ously understood Alex’s struggles before they came out as nonbinary. After that, I
shifted my attention to helping Lisa and Charlie externalize the problem and find
a way to describe the feelings that were getting in the way of them really being
there for Alex.
TABLE 20.1. LISA: SESSION 1
Transcript Analysis
T: “How have you understood Alex’s loneliness and Clients need space to tell the story as it exists
isolation in the past? What stories has your family currently before entering into a revising and
told about why Alex’s life is the way it is?” re-­storying.
L: “I always put it in the framework of adoption— Lisa was quick to identify the meta-­frameworks
that Alex struggled because they were (almost impacting her understanding, and names “being
always) the only adopted, only Korean American adopted” as the lens through which she saw
person in the room. I always thought about it in Alex’s distress.
those terms first.”
T: “And now things are starting to shift in your Tentative question from therapist invites the
understanding?” client to language more of the insight.
L: “Right. Gender was not on my radar in any way
until recently, even though as I think back on it
now, there were lots of gender-­related moments of
distress throughout the years.”
T: “It makes sense to me that the very real The therapist looks for opportunities to frame
importance you saw in Alex’s status as an adopted the work as a process of discovery, a quest
kid got in the way of you seeing other aspects of the parent is embarking on. This provides the
their identity. I think that’s part of what’s so powerful foundation for the new narratives (alternative
about dominant discourses—the stories we as a and local discourses) to be created.
culture tell to make sense of experience—they shine
a big light on some things and leave so much else
in total darkness. So, you’re starting to turn your
flashlight to other areas, yes?”

After an initial meeting with Lisa alone, I asked that she come to the next
session with Charlie as well. Early on, the main task is to externalize and shift the
problem language away from the child’s gender identity and locate the problem
in whatever is getting in the way of the parents being supportive. This is best
done without the transgender person, who does not need to be subjected to the
microaggressions of their parents; therapists can be the buffer between the child
and their parents’ early journey out of the stranglehold of anti-­trans discourse.
Charlie and Lisa were very open to shifting the focus to becoming a stronger
team again and “getting their car back on the road.” This was the first part of
externalizing the problem and shifting the problem focus away from Alex’s gen-
der itself. In this case, what was getting in the way most for Lisa and Charlie was
a feeling of fear and pressure—fear that Alex was more in harm’s way as a result
of being a nonbinary trans person, and pressure to stop Alex “from making a
huge mistake.” As part of this therapeutic approach, I always directly address and
challenge anti-­trans rhetoric as it comes up for clients, and ultimately give the
child strategies for self-­advocating in different contexts, including with their par-
ents. I explain and demonstrate this therapist posture and intervention in session
3 with Alex’s stepfather, Charlie, who brought up a term he learned from a quick
internet search called Rapid-­Onset Gender Dysphoria.
TABLE 20.2. LISA AND CHARLIE: SESSION 2
Transcript Analysis
T: “I see you two as very caring, engaged parents. These questions help clients externalize the
I wonder what it’s like for you to be in a situation problem and shift problem talk away from the
where you are at odds with Alex and unable to child’s gender identity itself.
connect. That must be a terrible feeling, and
certainly a problem we can work on together. Can
we find words to describe this problem? Take it out
of Alex, away from gender completely, and give it a
name?”
C: “I’m not sure I follow you.” Clients can be confused early on and need
guidance to shift an entrenched problem away
from a family member.
T: “Understandable! I am asking you to think and The therapist uses a strengths-­based
talk about this in a very different way. Here’s what I approach to join the client system and create a
mean. From everything I’ve heard thus far, it seems collaborative atmosphere.
like you two are a great team and can handle just
about anything in terms of family and parenting
life. [Both parents nod] So, it strikes me as a big
problem that you are not able to join together and
support your kid through this new development. It
has shaken up your family and put you all at odds.
That seems like a problem to me.”
C: “Ah, I get it now. Like we have to get the car Charlie offers a metaphor that will be used
started again before we figure out where to go.” throughout therapy.
T: “Exactly! Your car is limping along on the The therapist looks for opportunities to use client
shoulder of the road right now.” language and images and increase the field of
possibilities in terms of how the clients story
their experience.
L: “It might actually be in the ditch at this point”
[both parents chuckle ruefully].
T: “You need some help getting back on the road, Therapist occupies a hopeful position that
and we can definitely do that together.” emphasizes a future with possibilities not yet
articulated. Importantly, therapist does not
create conversations that guarantee a specific
outcome in terms of the child’s gender identity
but, rather, emphasizes the journey the family
is on to be as present and engaged with one
another as possible.
TABLE 20.3. LISA AND CHARLIE: SESSION 3
Transcript Analysis
C: “I found something online that I think is really Anti-­trans discourse makes its way into the
important. It explains how this stuff comes therapeutic conversation. This is an important
up so quick, out of nowhere. [Charlie looks to moment to intervene upon both to deepen the
me.] Have you heard of Rapid-­Onset Gender alliance with Charlie as well as open up alternative,
Dysphoria (ROGD)? Apparently, it’s spreading like more local discourses.
crazy.”
T: “I’ve heard those words before, social These questions locate the term ROGD firmly
contagion and ROGD, they keep coming up in in the sphere of cultural/public discourse and
conversations like this one and on my computer then ask the client to find more personal, local
screen, and it seems like they mean so many meanings. There is more possibility and room for
different things depending on who is speaking. new meanings in the personal, and so the therapist
Charlie, I am wondering what those words mean deepens this as much as possible.
for you, what they bring up?”
C: “I saw it online, in a forum for parents of kids The therapist observes the dynamic between
who suddenly come out as trans, just like Alex. Charlie and Lisa at this moment, noting Charlie’s
It explains a lot for me. [Lisa tries to speak, but need to keep speaking and not allow Lisa’s voice
Charlie talks over her.] I thought, OK, there’s a to interject. The power of the dominant discourse
name for this thing, and a reason so many kids is directly affecting how the partners interact,
are coming out nowadays. I mean, this wasn’t changing what is usually a reciprocal give-­and-­take
happening in my high school!” into a monological speech.
T: “I’m glad you brought this up, Charlie. It’s so Therapist validates importance of content and
important to address these messages head-­on. potential emotional reasoning behind it before
It makes sense to me that a part of you would challenging.
welcome this type of explanation because it
makes it feel like this gender thing might go away
if you challenge it correctly. Is that right?”
C: “Yeah. This all just feels so sudden. I just want Charlie is able to share the fear behind their interest
to make sure Alex isn’t doing something to be in ROGD and opens the door to talking more about
cool, or get attention or something, in a way that his anxieties about the future.
will later feel like a huge mistake.”
T: “I hear you. You really want Alex to be safe The therapist validates the emotion and fear behind
and feel good. I have some resources to share the parents’ content, and then directly challenges
with you that will help put ROGD into context the anti-­trans discourse by providing context and
[see resource list for Serano]. The truth is that psychoeducation. Then the therapist asks the
term is being deployed in a really sneaky way to client to tell a more personal, local story about how
invalidate young people’s experience. The rapid they have seen and understood their child’s gender
part is really insidious because it makes it sound identity over time.
like a kid disclosing their identity is the same
thing as a kid having an identity. Let’s pause
there. Can you look back and tell me about how
Alex’s gender has made itself known to you over
the years?”
L: “I’d like to jump in here. I’ve been thinking Lisa enters the conversation speaking from more of
about this a lot, actually, about how the words a personal, local location as opposed to Charlie’s
Alex is using are so jarring and alarming to us, talk, which is heavily influenced at the moment by
while at the same time not much has changed. public discourse. The therapist must attend to both
Charlie, you might not agree with me, but I don’t levels of talk and always try to create more space
think Alex’s presentation has changed much at for alternative stories to grow.
all. Still our little tomboy in most ways. So, I think Lisa also offers powerful language that the
for me it’s about what this means for the future, therapist uses to externalize the problem. The
what being transgender means for Alex in three Monster Feeling becomes shared language for
or five or even ten years. That part really scares when the parents are snagged by fear and start
me. That is the feeling I really want to shake, it’s to feel drawn to anti-­trans discourses that invite
like a monster comes over me—us?—and all parents to adjudicate their children’s identities.
I can think of is the future, and I feel so much
worry.”
 Gender 281

