Therapeutic skills in CCPT for school-aged Filipino boys with externalizing problem behaviors

Therapeutic skills in CCPT for school-aged Filipino boys with externalizing problem behaviors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Therapeutic skills in CCPT for school-aged Filipino boys with externalizing problem behaviors Peejay D. Bengwasan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6630345/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract In Child-Centered Play Therapy (CCPT), it is the therapeutic relationship that has been emphasized as the driver of behavioral change. Underlying such a relationship is the administration of therapeutic skills. Hence, the study examined underlying processes of CCPT, particularly the use of therapeutic skills in building the therapeutic relationship in CCPT for 23 school-aged boys who present with externalizing problem behaviors. Raters who were experienced in providing CCPT examined recorded sessions, focusing on the play psychologists’ use of therapeutic skills. Across 8 sessions, separate Friedman tests with Wilcoxon signed rank test as post hoc analyses revealed significant differences in the usage of tracking, reflecting feelings, reflecting content and limit setting. This indicates a dynamic nature of using such skills across different sessions in short-term CCPT. A methodical use of therapeutic skills develops empathy, which facilitates the building the therapeutic relationship, eliciting reduction of externalizing problem behaviors in school-aged Filipino children. Child-Centered Play Therapy externalizing problem behaviors therapeutic relationship therapeutic skills Filipinos children Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The therapeutic relationship in Child-Centered Play Therapy (CCPT) provides a valuable way for children to explore their feelings and access self-actualizing tendencies in a safe environment (Axline, 1969; Rogers, 1951). Landreth (2012) defined it as “a mutually shared relationship of acceptance and appreciation in which each person is regarded as an individual” (p.74), where empathy, congruence and unconditional positive regard are important components (Rogers, 1952) and contribute to resolving aggressive behaviors (Landreth, 2012; Peterson & Flanders, 2005; Trotter et al., 2003). Gordon (2005) emphasized that empathy is essential in healthy relationships. It is an affective response congruent with another’s situation (Dadds et al., 2008), which regulates aggression (Bjorkqvist, 2007; Peterson & Flanders, 2005). The empathic understanding that children experience from play psychologists relates to effectively demonstrating empathy (Ray, 2008). Externalized behaviors mirror internal experiences (Landreth, 2012) and these aggressive behaviors are also self-enhancing (Dorfman, 1951; Ray, 2011) and a means to self-actualize (Rogers, 1989). Maladjustment exists when a person lacks sufficient self-confidence to evaluate behaviors and channel drives to productive directions (Axline, 1969). Subsequently, aggressive behaviors subside when a child learns abilities that lead to self-regulation (Olson et al., 2011). Keenan and Shaw (2003) suggested that emotional self-control was responsible for declines in aggression. Yet, children continue to struggle with self-regulation and aggression from preschool into elementary school (Olson et al., 2011). Extended aggressive plays in CCPT connote improvement but when children show mastery behaviors, the therapeutic work is completed (Guerney, 2001). Difficulty in relating to others contributes to disruptive behaviors, making therapeutic relationships particularly effective in promoting positive outcomes (Cochran & Cochran, 2006; Langhoff et al., 2008; Shirk & Karver, 2003). McLeod’s (2011) meta-analysis of 38 studies revealed a strong positive correlation between therapeutic alliance and outcomes in youth psychotherapy. The quality of this alliance is crucial, even for youth with externalizing problems (McLeod, 2011; Orlinsky et al., 2004; Shirk & Karver, 2003). Single case designs highlight the effectiveness of CCPT, emphasizing beneficial aspects of the intervention (Cochran et al., 2011). Cochran et al. (2010) noted improvements in self-concept and peer relationships at various therapy stages. Landreth (2012) describes the transition from maladjustment to psychological health as involving empathic listening, observation, and recognition statements that facilitate growth. Play offers an avenue to learn self-control especially when the psychologist provides appropriate therapeutic limit-setting (Landreth, 2012). CCPT demonstrates this by providing the opportunity to act out feelings, thoughts and experiences through play (Axline, 1969; Landreth, 2012). Understanding that externalized behaviors mirror internal experiences, a child-centered play psychologist does not seek to modify behaviors, but rather to empathically understand the child’s internal frame of reference (Landreth, 2012; Ray, 2008; Ray, 2011). Axline (1969) included eliciting self-awareness and self-direction in a child as an objective of CCPT. Such is brought about by following eight (8) basic principles (Axline, 1969; Landreth, 2012). Therapeutic change stems from the psychologist’s acceptance of the child as they are (Axline, 1969). The psychologist aims to understand the child's self-concept within a safe relationship (Landreth, 2012). When a child exhibits provocative behavior, the psychologist conveys understanding and acceptance through their words, attitude, tone, and body language. A psychologist’s uniqueness lies in their intention to create a relationship-building atmosphere by empathically listening, observing, and making growth-facilitating statements (Landreth, 2012). These concepts become tangible as psychologists apply skills in response to children's behaviors. Therapeutic Skills in CCPT CCPT is administered in totality, and a psychologist adheres to its beliefs and methods (Guerney, 2001), resulting to self-actualization (O’Connor et al., 2016). Landreth (2012) declares that the use of skills is intentional and careful use words and actions is needed in building the therapeutic relationship. Tracking Tracking is verbally describing what the child is doing out loud and reflecting the child’s words (O’Connor et al., 2016). The psychologist communicates in facial expression, tone of voice and general attitude the sense of wonder, puzzlement and intensity in the child’s play (Landreth, 2012). Tracking allows the child to continue playing and maintains the psychologist’s involvement (Landreth, 2012; O’Connor et al., 2016). This is important in initial stages of therapy, where play psychologists attempt to provide a safe and trusting environment, helping children express feelings (Mills & Allan, 1992) and verify the psychologist’s tracking behaviors (Withee, 1975). Reflecting Content In reflecting content, the psychologist summarizes or paraphrases verbal expressions, making the child know that they have been heard (O’Connor et al., 2016). This immerses the psychologist in the child’s world and communicates acceptance and understanding (Landreth, 2012). This is a necessity for sessions where children show high levels of expressions of happiness, begin to share information about their lives and engage in relationship play, where verbal exchanges are often seen (Withee, 1975). Reflecting content clarifies the child’s sense of self as may be seen when a child agrees or disagrees with a psychologist’s verbal reflections (Landreth, 2012). During latter stages where expressions of competence and mastery of previous fears are seen (Nordling & Guerney, 1999), reflecting content gives the opportunity for clarification and effective communication. Reflecting Feelings Landreth (2012) noted that reflecting feelings involves psychologists responding to children’s verbalizations of emotions, validating their feelings and fostering self-trust. Proper reflection and recognition are essential for helping children accept their full emotional range (O’Connor et al., 2016) and recognize their inner value (Landreth, 2012). This skill is particularly important during mid-sessions when aggressive play and varied emotions emerge (Withee, 1975). Ambivalent feelings of anxiety and hostility often arise in initial and final sessions (Moustakas, 1955a; Nordling & Guerney, 1999) and are likely reflected back by psychologists. Empathic listening starts with recognizing feelings and leads to responses that convey acceptance and a nonjudgmental attitude (VanFleet et al., 2010). When children re-experience acceptance and security, their potential for inner growth increases (Mills & Allan, 1992). Limit Setting Minimizing rules while allowing children to express themselves promotes safety and self-regulation (O’Connor et al., 2016). This is achieved by pairing limit-setting statements with empathic responses to a child's desire to break limits (Guerney, 2001). The ACT model guides limit setting, which involves Acknowledging the child’s feelings, Communicating the limit, and Targeting an acceptable alternative (Landreth, 2012). This skill is particularly important during sessions with aggressive behaviors (Hendricks, 1971; Withee, 1975; Mills & Allan, 1992; Moustakas, 1955a; Nordling & Guerney, 1999). It helps children understand how emotions impact decision-making (Landreth, 2012) and offers new ways of self-expression, leading to decreased oppositionality (Trice-Black et al., 2013). Clients who test limits often reassess relational expectations, revisit unmet needs, and transform their self-concept (Cochran et al., 2011). A therapist’s ability to apply CCPT principles through these skills fosters optimal functioning and empowers a child to develop a healthy sense of self (Wilson & Ryan, 2005). When psychologists reflect a child’s thoughts, feelings, and actions, the child learns to accept and manage them (Axline, 1969; Landreth, 2012). This recognition enhances self-concept and aids in psychological and behavioral realignment (Guerney, 2001). Landreth (2012) emphasizes the intentional use of therapeutic skills, suggesting that examining their frequency can reveal the best times to use each skill and strengthen the therapeutic relationship. Relationship-building between therapist and child was initially thought to require long-term interaction, with many studies showing CCPT's effectiveness in extended frames (Blanco et al., 2012; Bratton et al., 2005; Leblanc & Ritchie, 2001). However, short-term frames have also demonstrated reductions in problematic aggressive behaviors (Bengwasan, 2023; Cochran & Cochran, 2017; Guerney, 2001; Landreth, 2012; Kaduson & Schaefer, 2006; Kent & Hersen, 2000; Ray, 2008; Ray et al., 2017). Ritzi et al. (2017) found that an intensive short-term approach (two 30-minute sessions daily for 10 days) led to decreases in externalizing problems. Overall, clients typically receive a median of 3-5 sessions and a mean of 5-8 sessions of CCPT (Cohen & Cohen, 1984). Many clients approach mental health practitioners expecting brief, effective treatment, highlighting the emphasis on short-term therapy (Kaduson & Schaefer, 2006; Reddy et al., 2005). Therefore, this study examines therapeutic skills in CCPT within a short-term frame of 8 weeks, following the standard weekly administration. Purpose of the Study This study explores underlying mechanisms, particularly therapeutic skills used in short-term CCPT, and in the process, discovering a possible system in which these skills operate in response to children’s play behaviors. This responds to the necessity to conduct research that provides empirical understanding of mechanisms of therapeutic change and explaining how and why therapeutic powers work (Kazdin, 2009). The study answers the research question: In maintaining the therapeutic relationship, to what extent is each therapeutic skill employed across short term CCPT sessions of children who exhibit externalizing problem behaviors? It is hypothesized that each skill will be significantly used to a greater extent at a particular session in short-term CCPT. Method Participants Psychologists Psychologists who administered CCPT have successfully accomplished an Introductory course in Play Therapy. They were registered psychologists in the Philippines with at least 2 years of experience in administering child psychotherapy including CCPT and other play intervention variants. There were six (6) psychologists and there was only one psychologist assigned per participant. Each psychologist had 4 participants assigned to them, except one who was assigned 3 participants. Raters Raters have also successfully accomplished an Introductory course in Play Therapy. They were also registered psychologists with at least 2 years of experience in child psychotherapy including CCPT. They performed the major task of quantifying the therapeutic skills. There were six (6) raters including the researcher, who were separate from the psychologists. Clients The 23 clients who participated in this study came from one primary school in the Northern Philippines. All of them were boys aged 6-12 years and came from an outcome study of CCPT for school-aged Filipino children with externalizing problem behaviors (Bengwasan, 2023). Procedure An observational research design was employed to study therapeutic skills during 8 CCPT sessions with 23 children. Permission was obtained from a primary school principal in Northern Philippines. The children were screened after parents signed consent forms, and clients capable of doing so provided assent. If not, a parent signed on their behalf, and all were informed of their right to discontinue. The 23 children received Child-Centered Play Therapy (CCPT) by Landreth (2012) and Axline (1969) in 8 weekly individual sessions, each lasting at least 45 minutes, in a designated playroom at the primary school. Each was randomly assigned to one psychologist, and all sessions were videotaped with psychologists signing a confidentiality agreement. Video recordings were stored on a passcode-protected hard drive accessible only to the researcher. Before the intervention, six psychologists received training for the study’s protocol on two occasions, each lasting 3 hours, facilitated by a registered psychologist in the Philippines with over 15 years of child psychotherapy experience, who also supervised the study. The supervisor provided individual feedback every two weeks and reviewed at least three randomly selected video recordings per psychologist. Raters received the same training, noted definitions and examples of therapeutic skills, and were assigned sets of sessions to rate separately. Each video was rated by two individuals, and they met to discuss and agree on final ratings. The study was done in accordance with the principles of the Declaration of Helsinki (WMA, 2013). All participants provided informed consent prior to participation, and the study protocol was reviewed by experts who served as panel members of the author’s dissertation as a requirement for the degree Doctor of Philosophy major in Clinical Psychology from De La Salle University-Manila, Philippines. The study was done in accordance to the guidelines set by the De La Salle University (DLSU) Code for the Responsible Conduct of Research as established by the DLSU-Research Ethics Review Committee (RERC) and Research Ethics Review Panels (RERPs). This paper is part of the author’s dissertation as a requirement for the degree Doctor of Philosophy major in Clinical Psychology from De La Salle University-Manila, Philippines. Ethical approval was granted by the panel who reviewed and approved the author’s paper. The panel consisted of four (4) full-time professors from De La Salle University, namely: Roseanne Tan-Mansukhani, PhD, Ron R. Resurreccion, PhD, Homer J. Yabut, PhD, and Maria Guadalupe C. Salanga, PhD, and one (1) external panel member from the Ateneo De Manila University, Edith Liane C. Alampay, PhD. The ethics clearance was given following the approval of the author’s supervisor, Ma. Caridad H. Tarroja, PhD. Psychologists, raters and the supervisor who took part in this study provided consent by signing individual informed consent forms. They were informed of their right to discontinue at any point or phase of the study. All parties consented to have the collected data from the author’s dissertation to be included or used for publication. Statistical Analyses Statistical analyses were conducted using SPSS version 29.1. Inter-rater reliability was assessed by comparing observations from two raters across 184 videotaped sessions, with separate scores calculated for each therapeutic skill based on Krippendorff’s alpha: < 0 (unacceptable), 0.66-0.80 (tentatively acceptable), 0.81-0.99 (acceptable), and 1 (perfect agreement). To analyze fluctuations in therapeutic skills from session 1 to session 8, one-way Friedman Tests were performed, followed by Wilcoxon signed-rank tests with Bonferroni correction for post hoc analysis of significant differences among session frequencies. Results Inter-rater Reliability Based on the separate inter-rater reliability computations, comparisons of observations of 184 session per child made by 2 raters resulted to acceptable agreement for Tracking ( α = 0.854), Reflecting Feelings ( α = 0.819), Reflecting Content ( α = 0.877), and Limit Setting ( α = 0.815). These results indicate an adequate level of reliability in terms of the raters’ observations and are summarized in Table 1 . Table 1 Inter-rater reliability per therapeutic skill Therapeutic Skill Krippendorff’s alpha SE 95% CI Lower CI Upper CI Tracking 0.854 0.026 0.803 0.906 Reflecting Feelings 0.825 0.031 0.764 0.885 Reflecting Content 0.829 0.029 0.771 0.887 Limit Setting 0.848 0.029 0.790 0.905 Therapeutic Skills The following paragraphs discuss children's play behaviors and reactions to therapeutic skills to provide context for their impact during sessions. Separate Friedman Tests were conducted to assess how psychologists used skills to maintain the therapeutic relationship in short-term CCPT. Random sampling assumptions were met by assigning each session randomly to raters. Independence of observation was ensured as each session was analyzed separately by each rater before final ratings. The assumption of normal distribution was also met, with outliers addressed through discussions between raters. Tracking As each child enters the playroom, the psychologists’ tracking behavior began by turning and verbalizing movement toward the child. Children often reacted by looking back at the psychologists, nodding or proceeding to play with toys. The Friedman Test revealed that the instances of tracking differ across the 8 sessions, χ 2 (7) = 47.926, p < .001. Wilcoxon signed-rank tests with Bonferroni correction applied resulted to a significance level set at p < .006. Psychologists tracked the children’s behaviors at a comparable frequency during sessions 1 ( Mdn = 59) and 2 ( Mdn = 58), T = 72.50, z = -1.993, p = .046. Most of the children went around the playroom and looked at different toys. Psychologists mainly tracked by moving positions toward the children and saying: “You seem to be looking at the toys” or “You are going around the room”. Children responded by either saying “Yes” or “No”, looking at the psychologist, playing or moving around. Meanwhile, tracking appeared to significantly drop in frequency beginning session 3 ( Mdn = 46), T = 44.00, z = -2.861, p = .004. Children played with the toys they previously interacted with in the beginning sessions. Psychologists tracked by saying “You are playing with that toy” or “Oh, you found that”. Children then reacted by continuing to play or nodding. Tracking appeared to stay at a similar frequency from sessions 4 to 8. Figure 1 represents the median observations of tracking. Reflecting Content Psychologists reflected content by rephrasing children’s statements and comments while being careful enough to use the children’s own words. When a child said, “I have like this at home”, the psychologist responded by saying “Oh, you have like that at home”. Children continued to add details, which the psychologists reflected back until the children ended the exchange. Instances of reflecting content tended to differ across the 8 CCPT sessions, χ 2 (7) = 71.172, p < .001. Wilcoxon signed-rank tests with Bonferroni correction resulted to a significance level set at p < .006. Compared to session 1 ( Mdn = 11), session 2 ( Mdn = 37) showed significant increase, T = 275.00, z = -4.169, p = .000. The familiarity that children seemed to have established led to comfort in interacting with the psychologists verbally. Frequencies were maintained at session 3 ( Mdn = 30), T = 135.50, z = − .076, p = .939 and session 4 ( Mdn = 30), T = 147.00, z = − .274, p = .784. These sessions reveal a maintained exchange between the psychologists and the children. As the children also began to do role-play, the dialogue from the movies and scenes in which they may have heard them were repeated. A child played with a Hulk action figure, while saying “Hulk smash!”, the psychologist responded to this by repeating “Hulk smash!” with the same emotion and effort. A significant increase in reflecting content was found at session 5 ( Mdn = 45), T = 228, z = -2.738, p = .005. The frequencies appear to be maintained at sessions 6 ( Mdn = 54), T = 199.00, z = -1.857, p = .063 and session 7 ( Mdn = 56), T = 144.50, z = − .198, p = .843. During these sessions, children were observed to share more about their experiences in real life. Some of them shared about their family e.g. a child said: “My aunt and I went out. We went to the park”, and the psychologist responded with “Ah, you and your aunt went to the park”. The child responded by sharing a lot more of the experience while simultaneously playing with some of the toys or affirmed the psychologists’ statements by nodding or saying “Yes” and continued to share more about the topic at hand. The more details the children shared, the more content the psychologists reflected. At session 8 ( Mdn = 60), a significant increase was found, T = 226.50, z = -3.248, p = .001. As this was the last session, children were informed of such; hence, the children often asked, “When will I come back here?”. The psychologists responded by saying: “You’re asking when you’ll come back here”. The children responded by saying “I want to play again”. Instances of sharing about experiences also increased; hence, psychologists continued to reflect content. Figure 2 represents the increasing trend of reflecting content. Reflecting Feelings Children came into the playroom with different facial expressions, to which psychologists reflected feelings by saying “You seem happy”, “You seem sad” or “It looks like you are angry while playing with that.” In turn, the children sometimes responded by nodding in agreement or continuing to play. Friedman Tests performed revealed significant differences, χ 2 (7) = 28.533, p < .001. Wilcoxon signed-rank tests with Bonferroni correction resulted to a significance level set at p < .006. Reflecting feelings significantly decreased from session 1 ( Mdn = 11) to session 2 ( Mdn = 3), T = 27.00, z = -3.381, p = .001. It was noted that the children’s typical first reactions were surprise or excitement. As the psychologists reflected such feelings, the children explored. There were also times where the psychologists verbalized “You seem confused about which toy to play with” as the children held two toys or looked at different areas of the playroom back and forth. Other children showed somewhat confused or awkward facial expressions while saying, “What will we be doing here?”. During second sessions, children seemed either engrossed in familiar toys or explored other parts of the playroom with relatively fewer novel reactions. Conversely, reflecting feelings significantly increased at session 3 ( Mdn = 11), T = 236.50, z = -2.999, p = .003, where emotions tended to rise as most of the children have started to play more actively by punching, kicking and hitting aggressive-release toys. Reflecting feelings maintained the same frequency at session 4 ( Mdn = 14), T = 175.50, z = -1.594, p = .111. Children often role-played scenes from media that involved fighting, growling and roaring. Some re-enacted a fight scene involving ‘The Avengers’ fighting ‘Thanos’, where the participants mimicked some the action figures’ common dialogues and catchphrases (e.g. “Avengers, assemble”, “Hulk Smash!” and “Bring me Thanos!”). These phrases were often accompanied by different facial expressions e.g. angry, determined or excited. The psychologists reflected by verbalizing: “You seem happy that you shot me”, “You looked very angry while those were fighting” or “You look excited that you won”. In turn, the children resumed such plays or acknowledged these reflections. Reflecting feelings dropped significantly at session 5 ( Mdn = 9), T = 45.00, z = -2.652, p = .005 and remained at the same level at session 6 ( Mdn = 7), T = 95.00, z = − .715, p = .475. Children continued with aggressive plays from time to time; however, there were instances of water and sand play or cooking and painting, which evoked less movement and expressions of feelings. Reflecting feelings significantly increased by session 7 (Mdn = 12), T = 195.50, z = -2.784, p = .005. As the children were informed by the psychologist about the session being the penultimate one, emotions such as wonder, and excitement seemed to have come about. Some children shared stories and experiences related to some of the toys. One cited being scared of dolls, for which the psychologist reflected by saying “You were afraid”. Another child also seemed to reflexively throw away a toy spider once he held it and the psychologist reflected such by saying “It looked like you were scared of the spider”. Children with similar reactions said “Yes” and kicked the toy away. Reflecting feelings significantly decreased in frequency at session 8 ( Mdn = 7), T = 21.500, z = -3.299, p = .001. Most children played with cards and some boardgames. Others chose painting and paper folding. Emotions tended to be less evident; thus, the opportunity to reflect feelings lessened, apart from the occasional “You’re happy that you won!” or “You’re excited you got that card”. Children reacted by laughing, smiling, starting a small