Ethical and Cultural Considerations

Working with families with transgender or nonbinary adolescents will mean
starkly different things depending on what state you are practicing in. As I write
this, news is coming across my screens about state legislatures moving bills along
that would limit or outright ban affirming care for minors. Based on the Amer-
ican Counseling Association Code of Ethics (2014), competencies for working
with transgender clients (Burnes et al., 2010), and social justice competencies
(Toporek, Lewis, & Ratts, 2010), counselors need to advocate for the rights of
transgender people to exist, use public facilities, and receive medical care while
we also advocate for the protections of medical providers who in some states
could be prosecuted for providing care to trans patients. Now is the time to step
forward and engage in the fight. The dominance of cisgender privilege is quite lit-
erally crushing the transgender community, and although therapists tend to work
on a small individual/family scale, this is a moment that calls for more public
engagement.
When working with families, being outspoken about your support for trans
rights is paramount. Being explicit about my understanding that transgender peo-
ple have always existed and will continue to exist, that the identity is not a ques-
tion or something to poke and prod for veracity is foundational to my approach
with Alex. To join with the parents, Charlie especially, I had to demonstrate my
ability to hear nuance, engage with his specific experience, and see the best in
him. In my work with families, it has served me well to treat each member of
the family as a person doing their best with the information they have. This is
the foundation from which families can successfully navigate questions about if
(and when) the young person needs to access medical care to support their iden-
tity. Conversations about puberty blockers, hormone therapy, and surgeries come
after this primary work is firmly in place.
It is not the job of the therapist to talk anyone into (or out of) accessing med-
ical care to support their transgender identity. Rather, it is the job of the thera-
pist to help families function at the highest level possible, access information, be
connected to communities and resources, and make informed decisions. A fam-
ily with a 12-year-­old will need personalized support navigating these questions,
and a therapist can be a great help in connecting them to other families living
through these same issues. By meeting other trans families and seeing examples of
adolescents thriving in their trans and nonbinary identities, with some accessing
puberty blockers and hormones, Alex and their family can feel less isolated and
on the edge of their social world. In this way, gender identity development can
exist in the same matrix as other aspects of identity—things we as parents expect
to evolve and develop over time. Therapists can help parents remain open and
engaged to the unfolding process of witnessing their child become more and more
themselves, thereby providing that crucial ingredient of support and engagement
that deeply impacts child well-­being.
282 Chapter 20

Conclusion
Alex benefited greatly from having a space for their parents to explore, make
mistakes, and learn about transgender and nonbinary identities. Meeting other
families with trans children and teens created a network of mirroring and alli-
ances for all three family members and a rich resource where they could bring
specific questions as they arose. The issues they faced when Alex was 12 were
different than when they were 15, and having a deep and broad community was
paramount. Alex continues to identify as a nonbinary transgender person, and
now at age 15 has added understanding of other aspects of their identity as well.
They have recently become more interested in learning more about their heritage
as a person of Korean descent and have enlisted Lisa and Charlie to take Korean
classes with them. The family continues to prioritize “being in it together” above
all else and ensuring that they are relating with one another in real and authentic
ways that fit for their family as opposed to letting That Monster Feeling take over
and make decisions for them. They continue to meet with me as needed, mostly
to process continuing anxiety about Alex’s future as a trans person in a violently
oppressive anti-­trans culture.

Sample Case Notes

Session 3
Subjective: Charlie expressed his perception that Alex’s gender was the result of
“peer pressure” and an “attempt to be cool” and brought up a resource he found
on the internet about Rapid-­Onset Gender Dysphoria.
Objective: Charlie’s speech was tense and pressured at times, and he interrupted
and talked over Lisa when she questioned his assessment. After therapist vali-
dated and joined Charlie in his fear and concern for Alex, Charlie reported feeling
calmer, spoke more slowly, and allowed Lisa to participate in the conversation.
Assessment: From a narrative perspective, Charlie is currently under the influ-
ence of dominant discourses that invalidate trans and nonbinary identities, and
position gender nonconformity as ahistorical and a product of internet culture.
Throughout the session, Charlie appeared to become more open to the idea that
his panic and fear (externalized by the clients as That Monster Feeling) was limit-
ing his ability to learn and connect with Alex.
Plan: Continue identifying the role oppressive anti-­trans discourses (The Monster
Feeling) are playing in individual emotional experience and family interactions;
begin to invite alternative re-­storying by providing clients with resources to learn
the history of transgender people (see resource list).
 Gender 283

Resources
For Adolescents
The Gender Quest Workbook by Rylan Jay Testa, Jayme Peta, & Deborah Cool-
hart. Instant Help Books.
It’s Perfectly Normal: Changing Bodies, Growing Up, Sex, and Sexual Health by
Robie H. Harris. Family Library.
Some Assembly Required: The Not-­So-­Secret Life of a Transgender Teen by Arin
Andrews. Simon & Schuster.

Current Resources for Therapists and Adult Clients

to Better Understand Gender Identity
Beyond the Gender Binary (book) by Alok Vaid-­ Menon. Pocket Change
Collective.
The Bold World: A Memoir of Family and Transformation (book) by Jodie Pat-
terson. Random House.
Gender Queer: A Memoir (graphic novel) by Maia Kobabe. Lion Forge Comics
Oni Press.
Serano, J. (2018). Everything you need to know about Rapid Onset Gender Dys-
phoria. https://juliaserano​.medium​.com/everything-­you-­need-­to-­know-­about-­
rapid-­onset-­gender-­dysphoria-1940b8afdeba (article)
Trans* Ally Workbook: Getting Pronouns Right (booklet) by Davey Shlasko.
Think Again Training and Consultation.

Historical Resources for Therapists and Adult Clients to Learn

the History of Transgender and Gender-­Diverse People
Before We Were Trans: A New History of Gender (book) by Kit Heyam. Seal
Press.
Disclosure (film) by Sam Feder.
Female Husbands (book) by Jen Manion. Cambridge University Press.
Transgender History (book) by Susan Stryker. Seal Press.
Transgender Warriors (book) by Leslie Feinberg. Beacon Press.

Discussion Questions
1. What is the main role of the therapist in working with transgender adoles-
cents and their parents? Does this case challenge any of your notions about
the role of assessment in this work?
2. How does narrative inquiry invite therapists to challenge dominant cultural
discourses? Does this bring up any misgivings or confusion about your role?
3. As a therapist, what might you need to learn about transgender history as
well as the current political landscape to work effectively with Alex and their
family?
284 Chapter 20

4. What professional community might you need to find to work with transgen-
der families? How would you respond if you received a request from a client
who wanted to be connected to more community?

References
American Counseling Association. (2014). 2014 ACA code of ethics. https://www​
.counseling​.org/docs/default-­source/default-­document-­library/2014-code-­of​
-­ethics-­finaladdress​.pdf
Andrzejewski, J., Pampati, S., Steiner, R. J., Boyce, L., & Johns, M. M. (2021).
Perspectives of transgender youth on parental support: Qualitative findings
from the resilience and transgender youth study. Health Education & Behav-
ior, 48(1), 74–81. https://doi.org/10.1177/1090198120965504
Burnes, T. R., Singh, A. A., Harper, A. J., Harper, B., Maxon-­Kann, W., Pickering,
D. L., Moundas, S., Scofield, T. R., Roan, A., Hosea, J., & ALGBTIC Trans-
gender Committee. (2010). American Counseling Association: Competencies
for counseling with transgender clients. Journal of LGBT Issues in Counsel-
ing, 4(3–4), 135–159.
Chang, S., Singh, A., & Dickey, L. M. (2018). A clinician’s guide to gender affirm-
ing care: Working with transgender and gender non-­conforming clients. New
Harbinger Publications.
Johns, M. M., Lowry, R., Andrzejewski, J., Barrios, L. C., Demissie, Z., McMa-
nus, T., Rasberry, C. N., Robin, L., & Underwood, J. M. (2019). Transgender
identity and experiences of violence victimization, substance use, suicide risk,
and sexual risk behaviors among high school students—19 states and large
urban school districts, 2017. Morbidity and Mortality Weekly Report, 68(3),
67–71. https://doi​.org/10.15585/mmwr​.mm6803a3
Kuvalanka, K. A., Weiner, J. L., Munroe, C., Goldberg, A. E., & Gardner, M.
(2017). Trans and gender-­nonconforming children and their caregivers: Gen-
der presentations, peer relations, and well-­being at baseline. Journal of Fam-
ily Psychology, 31(7), 889–899. https://doi​.org/10.1037/fam0000338
Lefevor, G. T., Boyd-­Rogers, C. C., Sprague, B. M., & Janis, R. A. (2019). Health
disparities between genderqueer, transgender, and cisgender individuals: An
extension of minority stress theory. Journal of Counseling Psychology, 66(4),
385–395. https://doi​.org/10.1037/ cou0000339
Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental
health of transgender children who are supported in their identities. Pediat-
rics, 137(3), Article e20153223. https://doi​.org/10.1542/peds.2015-3223
Ryan, C. (2010). Engaging families to support lesbian, gay, bisexual, and trans-
gender youth: The family acceptance project. Prevention Researcher, 17(4),
11–13. https://doi​.org/10.1037/e509042011-003
Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family
acceptance in adolescence and the health of LGBT young adults. Journal
 Gender 285

of Child and Adolescent Psychiatric Nursing, 23(4), 205–213. https://doi​

.org/10.1111/j.1744-6171.2010.00246.x
Serano, J. (2018). Everything you need to know about Rapid Onset Gender Dys-
phoria. https://juliaserano​.medium​.com/everything-­you-­need-­to-­know-­about​
-­rapid-­onset-­gender-­dysphoria-1940b8afdeba
Toporek, R. L., Lewis, J. A., & Ratts, M. J. (2010). The ACA advocacy com-
petencies: An overview. In M. J. Ratts, R. L. Toporek, & J. A. Lewis (Eds.),
ACA advocacy competencies: A social justice framework for counselors (pp.
11–20). American Counseling Association.
White, M., & Epston, D. (1990). Narrative means to therapeutic ends. Norton.
Winslade, J., & Monk, G. (2008). Narrative mediation: Loosening the grip of
conflict. Jossey-­Bass, Wiley Imprint.
 Index