jig or dance and saying “Your turn”. Figure 3 represents the fluctuating trend of reflecting feelings over 8 CCPT sessions. Limit Setting In instances where establishing was needed, limit setting was employed. For example, the psychologist communicated “It seems you like to hit me, but I am not for hitting. You can hit the stuffed toy over there instead”. Children usually responded by hitting other toys instead of the psychologist and for those that continued to hit psychologists, imit setting statements were repeated. Friedman Tests revealed that limit setting is used at different rates, χ 2 (7) = 32.555, p < .001. Wilcoxon signed-rank tests with Bonferroni correction applied resulted to a significance level set at p < .006. In contrast to session 1 ( Mdn = 15), there appears to be significant decrease limit setting at session 2 ( Mdn = 11), T = 40.50, z = -2.797, p = .005. During the first session, most of the children flung toys around and even at the psychologists. Hence, psychologists set limits by saying “It seems like you have fun with throwing toys at me. But I am not for hitting; you can throw it at other toys”. Most children stopped doing so and proceeded with other forms of play. Frequently, children also extended their stay in the playroom by continuing to play when the psychologists prompted them that the 45 minutes were up. Some children also said, “I want 100 minutes!” As such, the psychologists responded with “I know you want to play some more, but we only have 45 minutes in this session. You can come play again next time”. The children continued to play and left the playroom after the limit was repeated. At session 3 ( Mdn = 16), frequencies appeared to spike significantly, T = 231.00 z = -2.832, p = .005 and were maintained at session 4 ( Mdn = 16), T = 113.00, z = − .762, p = .446. Children played with bows and arrows, swords and guns. At times, they threw toys such as balls, blocks and other play materials at the psychologists, who set limits as before. Frequencies appeared to drop significantly at session 5 ( Mdn = 10), T = 40.50, z = -2.794, p = .005, and were maintained at session 6 ( Mdn = 10), T = 143.00, z = − .152, p = .879. Towards latter sessions, psychologists set limits in terms of the number of sessions by saying to the children “This is our second to the last session. Next time will be our last session”. Children often asked if they get to return to the playroom after that and later proceeded with playing. At times, the children tested some of the limits by resorting to means of extending the session. Hence, there was significantly rise at session 7 ( Mdn = 16), T = 220.50, z = -3.058, p = .002. Limit setting then significantly dropped at session 8 ( Mdn = 12), T = 16.50, z = -3.445, p = .001, as the children were prepared by the psychologist by saying “This will be our last session”. Children acknowledged by saying “Ok” and sometimes asked to return to the playroom. Psychologists responded with “You might come back here. But for now, this will be our last session”. This fluctuating pattern is represented by Fig. 4. Discussion The frequency of different therapeutic skills indicates a dynamic pattern in their use during short-term CCPT. Certain skills respond to behaviors of children with externalizing problem behaviors. As Landreth ( 2012 ) emphasizes, the intentional use of therapeutic skills facilitates understanding aggression and limit-testing within a healthy relationship. Maintaining the Therapeutic Relationship In the early sessions of short-term CCPT, frequent tracking helps maintain the connection between psychologist and child, reflecting the exploratory behaviors displayed during play. Hendricks ( 1971 ) and Withee (1975) noted that behaviors like exploring the playroom were met with appropriate tracking. This skill supports the therapeutic relationship without disrupting play (Landreth, 2012 ; O’Connor et al., 2016 ), allowing continuous engagement. Tracking keeps psychologists present without directing the child, fostering a warm relationship as envisioned by Axline ( 1969 ), and highlights behaviors the child may not recognize. Nonverbal cues, like nodding, indicate this continuity. A decrease in tracking by the third session may reflect shifts in behavior and emotions, especially in children with high aggression, resembling patterns seen in middle-stage CCPT (Hendricks, 1971 ; Mills & Allan, 1992 ; Moustakas, 1955a ; Nordling & Guerney, 1999 ; Withee, 1975). While tracking maintains connection, it may also allow aggression to persist, suggesting psychologists likely used other skills to address anger and opposition. In contrast to tracking, reflecting content showed an increasing trend as children grew more comfortable sharing and playing. Psychologists reflected these expressions, fostering deeper connections and helping children feel heard, accepted, and understood (O’Connor et al., 2016 ; Landreth, 2012 ). By the later sessions, the rise in reflecting content stemmed from children's willingness to share their thoughts and concerns. This aligns with Mills & Allan's (1992) findings of interactive play in the final stages of CCPT. Psychologists maintained connection by reflecting on children’s verbalizations without leading the conversation. As sessions progressed, a back-and-forth exchange of verbal and nonverbal information developed, like Hendricks' (1971) observations in dramatic play. Increased reflecting content allowed children to clarify their experiences and assess their anger-related issues, facilitating progress at their own pace. This approach aligns with Axline's (1969) principles of enabling children to solve their own problems, suggesting they were ready to address their concerns verbally by the end of therapy. Both tracking and reflecting content help maintain connection with children during sessions. Tracking focuses on nonverbal gestures, while reflecting content addresses verbalizations. Children with externalizing problems often start as nonverbal and gradually communicate more verbally. Those with aggressive impulses typically act physically rather than expressing emotions. This indicates a shift in children's modes of expression, supported by psychologists' skills in the therapeutic relationship. Reflecting Feelings and Limit Setting as Regulatory Skills The frequency of reflecting feelings varied during short-term CCPT. In early sessions, psychologists often reflected children’s happiness and excitement about toys to encourage self-expression and create a safe space (Mills & Allan, 1992 ). Drops in reflecting feelings indicated a shift to exploratory play as children became more comfortable, resulting in fewer expressions of anxiety, consistent with typical play stages (Hendricks, 1971 ; Withee, 1975). Increases mid-session aligned with emerging expressions of anger, mirroring findings from previous studies (Guerney, 2001 ; Hendricks, 1971 ; Moustakas, 1955b ; Nordling & Guerney, 1999 ; Withee, 1975). As children acted out themes of anger, psychologists helped them understand these emotions. Later sessions saw a decline in reflecting feelings as children engaged in nurturing play, supporting Nordling and Guerney's (1999) suggestion that such behaviors are better addressed through reflecting content. An increase toward the end of sessions indicated a need to address emotions children were comfortable sharing, allowing psychologists to clarify issues at the child’s pace, in line with Axline’s ( 1969 ) principle of fostering insight into behavior. Mills and Allan ( 1992 ) noted that issue emergence is common in later CCPT stages, prompting psychologists to use this skill. In the terminal phase of therapy, relationship play peaks (Withee, 1975). Reflecting feelings shows a downward trend in the final session, indicating that previous emotional responses have been expressed, allowing the child to address them within the safe therapeutic space. This fluctuation highlights the volatile nature of emotions, which psychologists must meet with acceptance in the playroom. Limit setting also varies across the 8 CCPT sessions. Initially, limits establish boundaries around time and behavior, creating safety for the child (O’Connor et al., 2016 ) and reflecting Axline’s ( 1969 ) principle of necessary limits. As children engage in exploratory play, they test boundaries to learn appropriate behaviors in a safe environment (Cochran et al., 2011 ). Setting limits provides structure, defining session duration (45 minutes) and acceptable activities, with drops in limit setting correlating with increased exploratory play in early sessions. The rise in limit setting during mid-sessions corresponds with an increase in aggressive play. As children test CCPT limits, psychologists remind them of boundaries using the ACT model (Landreth, 2012 ) or by combining empathic and limit-setting statements (Guerney, 2001 ). Conversely, the decrease in aggression in later sessions may result from nurturant play (Nordling & Guerney, 1999 ) and increased relationship play (Hendricks, 1971 ). The rise in limit setting in final sessions reflects psychologists’ efforts to prepare children for termination. A structured foundation allows for greater acceptance of this transition. Thus, the drop in limit setting aligns with mastery-focused play (Nordling & Guerney, 1999 ), role-plays with the psychologist (Hendricks, 1971 ), and a positive attitude (Moustakas, 1955a ). Overall, limit setting during aggressive moments helps maintain safety and fosters self-regulation in children. Reflecting feelings and limit setting show similar fluctuating trends. Children with externalizing behaviors often display volatile emotions and test established rules, driven by momentary impulses. Reflecting feelings helps them recognize their emotions through expressions, while limit setting establishes boundaries that guide them away from harmful behaviors. Consistent use of these skills can lead to behavioral changes beyond therapy. For example, reflecting feelings might lead a child to say, “I am mad,” while limit setting could prompt, “I know I’m mad, but I can’t hit my classmate; I can hit the stuffed toy instead.” The Methodical Use of Therapeutic Skills in CCPT These therapeutic patterns demonstrate that psychologists adopt a nondirective stance, aligning with Axline’s ( 1950 ) principle that the child leads while the psychologist follows. As children behave during therapy, psychologists respond to maintain the therapeutic relationship. Different skills are employed at various points to achieve specific outcomes. For instance, beginning a session requires tracking to foster the relationship while also setting limits to establish structure and reflecting the child's feelings and expressions. Importantly, no single skill is more effective than others in addressing different play behaviors. Instead, as Guerney ( 2001 ) suggests, CCPT functions as a system, where a combination of behaviors and words used by the psychologist can lead to positive outcomes. The dynamic use of therapeutic skills illustrates a play psychologist's flexibility within sessions and throughout the therapeutic relationship. By actively maintaining connection with the child, psychologists create a reservoir for learning and change, emphasizing Shirk and Karver's (2003) assertion that the therapeutic relationship significantly impacts intervention outcomes. This highlights the importance of a strong therapeutic alliance in youth psychotherapy (Langhoff et al., 2008 ; McLeod, 2011 ; Orlinsky et al., 2004 ). The effectiveness of this relationship hinges on the therapy's goal: fostering not just sporadic behavioral changes, but helping the child realize their innate potential for self-actualization. Thus, mastering therapeutic skills and underlying mechanisms of CCPT is essential for achieving desired outcomes. For CCPT practitioners, engaging with the findings of this study can refine therapeutic skills and prompt reflection on their effectiveness in facilitating behavioral change in child clients. Conclusion This study helped to describe how such an intervention is administered by trained play psychologists. The differing patterns of administering therapeutic skills display the dynamic and interactive quality of a therapeutic relationship that is needed in the process. This evidence gives much insight into explaining how CCPT works and operates despite its seemingly unstructured and nondirective nature. These patterns provide practitioners with insight regarding how to further improve and self-reflect on their own processes in dealing with clients that present with similar concerns as those who were selected for this study. Ultimately, the results of this study provide evidence that CCPT is capable of yielding positive outcomes with dynamic yet methodical processes. Limitations of the Study and Future Directions Observations of therapeutic skills relied heavily on raters’ judgments, guided by the CCPT Module and training. Despite regular supervision and discussion during data analysis, different practitioners might yield varying ratings. This study primarily focused on the frequency of therapeutic skills, without an in-depth analysis of their quality or other in-session behaviors, leaving out factors that could influence outcomes. Additionally, empathy and the therapeutic relationship were not measured through standardized tests, suggesting that future research should explore variables like therapeutic alliance and perceptions of empathy. Investigating themes within sessions may provide insights into how CCPT addresses externalizing problem behaviors, while examining the interactions between psychologists and children could clarify how the therapeutic relationship develops throughout the process. Further studies should establish the direct link between therapeutic skills and participants' behavioral outcomes, potentially revealing the connections between in-session behaviors of both psychologist and child. Additionally, investigating the quality of therapeutic skills used in CCPT could help practitioners refine their techniques and understand their relation to children's play behaviors outside the playroom. Given the importance of the therapeutic relationship in the intervention, more empirical studies focusing on this aspect and its impact on outcomes would be beneficial. Declarations I hereby declare that this research report is my own original and unaided work, and I have given full acknowledgement to all the cited and referred sources used. Ethical Approval This paper is part of the author’s dissertation as a requirement for the degree Doctor of Philosophy major in Clinical Psychology from De La Salle University-Manila, Philippines. Ethical approval was granted by the panel who reviewed and approved the author’s paper. Funding This research received no specific grant from any agency in the public, commercial, or non-profit sector. Availability of data and materials The data and materials that support the findings of this study are available on request from the corresponding author. Authors contribution PDB is the sole author of this paper and takes sole responsibility got the conception of study, presented results, and preparation of the manuscript. Conflict of Interest Statement The author declares that there is no personal, professional, or financial interests that could potentially compromise the objectivity or integrity of the research findings. Dual Publication The data, results, and figures used in this research have not been previously published, or are under consideration for publication elsewhere Data Availability Statement The data that support the findings of this study are available on request from the corresponding author, PDB. Consent to Participate The author assures that the individuals involved in this study have given consent both verbal and written forms. This includes the verbalizations, the analysis of video recordings, experiences during the intervention, and other information relevant to the results of the study). Consent to Publish All parties consented to have the collected data from the author’s dissertation to be included or used for publication. Clinical Trial Number: not applicable Disclosure Statement No potential competing interest was reported by the author. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References Axline, V. (1950). Play therapy experiences as described by child participants. Journal of Consulting Psychology, 14 (1), 53–63. Axline, V. (1969). Play therapy . Ballantine Books. Bjorkqvist, K. (2007). Empathy, social intelligence and aggression in adolescent boys and girls. In T. Farrow & P. Woodruff (Eds., pp. 76-88), Empathy in mental illness . Cambridge University Press. https://doi.org/10.1017/CBO9780511543753.006. Blanco, P. J., Ray, D. C., & Holliman, R. (2012). Long-term child centered play therapy and academic achievement of children: A follow- up study. International Journal of Play Therapy , 21 (1), 1-13. 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 , 376-390. Bengwasan, P. D. (2023). Short-term child-centered play therapy for school-aged Filipino boys with externalizing problem behaviors. International Journal of Play Therapy, 32 (1), 22–36. https://doi.org/10.1037/pla0000191 Cochran, J. L., & Cochran, N. H. (2006). The heart of counseling: A guide to developing therapeutic relationships. Thomson Brooks/Cole. Cochran, J. L., Cochran, N. H., Cholette, A. & Nordling, W. J. (2011). Limits and relationship in child-centered play therapy: Two case studies. International Journal of Play Therapy, 20 (4),236-251. https://doi.org/10.1037/a0025425. Cochran, J. L., Cochran, N. H., Nordling, W. J., McAdam, A. & Miller, D. T. (2010). Monitoring two boys’ processes through stages of child-centered play therapy. International Journal of Play Therapy, 19 (2),106-116. https://doi.org/10.1037/a0019092. Cohen, P., & Cohen, J. (1984). The Clinician's Illusion . Archives of General Psychiatry, 41 (12), 1178-1182. Dadds, M. R., Hunter, K., Hawes, D. J., Frost, A. D., Vassallo, S., Bunn, P., Merz, S., & Masry, Y. E. (2008). A measure of cognitive and affective empathy in children using parent ratings. Child Psychiatry and Human Development, 39, 111-122. Dorfman, E. (1951). Play therapy. In Rogers, C. R. (Ed.), Client-centered therapy (pp. 235-277). Houghton Mifflin. Gordon, M. (2005). Roots of empathy: Changing the world child by child. Thomas Allen Publishers. Guerney, L. (2001). Child-centered play therapy. International Journal of Play Therapy, 10, 13–31. http://doi.org/10.1037/h0089477. Hendricks, S. (1971). A descriptive analysis of the process of client-centered play therapy (Doctoral dissertation, North Texas State University, Denton). Dissertation Abstracts International, 32 , 3689A. Kaduson, H., & Schaefer, C. E. (2006). Short-term play therapy for children (2nd ed.). The Guilford Press. Kazdin, A. E. (2009). Understanding how and why psychotherapy leads to change. Psychotherapy Research, 19, 418–428. https://doi.org/10.1080/10503300802448899. Keenan, K., & Shaw, D. S. (2003). Starting at the beginning: Exploring the etiology of antisocial behavior in the first years of life. In B. B. Lahey, T. E. Moffitt, & A. Caspi (Eds.), Causes of conduct disorder and juvenile delinquency (pp. 153-181). The Guilford Press. Kent, A. J. & Hersen, M. (2000). A Psychologist’s Proactive Guide to Managed Mental Health Care. Lawrence Erlbaum Associates Publishers. Landreth, G. L. (2012). Play therapy: The art of relationship (3rd ed.). Routledge/Taylor & Francis Group. Kindle Version Langhoff, C., Baer, T., Zubraegel, D., & Linden, M. (2008). Psychologist-patient alliance, patient-psychologist alliance, mutual therapeutic alliance, psychologist-patient concordance, and outcome of CBT in GAD. Journal of Cognitive Psychotherapy: An International Quarterly, 22 (1), 68-79 . https://doi.org/10.1891/0889.8391.22.1.68. LeBlanc, M., & Ritchie, M. (2001). A meta-analysis of play therapy outcomes. Counselling Psychology Quarterly, 14, 149–163. https://doi.org/10.1080/09515070110059142. McLeod, B. D. (2011). Relation of the alliance with outcomes in youth psychotherapy: A meta-analysis. Clinical Psychology Review 31 (2011), 603-616. https://doi.org/10.1016/j.cpr.2011.02.001. Mills, B., & Allan, J. (1992). Play therapy with the maltreated child: Impact upon aggressive and withdrawn patterns of interaction. International Journal of Play Therapy, 1 , 1-20. https://doi.org/10.1037/h0090231. Moustakas, C. (1955a). Emotional adjustment and the play therapy process. Journal of Genetic Psychology, 86, 79–99. Moustakas, C. (1955b). The frequency and intensity of negative attitudes expressed in play therapy: A comparison of well adjusted and disturbed children. Journal of Genetic Psychology, 86, 309–324. Nordling, W. J., & Guerney, L. F. (1999). Typical stages in the child-centered play therapy process. Journal for the Professional Counselor , 14 , 17–23. O’Connor, K. J., Schaefer C. E. & Braverman, L. D. (2016). Handbook of Play Therapy (2nd ed.).John Wiley & Sons, Inc. Olson, S. L., Lopez-Duran, N., Lunkenheimer, E. S., Chang, H., & Sameroff, A. J. (2011). Individual differences in the development of early peer aggression: Integrating contributions of self-regulation, theory of mind, and parenting. Development and Psychopathology, 23 , 253-266. Orlinsky, D. E., Ronnestad, M. H., & Willutzki, U. (2004). Fifty years of psychotherapy process-outcome research: Continuity and change. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307–389). John Wiley & Sons, Inc. Ray, D. C. (2008). Impact of play therapy on parent-child relationship stress at a mental health training setting. British Journal of Guidance and Counselling, 36 , 165–187. Ray, D. C. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child practice . Routledge/Taylor & Francis Group. Ray, D. C., Blanco, P. J., Sullivan, J. M. & Holliman, R. (2017). An Exploratory Study of Child-Centered Play Therapy With Aggressive Children. International Journal of Play Therapy 2009, 18 (3), 162–175. https://doi.org/10.1037/a0014742. Reddy, L. A., Files-Hall, T. M., & Schaefer, C. E. (2005). Empirically based play interventions for children. American Psychological Association. Rogers, C. (1951). Client-centered therapy: Its current practice, implications, and theory. Boston: Houghton Mifflin. In L. G. Landreth Play Therapy: The Art of the Relationship (Vol. 2) . Taylor and Francis Group. Kindle Edition. Rogers, C. (1952). Client-centered psychotherapy. Scientific American, 187 , 70. Rogers, C. (1989). The Carl Rogers reader. Houghton Mifflin. Shirk, S. R., & Karver, M. (2003). Prediction of treatment outcome from relationship variables in child and adolescent therapy: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71 , 452−464. Trotter, K., Eshelman, D., & Landreth, G. (2003). A place for BoBo in play therapy. International Journal of Play Therapy, 12 (1) , 117–139. Trice-Black, S., Bailey, C., & Riechel, M. (2013). Play therapy in school counseling. Professional School Counseling, 16 (5), 303-312. https://doi.org/10.5330/PSC.n.2013-16.303. VanFleet, R., Sywulak, A. E. & Sniscak, C. C. (2010). Child-Centered Play Therapy. TheGuilford Press. Wilson, K., & Ryan, V. (2005). Play therapy: A non-directive approach for children and adolescents . Baillière Tindall. Withee, K. (1975). A descriptive analysis of the process of play therapy (Doctoral dissertation, North Texas State University, Denton). Dissertation Abstracts International, 36, 6406B. World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310 (20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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It is an affective response congruent with another\u0026rsquo;s situation (Dadds et al., 2008), which regulates aggression (Bjorkqvist, 2007; Peterson \u0026amp; Flanders, 2005). \u0026nbsp;The empathic understanding that children experience from play psychologists relates to effectively demonstrating empathy (Ray, 2008). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExternalized behaviors mirror internal experiences (Landreth, 2012) and these aggressive behaviors are also self-enhancing (Dorfman, 1951; Ray, 2011) and a means to self-actualize (Rogers, 1989). \u0026nbsp;Maladjustment exists when a person lacks sufficient self-confidence to evaluate behaviors and channel drives to productive directions (Axline, 1969). \u0026nbsp;Subsequently, aggressive behaviors subside when a child learns abilities that lead to self-regulation (Olson et al., 2011). \u0026nbsp; Keenan and Shaw (2003) suggested that emotional self-control was responsible for declines in aggression. Yet, children continue to struggle with self-regulation and aggression from preschool into elementary school (Olson et al., 2011). \u0026nbsp;Extended aggressive plays in CCPT connote improvement but when children show mastery behaviors, the therapeutic work is completed (Guerney, 2001). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc48123526\"\u003eDifficulty in relating to others contributes to disruptive behaviors, making therapeutic relationships particularly effective in promoting positive outcomes (Cochran \u0026amp; Cochran, 2006; Langhoff et al., 2008; Shirk \u0026amp; Karver, 2003). McLeod\u0026rsquo;s (2011) meta-analysis of 38 studies revealed a strong positive correlation between therapeutic alliance and outcomes in youth psychotherapy. The quality of this alliance is crucial, even for youth with externalizing problems (McLeod, 2011; Orlinsky et al., 2004; Shirk \u0026amp; Karver, 2003). Single case designs highlight the effectiveness of CCPT, emphasizing beneficial aspects of the intervention (Cochran et al., 2011). Cochran et al. (2010) noted improvements in self-concept and peer relationships at various therapy stages. Landreth (2012) describes the transition from maladjustment to psychological health as involving empathic listening, observation, and recognition statements that facilitate growth.\u003c/p\u003e\n\u003cp\u003ePlay offers an avenue to learn self-control especially when the psychologist provides appropriate therapeutic limit-setting (Landreth, 2012). \u0026nbsp;CCPT demonstrates this by providing the opportunity to act out feelings, thoughts and experiences through play (Axline, 1969; Landreth, 2012). Understanding that externalized behaviors mirror internal experiences, a\u0026nbsp;child-centered play psychologist does not seek to modify behaviors, but rather to empathically understand the child\u0026rsquo;s internal frame of reference (Landreth, 2012; Ray, 2008; Ray, 2011). \u0026nbsp;Axline (1969) included eliciting self-awareness and self-direction in a child as an objective of CCPT. \u0026nbsp;Such is brought about by following eight (8) basic principles (Axline, 1969; Landreth, 2012). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherapeutic change stems from the psychologist\u0026rsquo;s acceptance of the child as they are (Axline, 1969). The psychologist aims to understand the child\u0026apos;s self-concept within a safe relationship (Landreth, 2012). When a child exhibits provocative behavior, the psychologist conveys understanding and acceptance through their words, attitude, tone, and body language. A psychologist\u0026rsquo;s uniqueness lies in their intention to create a relationship-building atmosphere by empathically listening, observing, and making growth-facilitating statements (Landreth, 2012). These concepts become tangible as psychologists apply skills in response to children\u0026apos;s behaviors.\u003c/p\u003e\n\u003cp\u003eTherapeutic Skills in CCPT\u003c/p\u003e\n\u003cp\u003eCCPT is administered in totality, and a psychologist adheres to its beliefs and methods (Guerney, 2001), resulting to self-actualization (O\u0026rsquo;Connor et al., 2016). \u0026nbsp; Landreth (2012) declares that the use of skills is intentional and careful use words and actions is needed in building the therapeutic relationship.\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc48123527\"\u003eTracking\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eTracking is verbally describing what the child is doing out loud and reflecting the child\u0026rsquo;s words (O\u0026rsquo;Connor et al., 2016). The psychologist communicates in facial expression, tone of voice and general attitude the sense of wonder, puzzlement and intensity in the child\u0026rsquo;s play (Landreth, 2012). \u0026nbsp;Tracking allows the child to continue playing and maintains the psychologist\u0026rsquo;s involvement (Landreth, 2012; O\u0026rsquo;Connor et al., 2016). \u0026nbsp;This is important in initial stages of therapy, where play psychologists attempt to provide a safe and trusting environment, helping children express feelings (Mills \u0026amp; Allan, 1992) and verify the psychologist\u0026rsquo;s tracking behaviors (Withee, 1975).\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc48123528\"\u003eReflecting Content\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eIn reflecting content, the psychologist summarizes or paraphrases verbal expressions, making the child know that they have been heard (O\u0026rsquo;Connor et al., 2016). \u0026nbsp; This immerses the psychologist in the child\u0026rsquo;s world and communicates acceptance and understanding (Landreth, 2012). \u0026nbsp; This is a necessity for sessions where children show high levels of expressions of happiness, begin to share information about their lives and engage in relationship play, where verbal exchanges are often seen (Withee, 1975). \u0026nbsp;Reflecting content clarifies the child\u0026rsquo;s sense of self as may be seen when a child agrees or disagrees with a psychologist\u0026rsquo;s verbal reflections (Landreth, 2012). \u0026nbsp;During latter stages where expressions of competence and mastery of previous fears are seen (Nordling \u0026amp; Guerney, 1999), reflecting content gives the opportunity for clarification and effective communication.\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc48123529\"\u003eReflecting Feelings \u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc48123530\"\u003eLandreth (2012) noted that reflecting feelings involves psychologists responding to children\u0026rsquo;s verbalizations of emotions, validating their feelings and fostering self-trust. Proper reflection and recognition are essential for helping children accept their full emotional range (O\u0026rsquo;Connor et al., 2016) and recognize their inner value (Landreth, 2012). This skill is particularly important during mid-sessions when aggressive play and varied emotions emerge (Withee, 1975). Ambivalent feelings of anxiety and hostility often arise in initial and final sessions (Moustakas, 1955a; Nordling \u0026amp; Guerney, 1999) and are likely reflected back by psychologists. Empathic listening starts with recognizing feelings and leads to responses that convey acceptance and a nonjudgmental attitude (VanFleet et al., 2010). When children re-experience acceptance and security, their potential for inner growth increases (Mills \u0026amp; Allan, 1992).\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eLimit Setting\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMinimizing rules while allowing children to express themselves promotes safety and self-regulation (O\u0026rsquo;Connor et al., 2016). This is achieved by pairing limit-setting statements with empathic responses to a child\u0026apos;s desire to break limits (Guerney, 2001). The ACT model guides limit setting, which involves Acknowledging the child\u0026rsquo;s feelings, Communicating the limit, and Targeting an acceptable alternative (Landreth, 2012). This skill is particularly important during sessions with aggressive behaviors (Hendricks, 1971; Withee, 1975; Mills \u0026amp; Allan, 1992; Moustakas, 1955a; Nordling \u0026amp; Guerney, 1999). It helps children understand how emotions impact decision-making (Landreth, 2012) and offers new ways of self-expression, leading to decreased oppositionality (Trice-Black et al., 2013). Clients who test limits often reassess relational expectations, revisit unmet needs, and transform their self-concept (Cochran et al., 2011).\u003c/p\u003e\n\u003cp id=\"_Toc48123532\"\u003eA therapist\u0026rsquo;s ability to apply CCPT principles through these skills fosters optimal functioning and empowers a child to develop a healthy sense of self (Wilson \u0026amp; Ryan, 2005). When psychologists reflect a child\u0026rsquo;s thoughts, feelings, and actions, the child learns to accept and manage them (Axline, 1969; Landreth, 2012). This recognition enhances self-concept and aids in psychological and behavioral realignment (Guerney, 2001). Landreth (2012) emphasizes the intentional use of therapeutic skills, suggesting that examining their frequency can reveal the best times to use each skill and strengthen the therapeutic relationship.\u003c/p\u003e\n\u003cp\u003eRelationship-building between therapist and child was initially thought to require long-term interaction, with many studies showing CCPT\u0026apos;s effectiveness in extended frames (Blanco et al., 2012; Bratton et al., 2005; Leblanc \u0026amp; Ritchie, 2001). However, short-term frames have also demonstrated reductions in problematic aggressive behaviors (Bengwasan, 2023; Cochran \u0026amp; Cochran, 2017; Guerney, 2001; Landreth, 2012; Kaduson \u0026amp; Schaefer, 2006; Kent \u0026amp; Hersen, 2000; Ray, 2008; Ray et al., 2017). Ritzi et al. (2017) found that an intensive short-term approach (two 30-minute sessions daily for 10 days) led to decreases in externalizing problems. Overall, clients typically receive a median of 3-5 sessions and a mean of 5-8 sessions of CCPT (Cohen \u0026amp; Cohen, 1984). Many clients approach mental health practitioners expecting brief, effective treatment, highlighting the emphasis on short-term therapy (Kaduson \u0026amp; Schaefer, 2006; Reddy et al., 2005). Therefore, this study examines therapeutic skills in CCPT within a short-term frame of 8 weeks, following the standard weekly administration.\u003c/p\u003e\n\u003cp\u003ePurpose of the Study\u003c/p\u003e\n\u003cp\u003eThis study explores underlying mechanisms, particularly therapeutic skills used in short-term CCPT, and in the process, discovering a possible system in which these skills operate in response to children\u0026rsquo;s play behaviors. \u0026nbsp;This responds to the necessity to conduct research that provides empirical understanding of mechanisms of therapeutic change and explaining how and why therapeutic powers work (Kazdin, 2009). \u0026nbsp;The study answers the research question: In maintaining the therapeutic relationship, to what extent is each therapeutic skill employed across short term CCPT sessions of children who exhibit externalizing problem behaviors? \u0026nbsp;It is hypothesized that each skill will be significantly used to a greater extent at a particular session in short-term CCPT.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychologists\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc48123536\"\u003ePsychologists who administered CCPT have successfully accomplished an Introductory course in Play Therapy. \u0026nbsp;They were registered psychologists in the Philippines with at least 2 years of experience in administering child psychotherapy including CCPT and other play intervention variants. \u0026nbsp;There were six (6) psychologists and there was only one psychologist assigned per participant. \u0026nbsp;Each psychologist had 4 participants assigned to them, except one who was assigned 3 participants. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRaters\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRaters have also successfully accomplished an Introductory course in Play Therapy. \u0026nbsp; They were also registered psychologists with at least 2 years of experience in child psychotherapy including CCPT. \u0026nbsp;They performed the major task of quantifying the therapeutic skills. \u0026nbsp;There were six (6) raters including the researcher, who were separate from the psychologists. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClients\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe 23 clients who participated in this study came from one primary school in the Northern Philippines. All of them were boys aged 6-12 years and came from an outcome study of CCPT for school-aged Filipino children with externalizing problem behaviors (Bengwasan, 2023).\u003c/p\u003e\n\u003cp id=\"_Toc48123542\"\u003eProcedure\u003c/p\u003e\n\u003cp\u003eAn observational research design was employed to study therapeutic skills during 8 CCPT sessions with 23 children. Permission was obtained from a primary school principal in Northern Philippines. \u0026nbsp;The children were screened after parents signed consent forms, and clients capable of doing so provided assent. If not, a parent signed on their behalf, and all were informed of their right to discontinue.\u003c/p\u003e\n\u003cp\u003eThe 23 children received Child-Centered Play Therapy (CCPT) by Landreth (2012) and Axline (1969) in 8 weekly individual sessions, each lasting at least 45 minutes, in a designated playroom at the primary school. Each was randomly assigned to one psychologist, and all sessions were videotaped with psychologists signing a confidentiality agreement. Video recordings were stored on a passcode-protected hard drive accessible only to the researcher.\u003c/p\u003e\n\u003cp\u003eBefore the intervention, six psychologists received training for the study\u0026rsquo;s protocol on two occasions, each lasting 3 hours, facilitated by a registered psychologist in the Philippines with over 15 years of child psychotherapy experience, who also supervised the study. The supervisor provided individual feedback every two weeks and reviewed at least three randomly selected video recordings per psychologist. Raters received the same training, noted definitions and examples of therapeutic skills, and were assigned sets of sessions to rate separately. Each video was rated by two individuals, and they met to discuss and agree on final ratings.\u003c/p\u003e\n\u003cp\u003eThe study was done in accordance with the principles of the Declaration of Helsinki (WMA, 2013). All participants provided informed consent prior to participation, and the study protocol was reviewed by experts who served as panel members of the author\u0026rsquo;s dissertation as a requirement for the degree Doctor of Philosophy major in Clinical Psychology from De La Salle University-Manila, Philippines. \u0026nbsp;The study was done in accordance to the guidelines set by the De La Salle University (DLSU) Code for the Responsible Conduct of Research as established by the DLSU-Research Ethics Review Committee (RERC) and Research Ethics Review Panels (RERPs). \u0026nbsp;This paper is part of the author\u0026rsquo;s dissertation as a requirement for the degree Doctor of Philosophy major in Clinical Psychology from De La Salle University-Manila, Philippines. Ethical approval was granted by the panel who reviewed and approved the author\u0026rsquo;s paper. \u0026nbsp;The panel consisted of four (4) full-time professors from De La Salle University, namely: Roseanne Tan-Mansukhani, PhD, Ron R. Resurreccion, PhD, Homer J. Yabut, PhD, and Maria Guadalupe C. Salanga, PhD, and one (1) external panel member from the Ateneo De Manila University, Edith Liane C. Alampay, PhD. \u0026nbsp; The ethics clearance was given following the approval of the author\u0026rsquo;s supervisor, Ma. Caridad H. Tarroja, PhD.