AAPT. See Animal Assisted Play Therapy aggressive behaviors, 44; in communication, 27; family
ableism, 98 settings and, 46; media violence and, 45; in play, 21,
abreaction, 64 35
academic achievement: child-centered play therapy and, alternative discourses, 275
6; Chinese, 78 ambivalence, 248
ACE. See adverse childhood experience American Association for Marriage and Family Therapy
A-C-T limit-setting approach, 144 Code of Ethics, 147
adaptive self-statements, 64 American Counseling Association Code of Ethics,
ADHD. See attention deficit hyperactivity disorder 146–47
Adler, Alfred, 78 American Psychological Association Ethical Principles of
Adlerian play therapy (AdPT): analysis, 85–88; anxiety Psychologists and Code of Conduct, 147
and, 77–94; Asian hate and, 77–94; basis for, 78; case AN. See anorexia nervosa
study application, 82–89; with Chinese American anger, 8, 50
child, 77–94; client conceptualization, 82–83; Animal Assisted Play Therapy (AAPT), 225–26
cultural considerations, 90; discussion questions, anorexia nervosa (AN), 235
93–94; egalitarian relationships in, 80; ethical antisocial behaviors, 44
considerations, 90; goals, 83–84; hoops of control, anxiety: Adlerian play therapy and, 77–94; Asian
91–92; parent consultations, 90; phases of, 80–81, hate and, 77–94; case study applications, 82–89;
85–86; security/insecurity blanket, 92–93; session childhood depression and, 4; Chinese American child
notes, 91–93; teacher consultations, 90; transcript, and, 77–94; Chinese parenting style and, 78; divorce
85–88; treatment process, 84–89 and, 138; separation, 34. See also social anxiety
adolescent depression: adolescent resources, 166; Asian hate, 159, 164; Adlerian play therapy and, 77–94;
analysis, 161–62; Asian culture and, 159; assessment, anxiety and, 77–94; cultural considerations, 90;
165–66; case conceptualization, 163; case study discussion questions, 93–94; ethical considerations,
application, 161–64; Chinese American adolescent 90; parent consultations, 90; session notes, 91–93;
and, 157–66; Cognitive Behavior Therapy and, teacher consultations, 90
157–66, 186–87; consequences of, 158; COVID-19 Association for Play Therapy Best Practices, 103
and, 159; cultural considerations, 164; discussion attention, 80–81
questions, 166; ethical considerations, 164; attention deficit hyperactivity disorder (ADHD):
Expressive Arts Therapy and, 157–66; Gen Z and, African American child and, 61–73; analysis, 66–69;
158; goals, 163; major, 247–48; objective process, associations with, 44–45; behaviors common with,
165–66; parent consultations, 164; parent resources, 45; case study applications, 65–70; child-centered
166; plan, 165–66; professional resources, 166; play therapy and, 5; Cognitive Behavioral Play
sample case notes, 165–66; social media and, Therapy and, 61–73; Cognitive Behavioral Therapy
158–59; subjective process, 165; symptoms of, 158; and, 62–63; COVID-19 and, 61–73; cultural
transcripts, 161–62 considerations, 70; delinquency and, 62; depression
adolescent resources: adolescent depression, 166; child symptoms differentiated from, 12; discussion
sexual abuse, 208; Cognitive Behavior Therapy, 166, questions, 73; disruptive behavior and, 44–45;
193; Dialectical Behavior Therapy, 220; divorce, emotional symptoms of, 62; ethical considerations,
193; eating disorder, 244; Enhanced Cognitive 70; indicators of, 62; parent resources, 73;
Behavior Therapy, 244; Expressive Arts Therapy, professional resources, 73; psychoeducation and, 65;
166, 193; extremism, 193; gender, 283; Motivational session notes, 65–73; specific learning disabilities
Interviewing, 256; self-harm, 220; substance use and, 45; statistics on, 44, 61–62; symptoms of,
disorders, 256; Trauma-Focused Cognitive Behavior 61–62; transcripts, 66–69; treatment goals, 65;
Therapy, 208 underachievement and, 62; working memory and, 62
AdPT. See Adlerian play therapy autism: analysis, 99–102; assessment, 104–5; case study
adverse childhood experience (ACE), 5 application, 99–102; child resources, 105; cultural
affect modulation skills, 199 considerations, 103; discussion questions, 105–6;
African American adolescent: Dialectical Behavior ethical considerations, 103; group approaches to,
Therapy and, 211–21; Motivational Interviewing 96; group play therapy and, 95–106; integrative
and, 247–57; self-harm and, 211–21; substance use play therapy and, 96–97; misinterpretations of, 96;
disorder and, 247–57 objective process, 104–5; parent consultations, 103;
African American child, 61–73 parent resources, 105; plan, 104–5; professional
age-appropriate assessments, 12 resources, 105; sample case notes, 104–5; session

287
288 Index

notes, 99–102; social activities and, 96; statistics on, Child Behavior Checklist, 48
96; subjective process, 104–5; transcripts, 99–102 child-centered play therapy (CCPT): academic
AutPlay Therapy: analysis, 99–102; assessment, 104–5; achievement and, 6; actualization and, 5; age-
belonging and, 97; case study application, 99–102; appropriate assessments and, 12; analysis, 9–10,
child resources, 105; cultural considerations, 103; 23, 24; assessment, 13, 27; ADHD and, 5; with
discussion questions, 105–6; ethical considerations, biracial child, 3–15, 19–28; caregiver resources,
103; foundation of, 97; neurodivergence, 99–102; 28; case study, 7–10, 22–25; childhood depression
objective process, 104–5; parent consultations, and, 5–7; child resources, 14, 28; conditions for,
103; parent resources, 105; plan, 104–5; process of, 6–7; confidentiality and, 11–12; critical race theory
97; professional resources, 105; sample case notes, and, 19–28; cultural considerations and, 11–12,
104–5; subjective process, 104–5; tenets of, 97; 22, 25; diagnosis session, 13; discussion questions,
transcripts, 99–102 14–15, 28; domestic violence and, 31–39; ethical
Axline, Virginia, 5 considerations, 11–12, 25; goals, 7–8, 23; homeless
children and, 6; intake sessions, 7; internalized
behavioral logs, 54 behavioral problems and, 6; interpersonal skills and,
behavioral reversal, 64 33–34; intervention session, 13; objective processes,
belonging, 91, 97 27; parent consultations, 12, 23, 25–26; parent
“Be-With” Attitudes, 142 resources, 14; plan, 27; presentation session, 13;
biracial adolescent, 197–209 professional resources, 14, 28; responses used in, 5–6;
biracial child: child-centered play therapy and, safe environment and, 6–8; self-acceptance and, 21;
3–15, 19–28; developmental stages, 20; identity self-understanding and, 21; session notes, 13–14, 22,
development, 20; in White community, 22 24, 27; space for, 5; subjective processes, 27; teacher
Black categorization bias, 20 consultations and, 12; transcripts, 9–10, 23, 24;
BN. See bulimia nervosa treatment process, 7–10, 23; with White child, 31–39;
breathing exercises, 35, 50, 116 White privilege and, 26
Bryson, Tina Payne, 37 childhood depression, 8–10, 13–15; adverse childhood
bulimia nervosa (BN), 235–36 experiences and, 5; anxiety and, 4; ADHD symptoms
bullying, 212–13 differentiated from, 12; child-centered play therapy
and, 5–7; communication and, 4, 6–7; conditions of
calming strategies, 35, 50 worth and, 6; criteria, 4; cultural background and,
capable, 81, 91 5; diagnostic difficulties with, 4; early life depressors
case study applications: Adlerian play therapy, 82–89; and, 4; factors linked to, 4; family history and, 4;
adolescent depression, 161–64; anxiety, 82–89; gender and, 4–5; impairment from, 3–4; later life
ADHD, 65–70; autism, 99–102; AutPlay Therapy, mental health problems and, 4; microaggressions and,
99–102; child-centered play therapy and, 7–10, 11; parent consultations and, 12; physical symptoms
22–25; Child-Parent Relationship Theory, 140–46; and, 5; self-concept and, 6; statistics on, 4; symptoms
child sexual abuse, 201–6; Cognitive Behavior of, 3–4
Play Therapy, 48–53, 65–70; Cognitive Behavior Child-Parent Relationship Therapy (CPRT), 12; analysis,
Therapy, 161–64, 188–90; critical race theory and, 143, 145; case study application, 140–46; cultural
22–25; Dialectical Behavior Therapy, 215; disruptive considerations, 146–47; discussion questions, 150;
behavior, 48–53; divorce, 140–46, 188–90; eating divorce and, 137–50; effectiveness of, 139; ethical
disorders, 239–42; Enhanced Cognitive Behavior considerations, 146–47; initial intake, 140–41;
Therapy, 239–42; Equine Assisted Family Play objectives, 141; origins of, 138; overview, 140; parent
Therapy and, 226–31; Expressive Arts Therapy, resources, 150; professional resources, 150; religion
161–64, 188–90; extremism, 188–90; family stress, and, 147; session notes, 141–46, 149; transcripts,
127–32; Filial Therapy, 127–32; gender, 276–78; 143, 145; with White child, 137–50
Gestalt therapy, 263–68; grief, 114–17; gun violence, Children’s Depression Inventory, 6, 7
114–17; LGBTQ people, 263–68; Mindfulness- child resources: autism, 105; AutPlay Therapy, 105;
Based Cognitive Behavior Therapy and, 171–74; child-centered play therapy, 14, 28; child sexual
Motivational Interviewing, 250–54; narrative abuse, 208; Cognitive Behavior Play Therapy, 56;
therapy, 276–78; neurodivergent, 99–102; nonbinary critical race theory, 28; disruptive behavior, 56;
transgender adolescent, 276–78; sand tray therapy, grief, 119; gun violence, 119; neurodivergence, 105;
114–17; self-harm, 215; social anxiety, 171–74; sand tray therapy, 119; Trauma-Focused Cognitive
substance use disorder, 250–54; Tourette syndrome, Behavior Therapy, 208; Trauma Informed Child-
226–31; Trauma-Focused Cognitive Behavior Centered Play Therapy, 39
Therapy, 201–6; Trauma Informed Child-Centered child sexual abuse (CSA): adolescent resources, 208;
Play Therapy, 34–36 analysis, 203, 205; biracial adolescent and, 197–209;
CBPT. See Cognitive Behavior Play Therapy case study application, 201–6; child resources, 208;
CBT. See Cognitive Behavior Therapy COVID-19 and, 197–209; cultural considerations,
CBT-BN. See Cognitive Behavioral Therapy Bulimia 206–7; developmental impacts of, 197; discussion
Nervosa questions, 209; ethical considerations, 206–7; goals,
CBT-E. See Enhanced Cognitive Behavior Therapy 202; intake, 201–2; parent consultations, 207; parent
CCPT. See child-centered play therapy resources, 208–9; professional resources, 208; sample
 Index 289