\u003c/p\u003e\n\u003cp\u003ePsychologists, raters and the supervisor who took part in this study provided consent by signing individual informed consent forms. \u0026nbsp;They were informed of their right to discontinue at any point or phase of the study. \u0026nbsp; All parties consented to have the collected data from the author\u0026rsquo;s dissertation to be included or used for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were conducted using SPSS version 29.1. Inter-rater reliability was assessed by comparing observations from two raters across 184 videotaped sessions, with separate scores calculated for each therapeutic skill based on Krippendorff\u0026rsquo;s alpha: \u0026lt; 0 (unacceptable), 0.66-0.80 (tentatively acceptable), 0.81-0.99 (acceptable), and 1 (perfect agreement). To analyze fluctuations in therapeutic skills from session 1 to session 8, one-way Friedman Tests were performed, followed by Wilcoxon signed-rank tests with Bonferroni correction for post hoc analysis of significant differences among session frequencies.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eInter-rater Reliability\u003c/h2\u003e\n \u003cp\u003eBased on the separate inter-rater reliability computations, comparisons of observations of 184 session per child made by 2 raters resulted to acceptable agreement for Tracking (\u003cem\u003e\u0026alpha;\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.854), Reflecting Feelings (\u003cem\u003e\u0026alpha;\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.819), Reflecting Content (\u003cem\u003e\u0026alpha;\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.877), and Limit Setting (\u003cem\u003e\u0026alpha;\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.815). These results indicate an adequate level of reliability in terms of the raters\u0026rsquo; observations and are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eInter-rater reliability per therapeutic skill\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTherapeutic Skill\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKrippendorff\u0026rsquo;s alpha\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e95% CI\u003c/span\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUpper CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTracking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.854\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.803\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.906\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReflecting Feelings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.825\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.764\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.885\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReflecting Content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.829\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.771\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimit Setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.790\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.905\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eTherapeutic Skills\u003c/h2\u003e\n \u003cp\u003eThe following paragraphs discuss children\u0026apos;s play behaviors and reactions to therapeutic skills to provide context for their impact during sessions. Separate Friedman Tests were conducted to assess how psychologists used skills to maintain the therapeutic relationship in short-term CCPT. Random sampling assumptions were met by assigning each session randomly to raters. Independence of observation was ensured as each session was analyzed separately by each rater before final ratings. The assumption of normal distribution was also met, with outliers addressed through discussions between raters.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eTracking\u003c/h2\u003e\n \u003cp\u003eAs each child enters the playroom, the psychologists\u0026rsquo; tracking behavior began by turning and verbalizing movement toward the child. Children often reacted by looking back at the psychologists, nodding or proceeding to play with toys. The Friedman Test revealed that the instances of tracking differ across the 8 sessions, \u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e(7)\u0026thinsp;=\u0026thinsp;47.926, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Wilcoxon signed-rank tests with Bonferroni correction applied resulted to a significance level set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.006. Psychologists tracked the children\u0026rsquo;s behaviors at a comparable frequency during sessions 1 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;59) and 2 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;58), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72.50, \u003cem\u003ez\u003c/em\u003e = -1.993, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.046. Most of the children went around the playroom and looked at different toys. Psychologists mainly tracked by moving positions toward the children and saying: \u0026ldquo;You seem to be looking at the toys\u0026rdquo; or \u0026ldquo;You are going around the room\u0026rdquo;. Children responded by either saying \u0026ldquo;Yes\u0026rdquo; or \u0026ldquo;No\u0026rdquo;, looking at the psychologist, playing or moving around. Meanwhile, tracking appeared to significantly drop in frequency beginning session 3 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;46), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;44.00, \u003cem\u003ez\u003c/em\u003e = -2.861, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.004. Children played with the toys they previously interacted with in the beginning sessions. Psychologists tracked by saying \u0026ldquo;You are playing with that toy\u0026rdquo; or \u0026ldquo;Oh, you found that\u0026rdquo;. Children then reacted by continuing to play or nodding. Tracking appeared to stay at a similar frequency from sessions 4 to 8. Figure 1 represents the median observations of tracking.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eReflecting Content\u003c/h2\u003e\n \u003cp\u003ePsychologists reflected content by rephrasing children\u0026rsquo;s statements and comments while being careful enough to use the children\u0026rsquo;s own words. When a child said, \u0026ldquo;I have like this at home\u0026rdquo;, the psychologist responded by saying \u0026ldquo;Oh, you have like that at home\u0026rdquo;. Children continued to add details, which the psychologists reflected back until the children ended the exchange. Instances of reflecting content tended to differ across the 8 CCPT sessions, \u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e(7)\u0026thinsp;=\u0026thinsp;71.172, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Wilcoxon signed-rank tests with Bonferroni correction resulted to a significance level set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.006. Compared to session 1 (\u003cem\u003eMdn\u0026thinsp;=\u003c/em\u003e\u0026thinsp;11), session 2 (\u003cem\u003eMdn\u0026thinsp;=\u003c/em\u003e\u0026thinsp;37) showed significant increase, \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;275.00, \u003cem\u003ez\u003c/em\u003e = -4.169, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.000. The familiarity that children seemed to have established led to comfort in interacting with the psychologists verbally. Frequencies were maintained at session 3 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;135.50, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.076, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.939 and session 4 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;147.00, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.274, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.784. These sessions reveal a maintained exchange between the psychologists and the children. As the children also began to do role-play, the dialogue from the movies and scenes in which they may have heard them were repeated. A child played with a Hulk action figure, while saying \u0026ldquo;Hulk smash!\u0026rdquo;, the psychologist responded to this by repeating \u0026ldquo;Hulk smash!\u0026rdquo; with the same emotion and effort.\u003c/p\u003e\n \u003cp\u003eA significant increase in reflecting content was found at session 5 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;45), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;228, \u003cem\u003ez\u003c/em\u003e = -2.738, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.005. The frequencies appear to be maintained at sessions 6 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;54), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;199.00, \u003cem\u003ez\u003c/em\u003e = -1.857, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.063 and session 7 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;56), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;144.50, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.198, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.843. During these sessions, children were observed to share more about their experiences in real life. Some of them shared about their family e.g. a child said: \u0026ldquo;My aunt and I went out. We went to the park\u0026rdquo;, and the psychologist responded with \u0026ldquo;Ah, you and your aunt went to the park\u0026rdquo;. The child responded by sharing a lot more of the experience while simultaneously playing with some of the toys or affirmed the psychologists\u0026rsquo; statements by nodding or saying \u0026ldquo;Yes\u0026rdquo; and continued to share more about the topic at hand. The more details the children shared, the more content the psychologists reflected. At session 8 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60), a significant increase was found, \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;226.50, \u003cem\u003ez\u003c/em\u003e = -3.248, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001. As this was the last session, children were informed of such; hence, the children often asked, \u0026ldquo;When will I come back here?\u0026rdquo;. The psychologists responded by saying: \u0026ldquo;You\u0026rsquo;re asking when you\u0026rsquo;ll come back here\u0026rdquo;. The children responded by saying \u0026ldquo;I want to play again\u0026rdquo;. Instances of sharing about experiences also increased; hence, psychologists continued to reflect content. Figure 2 represents the increasing trend of reflecting content.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003eReflecting Feelings\u003c/h2\u003e\n \u003cp\u003eChildren came into the playroom with different facial expressions, to which psychologists reflected feelings by saying \u0026ldquo;You seem happy\u0026rdquo;, \u0026ldquo;You seem sad\u0026rdquo; or \u0026ldquo;It looks like you are angry while playing with that.\u0026rdquo; In turn, the children sometimes responded by nodding in agreement or continuing to play. Friedman Tests performed revealed significant differences, \u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e(7)\u0026thinsp;=\u0026thinsp;28.533, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Wilcoxon signed-rank tests with Bonferroni correction resulted to a significance level set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.006. Reflecting feelings significantly decreased from session 1 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11) to session 2 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;27.00, \u003cem\u003ez\u003c/em\u003e = -3.381, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001. It was noted that the children\u0026rsquo;s typical first reactions were surprise or excitement. As the psychologists reflected such feelings, the children explored. There were also times where the psychologists verbalized \u0026ldquo;You seem confused about which toy to play with\u0026rdquo; as the children held two toys or looked at different areas of the playroom back and forth. Other children showed somewhat confused or awkward facial expressions while saying, \u0026ldquo;What will we be doing here?\u0026rdquo;. During second sessions, children seemed either engrossed in familiar toys or explored other parts of the playroom with relatively fewer novel reactions.\u003c/p\u003e\n \u003cp\u003eConversely, reflecting feelings significantly increased at session 3 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;236.50, \u003cem\u003ez\u003c/em\u003e = -2.999, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003, where emotions tended to rise as most of the children have started to play more actively by punching, kicking and hitting aggressive-release toys. Reflecting feelings maintained the same frequency at session 4 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;175.50, \u003cem\u003ez\u003c/em\u003e = -1.594, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.111. Children often role-played scenes from media that involved fighting, growling and roaring. Some re-enacted a fight scene involving \u0026lsquo;The Avengers\u0026rsquo; fighting \u0026lsquo;Thanos\u0026rsquo;, where the participants mimicked some the action figures\u0026rsquo; common dialogues and catchphrases (e.g. \u0026ldquo;Avengers, assemble\u0026rdquo;, \u0026ldquo;Hulk Smash!