case notes, 208; sex education and, 206; statistics, confidentiality: child-centered play therapy and, 11–12;
198; symptoms of, 197–98; transcript, 203, 205; Trauma Informed Child-Centered Play Therapy and,
Trauma-Focused Cognitive Behavior Therapy and, 36. See also ethical considerations
197–209. See also sexual exploitation risk connect, 81
A Child’s First Book about Play Therapy, 49, 53 COVID-19: adolescent depression and, 159; African
Chinese American adolescent: adolescent depression and, American child and, 61–73; ADHD and, 61–73; child
157–66; Cognitive Behavior Therapy and, 157–66; sexual abuse and, 197–209; Cognitive Behavior Play
Expressive Arts Therapy with, 157–66; nonbinary Therapy and, 61–73; coping strategy resources for,
transgender, 273–84 33; deaths from, 109–10; domestic violence and, 32;
Chinese American child, 77–94 grief and, 109–20; parental burnout and, 32; sand
Chinese parenting style, 78 tray therapy and, 111–20
Chinese virtues, 77–78, 82 courage, 81, 91; for imperfection, 90
Cognitive Behavioral Therapy Bulimia Nervosa CPRT. See Child-Parent Relationship Therapy
(CBT-BN), 236 criminal charges, 36–37
Cognitive Behavior Play Therapy (CBPT): with African critical race theory (CRT): assessments, 27; caregiver
American child, 61–73; analysis, 49, 52, 66–69; resources, 28; case study applications, 22–25; child-
aspects of, 63; assessment, 56; ADHD and, 61–73; centered play therapy and, 19–28; child resources,
case study application, 48–53, 65–70; check-ins, 28; cultural considerations and, 25; discussion
64; child resources, 56; collaborative structure questions, 28; ethical considerations and, 25; goals,
of, 64; communication engagement through, 63; 23; objective processes, 27; parent consultations and,
cultural considerations, 53–54, 70; discussion 25–26; plan, 27; professional resources, 28; session
questions, 57, 73; disruptive behavior and, 43–57; notes, 22, 24, 27; subjective processes, 27; tenets of,
ethical considerations, 53–54, 70; flexibility in, 64; 22
framework of, 46–47; goals, 48–49, 65; objective CRT. See critical race theory
process, 56, 65; parent consultations and, 54–55, Crucial Cs, 79, 81
70–71; parent resources, 57, 73; plan, 56; problem CSA. See child sexual abuse
solving skills and, 46; professional resources, 56, cultural considerations: Adlerian play therapy, 90;
73; rationale for, 43; role play and, 47–48; safe adolescent depression, 164; Asian hate, 90; ADHD
environment and, 63; sample case notes, 55–56, and, 70; autism, 103; AutPlay Therapy, 103; child-
71–73; school-based, 47; self-control and, 46; centered play therapy and, 11–12, 22, 25; Child-
self-reports, 64; self-talk built through, 63; session Parent Relationship Theory, 146–47; child sexual
notes, 49–53, 65–73; short term results of, 47; socio- abuse and, 206–7; Cognitive Behavior Play Therapy
emotional understanding and, 63; strategies, 49, and, 70; Cognitive Behavior Therapy, 164, 191;
64–65; subject process, 55–56; techniques, 47–48; critical race theory and, 25; Dialectical Behavior
transcripts, 49, 52, 66–69; with White child, 43–57 Therapy, 219; disruptive behavior, 53–54; divorce,
Cognitive Behavior Therapy (CBT): ADHD and, 146–47, 191; eating disorders, 242; Enhanced
62–63; adolescent depression and, 157–66, Cognitive Behavior Therapy, 242; Equine Assisted
186–87; adolescent resources, 166, 193; analysis, Family Play Therapy, 231; Expressive Arts Therapy,
161–62, 189–90; assessment, 165–66, 192–93; 164, 191; extremism, 191; family stress, 132–33;
case conceptualization, 163; case study application, Filial Therapy, 132–33; gender and, 281; grief,
161–64, 188–90; with Chinese American adolescent, 117; gun violence, 117; LGBTQ people, 268–69;
157–66; cultural considerations, 164, 191; discussion Mindfulness-Based Cognitive Behavior Therapy, 176;
questions, 166, 194; divorce and, 183–94; ethical Motivational Interviewing, 254; neurodivergence,
considerations, 164, 191; extremism and, 183–94; 103; nonbinary transgender adolescent, 281; parent
goals, 163; lasting effects from, 62; objective consultations and, 26; religion and, 54; sand tray
process, 165–66, 192–93; overview of, 46; parent therapy, 117; self-actualization and, 11; self-harm,
consultations, 164, 191–92; parent resources, 219; social anxiety, 176; substance use disorder, 254;
166, 193–94; plan, 165–66, 192–93; professional Tourette syndrome, 231; Trauma-Focused Cognitive
resources, 166, 193; reinforcement techniques of, Behavior Therapy and, 206–7; Trauma Informed
63; sample case notes, 165–66, 192–93; subjective Child-Centered Play Therapy, 36–37
process, 165, 192–93; transcripts, 161–62, 189–90; cultural discourses, 275
with White adolescent, 183–94
cognitive coping skills, 199, 203 DBT. See Dialectical Behavior Therapy
cognitive distortions, 186 delinquency, 62
cognitive triangle, 189, 203 Dialectical Behavior Therapy (DBT): adolescent
collaboration, 125 resources, 220; African American adolescent and,
comfort, 80 211–21; analysis, 217–18; assessment, 220; case
communication: through aggression, 27; childhood study application, 215; core beliefs, 213–14; cultural
depression and, 4, 6–7; Cognitive Behavior Play considerations, 219; design of, 213–14; discussion
Therapy and engagement in, 63; of feelings, 49 questions, 221; ethical considerations, 219; objective
community feeling, 80 processes, 220; parent consultations, 219; parent
Competencies for Counseling with Transgender Clients, resources, 220; plan, 220; professional resources,
269 220; sample case notes, 220; self-harm and, 211–21;
290 Index

skills sets, 214; subjective processes, 220; transcript, Ecological Systems Theory, 124–25, 127
217–18; treatment goals, 215–16; treatment process, emotional regulation, 34, 214
216–18 empathic understanding, 248
discrepancy, 249 empathy, 125, 249, 252
disruptive behavior: analysis, 49, 52; assessment, 56; empowerment, 125
ADHD and, 44–45; case study application, 48–53; encouragement, 12
child resources, 56; Cognitive Behavior Play Enhanced Cognitive Behavior Therapy (CBT-E):
Therapy and, 43–57; cultural considerations, 53–54; adolescent resources, 244; analysis, 240–41;
domestic violence and, 32; emotional factors in, 44; assessment, 243–44; case study, 239–42; cultural
environmental factors in, 44; ethical considerations, considerations, 242; discussion questions, 245; eating
53–54; family factors in, 44, 46; genetic factors in, disorders and, 235–45; ethical considerations, 242;
44; interventions, 47; January 6 uprising and, 43–57; limitations to, 236; Mexican American adolescent
media violence and, 45; objective process, 56; parent and, 235–45; objective processes, 243–44; overview,
consultations and, 54–55; parent resources, 57; 237; parent consultations, 243; parent resources,
physiological factors in, 44; plan, 56; professional 244; plan, 243–44; professional resources, 244;
resources, 56; reenactments and, 49–50; sample case research on, 236; sample case notes, 243–44; stages,
notes, 55–56; session notes, 49–53; statistics on, 237–39; subjective processes, 243–44; transcripts,
44–46; subjective process, 55–56; transcripts, 49, 52; 240–41; treatment goals, 237
triggers, 44; with White child, 43–57 Equine Assisted Family Play Therapy (EAFPT): analysis,
distress tolerance, 214, 216 229–30; barriers activity, 228–29; case study
divorce: adolescent resources, 193; analysis, 143, application, 226–31; cultural considerations, 231;
145, 189–90; anxiety and, 138; assessment, discussion questions, 232; effectiveness of, 231–32;
192–93; case study application, 140–46, 188–90; ethical considerations, 231; learning from, 230–31;
Child-Parent Relationship Therapy and, 137–50; overview, 227–28; resources, 232; sexual exploitation
Cognitive Behavior Therapy and, 183–94; cultural risk and, 223–32; skills required, 232; Tourette
considerations, 146–47, 191; discussion questions, syndrome and, 223–32; transcript, 229–30; treatment
150, 194; ethical considerations, 146–47, 191; goals, 227; treatment process, 227; White adolescent
Expressive Arts Therapy and, 183–94; extremism and, 223–32
and, 183–94; impact of, 138, 183–84; initial intake Equine Assisted Growth and Learning Association
session, 140–41; objective process, 192–93; parent (EAGALA), 227
consultations and, 191–92; parent resources, 150, ethical considerations: ADHD and, 70; Adlerian play
193–94; plan, 192–93; professional resources, 150, therapy, 90; adolescent depression, 164; Asian hate,
193; rates, 183; routine shifts and, 140; sample case 90; autism, 103; AutPlay Therapy, 103; child-
notes, 192–93; session notes, 141–46, 149; statistics, centered play therapy and, 11–12, 25; Child-Parent
138; subjective process, 192–93; transcripts, 143, Relationship Theory, 146–47; child sexual abuse
145, 189–90; treatment approach to, 186–88; and, 206–7; Cognitive Behavior Play Therapy and,
treatment objectives, 141; White adolescent and, 53–54, 70; Cognitive Behavior Therapy, 164, 191;
183–94 confidentiality and, 11–12; critical race theory and,
domestic violence: behavioral impacts of, 31–32; child- 25; cultural background and, 12; Dialectical Behavior
centered play therapy and, 31–39; children’s books Therapy, 219; disruptive behavior, 53–54; divorce,
on, 33; cognitive strategies for, 33; COVID-19 and, 146–47, 191; eating disorders, 242; Enhanced
32; defining, 31; disruptive behavior and, 32; learning Cognitive Behavior Therapy, 242; Equine Assisted
and, 32; play themes and, 32; statistics on, 32; Family Play Therapy, 231; Expressive Arts Therapy,
triggers, 32; White child and, 31–39 164, 191; extremism, 191; family stress, 132–33;
Dominican American adolescent, 259–71 Filial Therapy, 132–33; gender and, 281; grief,
117; gun violence, 117; LGBTQ people, 268–69;
EAFPT. See Equine Assisted Family Play Therapy Mindfulness-Based Cognitive Behavior Therapy, 176;
EAGALA. See Equine Assisted Growth and Learning Motivational Interviewing, 254; neurodivergence,
Association 103; nonbinary transgender adolescent, 281; sand
early life stressors, 4 tray therapy, 117; self-harm, 219; social anxiety,
eating disorders: adolescent resources, 244; analysis, 176; substance use disorder, 254; Tourette syndrome,
240–41; assessment, 243–44; behavior and, 231; Trauma-Focused Cognitive Behavior Therapy
237; case study, 239–42; cultural considerations, and, 206–7; Trauma Informed Child-Centered Play
242; discussion questions, 245; Enhanced Therapy, 36–37
Cognitive Behavior Therapy and, 235–45; ethical Expressive Arts Therapy, 263; adolescent depression
considerations, 242; formulation, 238, 240; initial and, 157–66; adolescent resources, 166, 193;
assessment, 237–38; medical information, 238; analysis, 161–62, 189–90; assessment, 165–66,
Mexican American adolescent and, 235–45; objective 192–93; case conceptualization, 163; case study
processes, 243–44; parent consultations, 243; parent application, 161–64, 188–90; with Chinese American
resources, 244; plan, 243–44; professional resources, adolescent, 157–66; cultural considerations, 164,
244; sample case notes, 243–44; statistics, 236; 191; discussion questions, 166, 194; divorce and,
subjective processes, 243–44; transcripts, 240–41; 183–94; effectiveness of, 160; ethical considerations,
treatment goals, 237; types of, 235–36 164, 191; examples of, 262; extremism and, 183–94;
 Index 291

goals, 163; objective process, 165–66, 192–93; consultations, 117–18; parent resources, 119–20;
parent consultations, 164, 191–92; parent resources, plan, 118–19; professional resources, 119; recovery
166, 193–94; plan, 165–66, 192–93; professional from, 110; responses to, 110; sample case notes, 118–
resources, 166, 193; sample case notes, 165–66, 19; sand tray therapy and, 111–20; session notes,
192–93; self-awareness and, 160; self-expression and, 114–17; subjective processes, 118–19; transcripts,
160; subjective process, 165, 192–93; transcripts, 115–16; traumatic, 111
161–62, 189–90; with White adolescent, 183–94 Guerney, Bernard, 125
extremism: access to, 185; adolescent resources, Guerney, Louise, 125
193; analysis, 189–90; assessment, 192–93; case gun violence: analysis, 115–16; assessment, 118–19;
study application, 188–90; categorizing, 185; case study application, 114–17; child resources, 119;
Cognitive Behavior Therapy and, 183–94; cultural cultural considerations, 117; discussion questions,
considerations, 191; discussion questions, 194; 119–20; ethical considerations, 117; grief and,
divorce and, 183–94; ethical considerations, 191; 109–20; objective processes, 118–19; objectives, 115–
Expressive Arts Therapy and, 183–94; impact 16; parent consultations, 117–18; parent resources,
of, 184–85; objective process, 192–93; parent 119–20; plan, 118–19; professional resources, 119;
consultations and, 191–92; parent resources, 193–94; sample case notes, 118–19; sand tray therapy and,
plan, 192–93; professional resources, 193; sample 111–20; session notes, 114–17; statistics on, 111;
case notes, 192–93; subjective process, 192–93; subjective processes, 118–19; transcripts, 115–16
transcripts, 189–90; treatment approach to, 186–88;
White adolescent and, 183–94 Hall, G. Stanley, 158
hate speech, 212–13
facilitative responses, 65, 67 Herman, Judith, 33
Fairburn, C. G., 236 human nature, 21
family acceptance, 274 humility, 125
family constellations, 79, 82 hypervigilance, 34
family stress: analysis, 129; case study, 127–32; cultural
considerations, 132–33; discussion questions, 134; “I feel” statements, 50–51
ethical considerations, 132–33; Filial Therapy and, inadequacy, proving, 80–81
123–34; goals, 127–28; home-based sessions, 132; Indigenous American family, 123–34
office based sessions, 130–32; parent resources, Intake Questionnaire for Child-Parent Relationship
134; professional resources, 134; sample case notes, Therapy, 140
133–34; transcripts, 129 integrative play therapy, 96–97
Filial Therapy (FT), 138; analysis, 129; case study, internalized behavioral problems, 6
127–32; conceptualization, 127; core values of, interpersonal effectiveness, 214
125; cultural considerations, 132–33; development interpersonal skills, 33–34
of, 125; discussion questions, 134; environmental intersectionality theory, 262
contexts and, 123–25; ethical considerations, interventions: child-centered play therapy and, 13;
132–33; family stress and, 123–34; goals, 127–28; disruptive behavior, 47; for sexual exploitation risk,
home-based sessions, 132; with Indigenous American 224–25
family, 123–34; integrations into, 125; limits in, intimate partner violence. See domestic violence
126; office based sessions, 130–32; parent resources,
134; process, 128–32; professional resources, 134; January 6 uprising, 43–57
psychoeducation and, 125; sample case notes,
133–34; training, 126–27, 128–29; transcripts, 129 LGBTQ people: analysis, 265, 267; case study
application, 263–68; client resources, 270; cultural
gender: adolescent resources, 283; assessment, 282; case considerations, 268–69; discrimination towards,
study application, 276–78; childhood depression and, 260–61; discussion questions, 271; ethical
4–5; cultural considerations, 281; current resources, considerations, 268–69; Gestalt therapy and, 259–71;
283; ethical considerations and, 281; historical intake session, 264; liberatory approaches and,
resources, 283; narrative therapy and, 273–84; 259–71; mental health risks, 259–60; minority stress
objective processes, 282; plan, 282; sample case and, 260; parent consultations, 269; parent resources,
notes, 282; subjective processes, 282 271; professional resources, 270; sample case notes,
genuineness, 125 270; transcript, 265, 267
Gestalt therapy: case study application, 263–68; liberatory approaches, 259–71
Dominican American adolescent and, 259–71; lifestyles, 79; investigating, 80, 86–87
LGBTQ people and, 259–71; overview, 261–62 life tasks, 79, 81
grief: analysis, 115–16; assessment, 118–19; case study limit setting, 12; A-C-T approach, 144; Filial Therapy,
application, 114–17; child resources, 119; COVID- 126
19 and, 109–20; cultural considerations, 117; Linehan, Marsha, 213
defined, 110; discussion questions, 119–20; ethical local discourses, 275
considerations, 117; gun violence and, 109–20;
Mexican American child and, 109–20; objective MB-CBT. See Mindfulness-Based Cognitive Behavior
processes, 118–19; objectives, 115–16; parent Therapy
292 Index