\u0026rdquo; and \u0026ldquo;Bring me Thanos!\u0026rdquo;). These phrases were often accompanied by different facial expressions e.g. angry, determined or excited. The psychologists reflected by verbalizing: \u0026ldquo;You seem happy that you shot me\u0026rdquo;, \u0026ldquo;You looked very angry while those were fighting\u0026rdquo; or \u0026ldquo;You look excited that you won\u0026rdquo;. In turn, the children resumed such plays or acknowledged these reflections.\u003c/p\u003e\n \u003cp\u003eReflecting feelings dropped significantly at session 5 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;45.00, \u003cem\u003ez\u003c/em\u003e = -2.652, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.005 and remained at the same level at session 6 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;95.00, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.715, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.475. Children continued with aggressive plays from time to time; however, there were instances of water and sand play or cooking and painting, which evoked less movement and expressions of feelings. Reflecting feelings significantly increased by session 7 (Mdn\u0026thinsp;=\u0026thinsp;12), T\u0026thinsp;=\u0026thinsp;195.50, z = -2.784, p\u0026thinsp;=\u0026thinsp;.005. As the children were informed by the psychologist about the session being the penultimate one, emotions such as wonder, and excitement seemed to have come about. Some children shared stories and experiences related to some of the toys. One cited being scared of dolls, for which the psychologist reflected by saying \u0026ldquo;You were afraid\u0026rdquo;. Another child also seemed to reflexively throw away a toy spider once he held it and the psychologist reflected such by saying \u0026ldquo;It looked like you were scared of the spider\u0026rdquo;. Children with similar reactions said \u0026ldquo;Yes\u0026rdquo; and kicked the toy away.\u003c/p\u003e\n \u003cp\u003eReflecting feelings significantly decreased in frequency at session 8 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;21.500, \u003cem\u003ez\u003c/em\u003e = -3.299, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001. Most children played with cards and some boardgames. Others chose painting and paper folding. Emotions tended to be less evident; thus, the opportunity to reflect feelings lessened, apart from the occasional \u0026ldquo;You\u0026rsquo;re happy that you won!\u0026rdquo; or \u0026ldquo;You\u0026rsquo;re excited you got that card\u0026rdquo;. Children reacted by laughing, smiling, starting a small jig or dance and saying \u0026ldquo;Your turn\u0026rdquo;. Figure 3 represents the fluctuating trend of reflecting feelings over 8 CCPT sessions.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\n \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\n \u003ch2\u003eLimit Setting\u003c/h2\u003e\n \u003cp\u003eIn instances where establishing was needed, limit setting was employed. For example, the psychologist communicated \u0026ldquo;It seems you like to hit me, but I am not for hitting. You can hit the stuffed toy over there instead\u0026rdquo;. Children usually responded by hitting other toys instead of the psychologist and for those that continued to hit psychologists, imit setting statements were repeated. Friedman Tests revealed that limit setting is used at different rates, \u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e(7)\u0026thinsp;=\u0026thinsp;32.555, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Wilcoxon signed-rank tests with Bonferroni correction applied resulted to a significance level set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.006. In contrast to session 1 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15), there appears to be significant decrease limit setting at session 2 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40.50, \u003cem\u003ez\u003c/em\u003e = -2.797, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.005. During the first session, most of the children flung toys around and even at the psychologists. Hence, psychologists set limits by saying \u0026ldquo;It seems like you have fun with throwing toys at me. But I am not for hitting; you can throw it at other toys\u0026rdquo;. Most children stopped doing so and proceeded with other forms of play. Frequently, children also extended their stay in the playroom by continuing to play when the psychologists prompted them that the 45 minutes were up. Some children also said, \u0026ldquo;I want 100 minutes!\u0026rdquo; As such, the psychologists responded with \u0026ldquo;I know you want to play some more, but we only have 45 minutes in this session. You can come play again next time\u0026rdquo;. The children continued to play and left the playroom after the limit was repeated.\u003c/p\u003e\n \u003cp\u003eAt session 3 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16), frequencies appeared to spike significantly, \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;231.00 \u003cem\u003ez\u003c/em\u003e = -2.832, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.005 and were maintained at session 4 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;113.00, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.762, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.446. Children played with bows and arrows, swords and guns. At times, they threw toys such as balls, blocks and other play materials at the psychologists, who set limits as before. Frequencies appeared to drop significantly at session 5 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40.50, \u003cem\u003ez\u003c/em\u003e = -2.794, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.005, and were maintained at session 6 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;143.00, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.152, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.879. Towards latter sessions, psychologists set limits in terms of the number of sessions by saying to the children \u0026ldquo;This is our second to the last session. Next time will be our last session\u0026rdquo;. Children often asked if they get to return to the playroom after that and later proceeded with playing. At times, the children tested some of the limits by resorting to means of extending the session. Hence, there was significantly rise at session 7 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;220.50, \u003cem\u003ez\u003c/em\u003e = -3.058, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.002. Limit setting then significantly dropped at session 8 (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12), \u003cem\u003eT\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16.50, \u003cem\u003ez\u003c/em\u003e = -3.445, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001, as the children were prepared by the psychologist by saying \u0026ldquo;This will be our last session\u0026rdquo;. Children acknowledged by saying \u0026ldquo;Ok\u0026rdquo; and sometimes asked to return to the playroom. Psychologists responded with \u0026ldquo;You might come back here. But for now, this will be our last session\u0026rdquo;. This fluctuating pattern is represented by \u003cem\u003eFig. 4.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe frequency of different therapeutic skills indicates a dynamic pattern in their use during short-term CCPT. Certain skills respond to behaviors of children with externalizing problem behaviors. As Landreth (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) emphasizes, the intentional use of therapeutic skills facilitates understanding aggression and limit-testing within a healthy relationship.\u003c/p\u003e\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\u003ch2\u003eMaintaining the Therapeutic Relationship\u003c/h2\u003e\u003cp\u003eIn the early sessions of short-term CCPT, frequent tracking helps maintain the connection between psychologist and child, reflecting the exploratory behaviors displayed during play. Hendricks (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1971\u003c/span\u003e) and Withee (1975) noted that behaviors like exploring the playroom were met with appropriate tracking. This skill supports the therapeutic relationship without disrupting play (Landreth, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; O\u0026rsquo;Connor et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), allowing continuous engagement. Tracking keeps psychologists present without directing the child, fostering a warm relationship as envisioned by Axline (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1969\u003c/span\u003e), and highlights behaviors the child may not recognize. Nonverbal cues, like nodding, indicate this continuity. A decrease in tracking by the third session may reflect shifts in behavior and emotions, especially in children with high aggression, resembling patterns seen in middle-stage CCPT (Hendricks, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1971\u003c/span\u003e; Mills \u0026amp; Allan, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1992\u003c/span\u003e; Moustakas, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1955a\u003c/span\u003e; Nordling \u0026amp; Guerney, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Withee, 1975). While tracking maintains connection, it may also allow aggression to persist, suggesting psychologists likely used other skills to address anger and opposition.\u003c/p\u003e\u003cp\u003eIn contrast to tracking, reflecting content showed an increasing trend as children grew more comfortable sharing and playing. Psychologists reflected these expressions, fostering deeper connections and helping children feel heard, accepted, and understood (O\u0026rsquo;Connor et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Landreth, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). By the later sessions, the rise in reflecting content stemmed from children's willingness to share their thoughts and concerns. This aligns with Mills \u0026amp; Allan's (1992) findings of interactive play in the final stages of CCPT. Psychologists maintained connection by reflecting on children\u0026rsquo;s verbalizations without leading the conversation. As sessions progressed, a back-and-forth exchange of verbal and nonverbal information developed, like Hendricks' (1971) observations in dramatic play. Increased reflecting content allowed children to clarify their experiences and assess their anger-related issues, facilitating progress at their own pace. This approach aligns with Axline's (1969) principles of enabling children to solve their own problems, suggesting they were ready to address their concerns verbally by the end of therapy.\u003c/p\u003e\u003cp\u003eBoth tracking and reflecting content help maintain connection with children during sessions. Tracking focuses on nonverbal gestures, while reflecting content addresses verbalizations. Children with externalizing problems often start as nonverbal and gradually communicate more verbally. Those with aggressive impulses typically act physically rather than expressing emotions. This indicates a shift in children's modes of expression, supported by psychologists' skills in the therapeutic relationship.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eReflecting Feelings and Limit Setting as Regulatory Skills\u003c/h2\u003e\u003cp\u003eThe frequency of reflecting feelings varied during short-term CCPT. In early sessions, psychologists often reflected children\u0026rsquo;s happiness and excitement about toys to encourage self-expression and create a safe space (Mills \u0026amp; Allan, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1992\u003c/span\u003e). Drops in reflecting feelings indicated a shift to exploratory play as children became more comfortable, resulting in fewer expressions of anxiety, consistent with typical play stages (Hendricks, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1971\u003c/span\u003e; Withee, 1975). Increases mid-session aligned with emerging expressions of anger, mirroring findings from previous studies (Guerney, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Hendricks, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1971\u003c/span\u003e; Moustakas, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1955b\u003c/span\u003e; Nordling \u0026amp; Guerney, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Withee, 1975). As children acted out themes of anger, psychologists helped them understand these emotions. Later sessions saw a decline in reflecting feelings as children engaged in nurturing play, supporting Nordling and Guerney's (1999) suggestion that such behaviors are better addressed through reflecting content. An increase toward the end of sessions indicated a need to address emotions children were comfortable sharing, allowing psychologists to clarify issues at the child\u0026rsquo;s pace, in line with Axline\u0026rsquo;s (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1969\u003c/span\u003e) principle of fostering insight into behavior. Mills and Allan (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1992\u003c/span\u003e) noted that issue emergence is common in later CCPT stages, prompting psychologists to use this skill.