media violence, 45 282; plan, 282; sample case notes, 282; subjective
Mexican American adolescent, 235–45 processes, 282
Mexican American child: grief and, 109–20; sand tray noncompliant behaviors, 44
therapy and, 111–20 nondirective tenants, 5
MI. See Motivational Interviewing non-suicidal self-injury (NSSI), 213–14
microaggressions: childhood depression and, 11; racial
identity and, 22 one drop rule, 19–20
mindfulness, 214 oppositional behaviors, 44
Mindfulness-Based Cognitive Behavior Therapy oppression, 11
(MB-CBT): analysis, 173–76; assessment, 177–78;
case study application, 171–74; client resources, 178; Pakistani American adolescent, 169–78
cultural considerations, 176; discussion questions, parental burnout, 32
178; ethical considerations, 176; objective process, parent consultations: Adlerian play therapy, 90;
177; with Pakistani American adolescent, 169–78; adolescent depression, 164; Asian hate, 90; autism,
parent consultations, 176–77; plan, 178; professional 103; AutPlay Therapy, 103; child-centered play
resources, 178; sample case notes, 177–78; social therapy and, 12, 23, 25–26; childhood depression
anxiety and, 169–78; subjective process, 177; teacher and, 12; child sexual abuse, 207; Cognitive Behavior
consultations, 176–77; transcripts, 173–76 Play Therapy and, 54–55, 70–71; Cognitive Behavior
minority stress, 260 Therapy, 164, 191–92; critical race theory and,
misbehavior goals, 79 25–26; cultural considerations and, 26; Dialectical
Motivational Interviewing (MI): adolescent resources, Behavior Therapy, 219; disruptive behavior and,
256; African American adolescent and, 247–57; 54–55; divorce and, 191–92; eating disorder,
analysis, 253; assessment, 255–56; case study 243; Enhanced Cognitive Behavior Therapy, 243;
application, 250–54; cultural considerations, 254; Expressive Arts Therapy, 164, 191–92; extremism
discussion questions, 257; ethical considerations, and, 191–92; family dynamics and, 26; grief, 117–18;
254; objective processes, 255–56; parent gun violence, 117–18; LGBTQ people and, 269;
consultations and, 254–55; plan, 256; principles Mindfulness-Based Cognitive Behavior Therapy,
of, 249–50; professional resources, 256; sample 176–77; misunderstandings and, 37–38; Motivational
case notes, 255–56; subjective processes, 255–56; Interviewing and, 254–55; neurodivergence, 103; sand
substance use disorder and, 247–57; teacher tray therapy, 117–18; self-harm, 219; social anxiety,
consultations and, 254–55; tenets of, 248; transcript, 176–77; substance use disorders, 254–55; Trauma-
253; treatment goals, 251 Focused Cognitive Behavior Therapy, 207; Trauma
Multicultural and Social Justice Competencies, 268 Informed Child-Centered Play Therapy and, 37–38
muscle relaxation exercises, 35 parent resources: ADHD, 73; adolescent depression,
166; autism, 105; AutPlay Therapy, 105; child-
narrative storytelling, 22; racial identity and, 24–25; centered play therapy, 14; Child-Parent Relationship
responses to, 25 Theory, 150; child sexual abuse, 208–9; Cognitive
narrative therapy: analysis, 278–80; assessment, 282; Behavior Play Therapy, 57, 73; Cognitive Behavior
case study application, 276–78; gender and, 273–84; Therapy, 166, 193–94; Dialectical Behavior Therapy,
nonbinary transgender adolescent and, 273–84; 220; disruptive behavior, 57; divorce, 150, 193–94;
objective processes, 282; overview, 274–76; plan, eating disorder, 244; Enhanced Cognitive Behavior
282; sample case notes, 282; subjective processes, Therapy, 244; Expressive Arts Therapy, 166, 193–94;
282; transcript, 278–80 extremism, 193–94; family stress, 134; Filial Therapy,
National Association for Social Workers Code of Ethics, 134; grief, 119–20; gun violence, 119–20; LGBTQ
147 people, 271; neurodivergence, 105; sand tray therapy,
neurodivergence: analysis, 99–102; assessment, 119–20; self-harm, 220; Trauma-Focused Cognitive
104–5; AutPlay Therapy and, 99–102; case study Behavior Therapy, 208–9; Trauma Informed Child-
application, 99–102; child resources, 105; cultural Centered Play Therapy, 39
considerations, 103; defined, 98; discussion questions, pause button, 67, 68, 69, 70
105–6; ethical considerations, 103; group approaches personality priorities, 79, 80
to, 96; group play therapy and, 95–106; integrative Person-Centered theory, 5, 248
play therapy and, 96–97; objective process, 104–5; PGD. See Prolonged Grief Disorder
paradigm of, 98; parent consultations, 103; parent playfulness, 125
resources, 105; plan, 104–5; professional resources, Play Therapy Best Practices, 147
105; sample case notes, 104–5; session notes, pleasing, 80, 91
99–102; statistics on, 96; subjective process, 104–5; political views, 44. See also extremism
transcripts, 99–102 positive core adaptive cognitions, 64
No-Drama Discipline (Bryson & Siegel), 37 power, 80–81; affirmation, 187–88
nonbinary transgender adolescent: assessment, 282; problem-saturated stories, 275
case study applications, 276–78; Chinese American, problem solving skills, 64; Cognitive Behavior Play
273–84; cultural considerations and, 281; discussion Therapy and, 46
questions, 283–84; ethical considerations, 281; professional resources: ADHD, 73; adolescent
narrative therapy and, 273–84; objective processes, depression, 166; autism, 105; AutPlay Therapy, 105;
 Index 293

child-centered play therapy, 14, 28; Child-Parent consultations, 117–18; parent resources, 119–20;
Relationship Theory, 150; child sexual abuse, 208; plan, 118–19; procedures, 113–14; professional
Cognitive Behavior Play Therapy, 56, 73; Cognitive resources, 119; sample case notes, 118–19; session
Behavior Therapy, 166, 193; critical race theory, notes, 114–17; strategies, 113–14; subjective
28; Dialectical Behavior Therapy, 220; disruptive processes, 118–19; transcripts, 115–16
behavior, 56; divorce, 150, 193; eating disorder, saving face, 82
244; Enhanced Cognitive Behavior Therapy, 244; schemas, 186
Expressive Arts Therapy, 166, 193; extremism, 193; self-acceptance, 21
family stress, 134; Filial Therapy, 134; grief, 119; gun self-actualization: child-centered play therapy and, 5;
violence, 119; LGBTQ people, 270; Mindfulness- collectivistic cultures and, 11; cultural considerations
Based Cognitive Behavior Therapy, 178; Motivational and, 11; discrimination and, 11; individualistic
Interviewing, 256; neurodivergence, 105; sand cultures and, 11; oppression and, 11
tray therapy, 119; self-harm, 220; social anxiety, self-awareness, 160
178; substance use disorder, 256; Trauma-Focused self-calming techniques, 49
Cognitive Behavior Therapy, 208; Trauma Informed self-concept: childhood depression and, 6; from others,
Child-Centered Play Therapy, 39 27
Prolonged Grief Disorder (PGD), 110 self-control: aggressive toys and, 21; Cognitive Behavior
protection symbols, 188 Play Therapy and, 46; development of, 8
psychoeducation, 64, 199; ADHD and, 65; Filial Therapy self-efficacy, 249
and, 125 self-expression, 64, 160
self-harm: adolescent resources, 220; African American
racial identity: Black categorization bias, 20; conflict and, adolescent and, 211–21; analysis, 217–18;
21; development in children, 19–21; linear process of, assessment, 220; case study applications, 215;
20; microaggressions and, 22; narrative storytelling cultural considerations, 219; Dialectical Behavior
and, 24–25; physical features and, 20; pride in, 26; Therapy and, 211–21; discussion questions, 221;
recognizing, 20; social features and, 20; stages, 20 ethical considerations, 219; objective processes, 220;
racially colorblind ideology: disrupting, 22, 24–25; parent consultations, 219; parent resources, 220;
racism and, 21–22 plan, 220; professional resources, 220; religion and,
racism: racially colorblind ideology and, 21–22; 215; sample case notes, 220; subjective processes,
validation of, 22 220; transcript, 217–18; treatment goals, 215–16;
relationship, 125 treatment process, 216–18
relaxation skills, 199 self-reports, 64
religion: Child-Parent Relationship Theory and, 147; self-talk: Cognitive Behavior Play Therapy and, 63;
cultural considerations and, 54; self-harm and, 215; domestic violence and positive, 33
Trauma Informed Child-Centered Play Therapy and, self-understanding, 21
37 separation anxiety, 34
remembering, 276 sex education, 206
resistance, 249 sexual exploitation risk: defined, 224; Equine Assisted
RESPECTFUL model, 215 Family Play Therapy and, 223–32; interventions
responsibility, returning, 12 for, 224–25; statistics, 224; Tourette syndrome and,
Restorative Justice, 251 223–32; White adolescent and, 223–32
re-storying, 275 Siegel, Daniel, 33, 37
revenge, 80–81 SLD. See specific learning disabilities
Reynolds Children’s Manifest Anxiety Scale, 172 social anxiety: analysis, 173–76; assessment, 177–78;
River of Life activity, 252–53 case study application, 171–74; client resources, 178;
Rogers, Carl, 5 cultural considerations, 176; defined, 170; discussion
role play, 49, 64; Cognitive Behavior Play Therapy and, questions, 178; ethical considerations, 176; levels of,
47–48; fantasy in, 53 172; Mindfulness-Based Cognitive Behavior Therapy
and, 169–78; objective process, 177; with Pakistani
safe environment: child-centered play therapy and, 6–8; American adolescent, 169–78; parent consultations,
Cognitive Behavior Play Therapy and, 63; principles 176–77; plan, 178; professional resources, 178;
of, 33; Trauma Informed Child-Centered Play sample case notes, 177–78; subjective process, 177;
Therapy and, 33 teacher consultations, 176–77; transcripts, 173–76;
SAMHSA. See Substance Abuse and Mental Services triggers, 171–72
Administration social connection groups, 95
sand tray therapy, 188–89; analysis, 115–16; assessment, social interest, 80
118–19; case study application, 114–17; child social media: adolescent depression and, 158–59;
resources, 119; COVID-19 and, 111–20; cultural thinking errors in, 189
considerations, 117; discussion questions, 119–20; socio-emotional understanding, 63
ethical considerations, 117; goals, 113; grief and, Southern Poverty Law Center, 184–85
111–20; gun violence and, 111–20; materials, 112– specific learning disabilities (SLD), 45
13; Mexican American child and, 111–20; objective STAR sequence, 53
processes, 118–19; objectives, 115–16; parent strength shield, 188
294 Index

stress inoculation, 64 198–99; consolidation phase, 200–201; cultural

Substance Abuse and Mental Services Administration considerations, 206–7; discussion questions, 209;
(SAMHSA), 247–48 ethical considerations, 206–7; goals, 202; intake,
substance use disorders (SUD): adolescent resources, 256; 201–2; integration phase, 200–201; overview,
African American adolescent and, 247–57; analysis, 198–201; parent consultations, 207; parent resources,
253; assessment, 255–56; case study application, 208–9; professional resources, 208; sample case
250–54; cultural considerations, 254; discussion notes, 208; stabilization phase, 199–200, 202–4;
questions, 257; ethical considerations, 254; trauma narration phase, 200, 204–6
Motivational Interviewing and, 247–57; objective Trauma Informed Child-Centered Play Therapy (TI
processes, 255–56; parent consultations, 254–55; CCPT): analysis, 35–36; assessment, 38–39; case
plan, 256; professional resources, 256; sample case study application, 34–36; child resources, 39;
notes, 255–56; statistics on, 248; subjective processes, confidentiality and, 36; criminal charges and, 36–37;
255–56; teacher consultations and, 254–55; cultural considerations, 36–37; discussion questions,
transcript, 253; treatment goals, 251 39; ethical considerations, 36–37; format of, 33;
superiority, 80 goals, 34; objective process, 38; parent consultations
and, 37–38; parent resources, 39; plan, 38–39;
TAP. See Turn About Pegasus professional resources, 39; reenactment sessions,
teacher consultations: Adlerian play therapy, 90; Asian 33; resources, 39; restoring connections in, 33–34;
hate, 90; child-centered play therapy and, 12; safe environment and, 33; sample case notes, 38–39;
childhood depression and, 12; Mindfulness-Based session notes, 34–36, 38–39; stages of, 33–34, 35–36;
Cognitive Behavior Therapy, 176–77; Motivational subjective process, 38; transcripts, 35–36; White child
Interviewing and, 254–55; social anxiety, 176–77; and, 31–39
substance use disorder and, 254–55 Trauma Symptom Checklist for Children, 37
TF-CBT. See Trauma-Focused Cognitive Behavior TS. See Tourette syndrome
Therapy Turn About Pegasus (TAP), 227
therapist identity bias, 11 turtle technique, 52–53
TI CCPT. See Trauma Informed Child-Centered Play
Therapy underachievement, 62
timers, 66
Tourette syndrome (TS): case study application, 226–31; White adolescent: Cognitive Behavior Therapy and, 183–
cultural considerations, 231; Equine Assisted Family 94; divorce and, 183–94; Equine Assisted Family Play
Play Therapy and, 223–32; ethical considerations, Therapy and, 223–32; Expressive Arts Therapy and,
231; sexual exploitation risk and, 223–32; statistics, 183–94; extremism and, 183–94; sexual exploitation
224; symptoms of, 224; White adolescent and, risk and, 223–32; Tourette syndrome and, 223–32
223–32 White child: child-centered play therapy and, 31–39;
transgender adolescent, 273–84 Child-Parent Relationship Therapy and, 137–50;
transgender environmental context, 274 Cognitive Behavior Play Therapy and, 43–57;
Trauma-Focused Cognitive Behavior Therapy (TF-CBT): disruptive behavior and, 43–57; domestic violence
adolescent resources, 208; with biracial adolescent, and, 31–39
197–209; case study application, 201–6; child White privilege, 22; child-centered play therapy and, 26
resources, 208; child sexual abuse and, 197–209; Winnicott, D. W., 187
cognitive processing, 204–6; components of, worth, conditions of, 6
 About the Editors

Jennifer N. Baggerly, PhD, LPC-­S, RPT-­S, is professor of counseling and play

therapy at the University of North Texas at Dallas. She is a licensed professional
counselor supervisor and a registered play therapist supervisor with more than
25 years of play therapy experience. Dr. Baggerly also provides counseling and
play therapy at Kaleidoscope Behavioral Health in Flower Mound, Texas. She
is an award-­winning counselor educator and distinguished leader in the field of
counseling and play therapy.
Some of her notable awards across the decades include UNT Dallas Grad-
uate School Outstanding Faculty Award (2022), Texas Counseling Association
Outstanding Supervisor Award (2021), Viola Brody Outstanding Play Thera-
pist Award (2005), and Post-­Secondary Counselor of the Year for Hillsborough
Counseling Association (2004). She served as chair of the board of directors for
the Association for Play Therapy from 2013 to 2014 and was a member of the
board from 2009 to 2015. Having published in more than 75 publications, Dr.
Baggerly is recognized as a prominent expert in children’s crisis intervention and
play therapy. She has provided Disaster Response Play Therapy throughout the
world including Hurricane Maria in Puerto Rico, tsunami in Sri Lanka, Hur-
ricane Katrina in Louisiana, hurricanes in Florida, and tornadoes in Texas and
Oklahoma. She has demonstrated her play therapy skills through several training
videos such as Disaster Mental Health and Crisis Stabilization for Children and
Trauma Informed Child Centered Play Therapy.

Athena A. Drewes, PsyD, MA, MS Ed, RPT-­S, is a licensed psychologist, certified

school psychologist, registered play therapist and play therapist supervisor, and
noted author and coeditor of more than 13 books on play therapy including The
Therapeutic Powers of Play: 20 Core Agents of Change (with Charles Schaefer,
2014) and Cultural Issues in Play Therapy, 2nd ed. (with Eliana Gil, 2021). She
has produced a video demonstrating her Prescriptive Integrative Play Therapy
approach through the American Psychological Association Children and Adoles-
cents Series IX. She has had a long and prestigious career as a passionate play
therapist with more than 45 years of clinical experience in working with children
and adolescents with complex trauma and sexual abuse in schools, residential
treatment, and foster care settings.
She is currently semiretired in Ocala, Florida, is a guardian ad litem (court-­
appointed special advocate for foster care children), and has a private practice
focusing on supervision on the national and international level, consultation, and
national and international training. She is founder and president emeritus of the
New York Association for Play Therapy and past director of the Association for
Play Therapy.
295
 About the Contributors

Samuel Bore, PhD, LPC-­S, is associate professor and chair of counseling programs
at the University of North Texas at Dallas in the School of Behavioral Health and
Human Services. Dr. Bore is also a certified school counselor and licensed profes-
sional counselor in Texas, with expertise in school counseling, marriage, and fam-
ily counseling. He has more than 20 peer-­reviewed publications in research areas
such as group work in schools, school counselor and administrators’ collabora-
tion, ethics in school counseling, self-­injury among teenagers, cultural straddling
among immigrants and refugees, and spirituality.