\u003c/p\u003e\u003cp\u003eIn the terminal phase of therapy, relationship play peaks (Withee, 1975). Reflecting feelings shows a downward trend in the final session, indicating that previous emotional responses have been expressed, allowing the child to address them within the safe therapeutic space. This fluctuation highlights the volatile nature of emotions, which psychologists must meet with acceptance in the playroom.\u003c/p\u003e\u003cp\u003eLimit setting also varies across the 8 CCPT sessions. Initially, limits establish boundaries around time and behavior, creating safety for the child (O\u0026rsquo;Connor et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and reflecting Axline\u0026rsquo;s (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1969\u003c/span\u003e) principle of necessary limits. As children engage in exploratory play, they test boundaries to learn appropriate behaviors in a safe environment (Cochran et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Setting limits provides structure, defining session duration (45 minutes) and acceptable activities, with drops in limit setting correlating with increased exploratory play in early sessions.\u003c/p\u003e\u003cp\u003eThe rise in limit setting during mid-sessions corresponds with an increase in aggressive play. As children test CCPT limits, psychologists remind them of boundaries using the ACT model (Landreth, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) or by combining empathic and limit-setting statements (Guerney, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Conversely, the decrease in aggression in later sessions may result from nurturant play (Nordling \u0026amp; Guerney, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) and increased relationship play (Hendricks, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1971\u003c/span\u003e). The rise in limit setting in final sessions reflects psychologists\u0026rsquo; efforts to prepare children for termination. A structured foundation allows for greater acceptance of this transition. Thus, the drop in limit setting aligns with mastery-focused play (Nordling \u0026amp; Guerney, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1999\u003c/span\u003e), role-plays with the psychologist (Hendricks, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1971\u003c/span\u003e), and a positive attitude (Moustakas, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1955a\u003c/span\u003e). Overall, limit setting during aggressive moments helps maintain safety and fosters self-regulation in children.\u003c/p\u003e\u003cp\u003eReflecting feelings and limit setting show similar fluctuating trends. Children with externalizing behaviors often display volatile emotions and test established rules, driven by momentary impulses. Reflecting feelings helps them recognize their emotions through expressions, while limit setting establishes boundaries that guide them away from harmful behaviors. Consistent use of these skills can lead to behavioral changes beyond therapy. For example, reflecting feelings might lead a child to say, \u0026ldquo;I am mad,\u0026rdquo; while limit setting could prompt, \u0026ldquo;I know I\u0026rsquo;m mad, but I can\u0026rsquo;t hit my classmate; I can hit the stuffed toy instead.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eThe Methodical Use of Therapeutic Skills in CCPT\u003c/h3\u003e\n\u003cp\u003eThese therapeutic patterns demonstrate that psychologists adopt a nondirective stance, aligning with Axline\u0026rsquo;s (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1950\u003c/span\u003e) principle that the child leads while the psychologist follows. As children behave during therapy, psychologists respond to maintain the therapeutic relationship. Different skills are employed at various points to achieve specific outcomes. For instance, beginning a session requires tracking to foster the relationship while also setting limits to establish structure and reflecting the child's feelings and expressions. Importantly, no single skill is more effective than others in addressing different play behaviors. Instead, as Guerney (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2001\u003c/span\u003e) suggests, CCPT functions as a system, where a combination of behaviors and words used by the psychologist can lead to positive outcomes.\u003c/p\u003e\u003cp\u003eThe dynamic use of therapeutic skills illustrates a play psychologist's flexibility within sessions and throughout the therapeutic relationship. By actively maintaining connection with the child, psychologists create a reservoir for learning and change, emphasizing Shirk and Karver's (2003) assertion that the therapeutic relationship significantly impacts intervention outcomes. This highlights the importance of a strong therapeutic alliance in youth psychotherapy (Langhoff et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; McLeod, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Orlinsky et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2004\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe effectiveness of this relationship hinges on the therapy's goal: fostering not just sporadic behavioral changes, but helping the child realize their innate potential for self-actualization. Thus, mastering therapeutic skills and underlying mechanisms of CCPT is essential for achieving desired outcomes. For CCPT practitioners, engaging with the findings of this study can refine therapeutic skills and prompt reflection on their effectiveness in facilitating behavioral change in child clients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study helped to describe how such an intervention is administered by trained play psychologists. \u0026nbsp;The differing patterns of administering therapeutic skills display the dynamic and interactive quality of a therapeutic relationship that is needed in the process. \u0026nbsp; This evidence gives much insight into explaining how CCPT works and operates despite its seemingly unstructured and nondirective nature. \u0026nbsp;These patterns provide practitioners with insight regarding how to further improve and self-reflect on their own processes in dealing with clients that present with similar concerns as those who were selected for this study. \u0026nbsp; Ultimately, the results of this study provide evidence that CCPT is capable of yielding positive outcomes with dynamic yet methodical processes.\u003c/p\u003e\n\u003cp id=\"_Toc48123562\"\u003eLimitations of the Study and Future Directions\u003c/p\u003e\n\u003cp\u003eObservations of therapeutic skills relied heavily on raters\u0026rsquo; judgments, guided by the CCPT Module and training. Despite regular supervision and discussion during data analysis, different practitioners might yield varying ratings. This study primarily focused on the frequency of therapeutic skills, without an in-depth analysis of their quality or other in-session behaviors, leaving out factors that could influence outcomes. Additionally, empathy and the therapeutic relationship were not measured through standardized tests, suggesting that future research should explore variables like therapeutic alliance and perceptions of empathy.\u003c/p\u003e\n\u003cp\u003eInvestigating themes within sessions may provide insights into how CCPT addresses externalizing problem behaviors, while examining the interactions between psychologists and children could clarify how the therapeutic relationship develops throughout the process. Further studies should establish the direct link between therapeutic skills and participants\u0026apos; behavioral outcomes, potentially revealing the connections between in-session behaviors of both psychologist and child. Additionally, investigating the quality of therapeutic skills used in CCPT could help practitioners refine their techniques and understand their relation to children\u0026apos;s play behaviors outside the playroom. Given the importance of the therapeutic relationship in the intervention, more empirical studies focusing on this aspect and its impact on outcomes would be beneficial.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eI hereby declare that this research report is my own original and unaided work, and I have given full acknowledgement to all the cited and referred sources used. \u003c/p\u003e\n\u003cp\u003eEthical Approval\u003c/p\u003e\n\u003cp\u003eThis paper is part of the author’s dissertation as a requirement for the degree Doctor of Philosophy major in Clinical Psychology from De La Salle University-Manila, Philippines. Ethical approval was granted by the panel who reviewed and approved the author’s paper.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any agency in the public, commercial, or non-profit sector.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe data and materials that support the findings of this study are available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003eAuthors contribution\u003c/p\u003e\n\u003cp\u003ePDB is the sole author of this paper and takes sole responsibility got the conception of study, presented results, and preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003eConflict of Interest Statement\u003c/p\u003e\n\u003cp\u003eThe author declares that there is no personal, professional, or financial interests that could potentially compromise the objectivity or integrity of the research findings.\u003c/p\u003e\n\u003cp\u003eDual Publication\u003c/p\u003e\n\u003cp\u003eThe data, results, and figures used in this research have not been previously published, or are under consideration for publication elsewhere\u003c/p\u003e\n\u003cp\u003eData Availability Statement\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author, PDB. \u003c/p\u003e\n\u003cp\u003eConsent to Participate\u003c/p\u003e\n\u003cp\u003eThe author assures that the individuals involved in this study have given consent both verbal and written forms. This includes the verbalizations, the analysis of video recordings, experiences during the intervention, and other information relevant to the results of the study). \u003c/p\u003e\n\u003cp\u003eConsent to Publish\u003c/p\u003e\n\u003cp\u003eAll parties consented to have the collected data from the author’s dissertation to be included or used for publication.\u003c/p\u003e\n\u003cp\u003eClinical Trial Number: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential competing interest was reported by the author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAxline, V. (1950). 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A descriptive analysis of the process of play therapy (Doctoral dissertation, North Texas State University, Denton). \u003cem\u003eDissertation Abstracts International, 36,\u003c/em\u003e 6406B. \u003c/li\u003e\n\u003cli\u003eWorld Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. \u003cem\u003eJAMA\u003c/em\u003e, \u003cem\u003e310\u003c/em\u003e(20), 2191\u0026ndash;2194. https://doi.org/10.1001/jama.2013.281053\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Child-Centered Play Therapy, externalizing problem behaviors, therapeutic relationship, therapeutic skills, Filipinos, children","lastPublishedDoi":"10.21203/rs.3.rs-6630345/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6630345/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn Child-Centered Play Therapy (CCPT), it is the therapeutic relationship that has been emphasized as the driver of behavioral change. Underlying such a relationship is the administration of therapeutic skills. Hence, the study examined underlying processes of CCPT, particularly the use of therapeutic skills in building the therapeutic relationship in CCPT for 23 school-aged boys who present with externalizing problem behaviors. Raters who were experienced in providing CCPT examined recorded sessions, focusing on the play psychologists\u0026rsquo; use of therapeutic skills. Across 8 sessions, separate Friedman tests with Wilcoxon signed rank test as post hoc analyses revealed significant differences in the usage of tracking, reflecting feelings, reflecting content and limit setting. This indicates a dynamic nature of using such skills across different sessions in short-term CCPT. A methodical use of therapeutic skills develops empathy, which facilitates the building the therapeutic relationship, eliciting reduction of externalizing problem behaviors in school-aged Filipino children.\u003c/p\u003e","manuscriptTitle":"Therapeutic skills in CCPT for school-aged Filipino boys with externalizing problem behaviors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 09:46:06","doi":"10.21203/rs.3.rs-6630345/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9fce9cff-111c-41d1-a1d3-654c2c535346","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T05:09:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 09:46:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6630345","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6630345","identity":"rs-6630345","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}