Brooks Bull, PhD, LMFT, is adjunct instructor at Antioch University in New

England, a licensed marriage and family therapist, and owner of Collaborative
Therapy and Coaching. They provide trauma-­informed, socially just therapy to
people of all genders. They offer therapy to individuals, couples, and polycules as
well as nontherapeutic coaching. They also provide short-­term therapy for trans-
gender and nonbinary people to access medical services. Dr. Bull has published
numerous articles and chapters on families with trans children, sex therapy with
queer clients, and collaborative and narrative therapies.

Sara Cantu, PhD, LPC-­S, LMFT-­S, RPT-­S, CEDS-­C, counsels children and adoles-
cents in private practice in Frisco, Texas. She is also director of curriculum and
certification for the International Association for Eating Disorder Professionals.
Sara has worked with children, adolescents, and adults affected by eating disor-
ders and their families at all levels of care. She is a certified eating disorder spe-
cialist approved consultant.

Peggy L. Ceballos, PhD, NCC, is associate professor in the Department of Coun-

seling and Higher Education at the University of North Texas. She is a national
certified counselor, certified child centered play therapy-­supervisor, and a certified
child parent relationship therapy-­supervisor. Her research and numerous publi-
cations focus on play therapy and counseling for Latinx populations. She has
received several major grants related to play therapy research.

Allison Crowe, PhD, LCMHCS, NCC, is professor in the counselor education

program and interim department chair in the Department of Interdisciplinary
Professions at East Carolina University. She is a licensed clinical mental health
counselor and supervisor in North Carolina and a past president of the North
Carolina Counseling Association. She has published more than 60 peer-­reviewed
scholarly journal articles, many of which focus on topics related to mental health
concerns and the stigma that surrounds these.
297
298 About the Contributors

Dalena Dillman Taylor, PhD, LMHC, RPT-­S, is associate professor at the Uni-
versity of North Texas in the Department of Counseling and Higher Education.
She earned her doctoral degree in counseling and completed her master’s degree
in counseling from the University of North Texas. Dr. Dillman Taylor’s primary
research interests include advancement of Adlerian Play Therapy field toward
evidence-­based practice, counseling and educational services for high-­need chil-
dren and families, and counselor development and supervision.

Anelie Etienne, LMSW, dedicates her career to improving systems and serving
youth impacted by poverty, mental illness, substance abuse, housing instability,
and other contributing factors to child neglect and maltreatment. She has worked
with the local department of social services for nearly a decade as a child pro-
tective services investigator, project manager for families involved with the child
welfare system, and currently as grants coordinator, she accesses federal, state,
and local funding to create housing opportunities.

Tracie Faa-­Thompson, MA, AASW, PGdipNDPT, CAEBC-­I, is a social worker,

certified animal ethology and behavior consultant-­instructor, certified filial thera-
pist, and is cofounder of Animal Assisted Play Therapy. She is the founder of Turn
About Pegasus, an equine-­assisted program for at-­risk youth and families with
a variety of difficulties. She is EAGALA approved for both mental health and
equine specialist roles. She is also a practice teacher of social work students and
a trainer in life story work and attachment theory. She specializes in adoption,
working with traumatized children and their adoptive and foster families in the
United Kingdom.

Caitlin Frawley, PhD, LMHC, earned her doctorate degree in counselor educa-
tion from the University of Central Florida. She completed her master’s degree in
mental health counseling at Teachers College, Columbia University, in New York
City. She is a licensed mental health counselor. Her clinical experiences include
providing play therapy and counseling to children in the foster care system and
youth survivors of sexual abuse.

Robert Jason Grant, EdD, LPC, RPT-­S, is the creator of AutPlay® Therapy. He is a
therapist, supervisor, and consultant, and uses several years of advanced training
and his own lived neurodivergent experience to provide affirming services to chil-
dren and their families. He is an international trainer and keynote presenter and
multi-­published author of several articles and books. He is currently serving as
past chair on the board of directors for the Association for Play Therapy.

Chi-­Sing “Denny” Li, PhD, LPC-­S, LMFT, is professor in the Counselor Educa-
tion Department of Sam Houston State University. He has been a licensed pro-
fessional counselor (LPC) and a licensed marriage and family therapist (LMFT)
in Texas for 30 years. His research and numerous publications are focused on
 About the Contributors 299

cross-­cultural issues in counseling, group counseling, and crisis and trauma coun-
seling. Dr. Li was awarded the Outstanding Counselor Educator of the Year in
2023 by the Texas Association for Counselor Education and Supervision.

Yu-­Fen Lin, PhD, LPC-­S, is associate professor of counseling at the University

of North Texas at Dallas. She serves as internship coordinator in her counseling
program. She is the 2023 president elect of the Texas Association of Counselor
Education and Supervision. Dr. Lin has numerous publications on multicultural
counseling and gender wellness. In her private practice, she enjoys supervising
many LPC associates and working with Asian American clients across all ages.

Kristin K. Meany-­Walen, PhD, LMHC, RPT-­S, is adjunct professor at Univer-

sity of Northern Iowa and a counselor in private practice. Her areas of expertise
include Adlerian Play Therapy, school-­based counseling, and wellness. Kristin fre-
quently presents, publishes, and conducts research on these topics. She coauthored
Doing Play Therapy: From Building the Relationship to Facilitating Change and
Partners in Play: An Adlerian Approach to Play Therapy (3rd ed.).

Domonique Messing, LCSW, RPT, MBA, is a clinical social worker and registered
play therapist. She currently serves clients in private practice and specializes in
working with children, adolescents, young adults, parents, and expectant moth-
ers. Domonique has extensive experience in various evidence-­based treatments,
practicing from a person-­centered approach.

Felicia R. Neubauer, MSW, LCSW, currently works in private practice in Med-

ford, New Jersey, as a therapist, as well as a TF-­CBT trainer and consultant. Her
work passion is helping children, adults, and families to heal from trauma and
mental health issues.

Jason O. Perry, PhD, LCMHC, is teaching assistant professor and director of the
McClammy Counseling and Research Laboratory at East Carolina University.
He has a passion for serving the needs of the people from his home of Eastern
North Carolina. He has nearly 23 years of combined experience in the areas of
child and family mental health, adolescent substance abuse, career counseling,
and corrections.

Keith I. Raymond, MA, CMHC, NCC, is a doctoral counseling student at Mont-

clair State University. He holds a master of arts in clinical mental health coun-
seling from New Jersey City University. Keith is a national certified counselor
(NCC), licensed professional counselor (LPC), and psychotherapist working in
private practice providing counseling services to children, adolescents, adults,
families, and couples. His counseling specialty areas are providing play therapy
services in various clinical settings and social justice advocacy for Black, indige-
nous, and people of color (BIPOC).
300 About the Contributors

Lisa Remey, MEd, LPC-­S, RPT-­S™, Certified FirstPlay® Practitioner, and private
practice owner, Bluebonnet Center for Play Therapy in New Braunfels, Texas. She
has specialized in play therapy for 20 years and has worked with children, fam-
ilies, and the military community, supporting them from infancy to adolescence
and is passionate about training play therapists through speaking and supervision.

Ana Guadalupe Reyes, PhD, LPC, NCC, CHST (elle/le/they/them), is assistant

professor in the Department of Counseling at California State University, Fuller-
ton. They are a national certified counselor, licensed professional counselor in
the state of Texas, and certified humanistic sand tray therapist. Dr. Reyes is also
a Usui Reiki master/teacher who practices various forms of energy healing. With
more than 13 years of experience working with marginalized and racialized com-
munities in multiple settings, Dr. Reyes integrates somatic, liberatory, and holistic
approaches into their work as a scholar, educator, advocate, and counselor.

Marium Sadiq, MA, LPC, RPT, is a third-­year counseling doctoral student at the
University of North Texas. She is a licensed professional counselor and a regis-
tered play therapist who practices using Child-­Centered Play Therapy. Through-
out her time as a therapist, she has continuously noticed the impact of CCPT as a
culturally aware approach to help support children with depression.

Clarissa L. Salinas, PhD, LPC-­S, RPT-­S, is assistant professor of counseling at the

University of Texas Rio Grande Valley. She teaches a variety of courses to include
Introduction to Counseling, Internship, and Child and Adolescent Counseling.
She also works in private practice, where she provides play therapy to children
in the community. Her scholarly contributions include publications on the topics
of creative interventions, play therapy, and teaching and learning at a Hispanic
Serving Institution (HSI).

Angela I. Sheely-­Moore, PhD, is associate professor in the Counseling Department

at Montclair State University. With eight years of clinical experience counseling
children and families from diverse populations in school and agency settings, Dr.
Sheely-­Moore specializes in researching counseling services to marginalized com-
munities from a social justice lens. She has published in the areas of multicultural
competencies, play-­based counseling services, and counselor education andragogy.

Risë VanFleet, PhD, RPT-­S, CDBC, CAEBI, is a licensed psychologist (PA), reg-
istered play therapist-­supervisor, certified dog behavior consultant, and certified
animal ethology and behavior instructor with 48 years of clinical, supervisory,
administrative, and teaching experience. She is well known internationally for her
decades of work training mental health professionals in Play Therapy and Filial
Therapy. She is president of the Family Enhancement & Play Therapy Center,
Inc., in Boiling Springs, Pennsylvania. She is the founder and president of the
International Institute for Animal Assisted Play Therapy®.