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Person-Centered & Experiential

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Contact work in child-centered play

therapy: a case study
a b
Karrie L. Swan & April A. Schottelkorb
a
Department of Special Education, Counseling, and Student
Affairs, Kansas State University, Manhattan, KS, USA
b
Department of Counseling, Boise State University, Boise, ID, USA
Published online: 27 Nov 2014.

To cite this article: Karrie L. Swan & April A. Schottelkorb (2014): Contact work in child-
centered play therapy: a case study, Person-Centered & Experiential Psychotherapies, DOI:
10.1080/14779757.2014.976798

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 Person-Centered & Experiential Psychotherapies, 2014
http://dx.doi.org/10.1080/14779757.2014.976798

Contact work in child-centered play therapy: a case study

Karrie L. Swana* and April A. Schottelkorbb
a
Department of Special Education, Counseling, and Student Affairs, Kansas State University,
Manhattan, KS, USA; bDepartment of Counseling, Boise State University, Boise, ID, USA
Downloaded by [World Association for Person-Centered ] at 09:11 28 November 2014

(Received 1 October 2013; final version received 11 October 2014)

In this study, a case study approach (N = 1) was employed to investigate the process of
change in child-centered play therapy for a child with an intellectual disability. A task
analytic method was used to assess the effects of therapist use of contact reflections on
reparation of contact for the client. Process and outcome measures were used to
differentiate treatment processes and outcome. Results indicated that the client’s use
of contact behaviors and exhibition of behavioral problems were affected by contact
work in child-centered play therapy. Possible implications and future research are
discussed.
Keywords: play therapy; psychological contact; intellectual disability; Pre-Therapy

Travail de contact dans la thérapie par le jeu centrée sur l’enfant : une
étude de cas
Dans cette recherche, une méthode d’étude de cas (N = 1) a été employée pour
investiguer le processus de changement dans la thérapie par le jeu centrée sur l’enfant
avec un enfant présentant une altération du contact. Une procédure d’analyse des
tâches a été utilisée pour évaluer les effets de l’utilisation des réflexions de contact
du thérapeute sur la restauration du contact chez le client. Des mesures de processus et
de résultats ont été utilisées pour différencier processus et effets du traitement. Les
résultats obtenus montrent que la manifestation des comportements de contact et
l’expression des problèmes de comportements présentés par le client ont été
influencées par le travail du contact dans la thérapie par le jeu centrée sur l’enfant.
Les implications possibles de ces résultats ainsi que des ouvertures pour des recherches
futures sont discutées.

Trabajo de contacto en terapia de juego centrada en el niño: caso de

estudio
En este estudio, se utilizo un enfoque de caso de estudio (N = 10) para investigar el
proceso de cambio en la terapia de juego centrada en el niño con un niño que exhibía
un dificultad de contacto. Se utilizo un método analítico de tarea para evaluar los
efectos del uso de reflejos de contacto para reparar el contacto con el consultante. Las
mediciones de proceso y resultado se utilizaron para diferenciar procesos de trata-
miento y resultado. Los resultados indicaron que el uso que hizo el consultante de los
comportamientos de contacto y la exhibición de problemas de comportamiento fueron
afectados por trabajo de contacto en terapia de juego centrada en el niño. Discutimos
posibles implicaciones y futuras investigaciones.

*Corresponding author. Email: [email protected]

© 2014 World Association for Person-Centered & Experiential Psychotherapy & Counseling
 2 K.L. Swan and A.A. Schottelkorb

Kontaktarbeit in der kindzentrierten Spieltherapie: eine Fallstudie

Diese Forschungsarbeit wählte den Ansatz einer Fallstudie (N = 1), um den
Veränderungsprozess in einer kindzentrierten Spieltherapie zu untersuchen. Es handelte
sich um ein Kind, das an einer Kontaktbeeinträchtigung litt. Mit einer aufgaben-
analytischen Methode wurde untersucht, welche Wirkungen es hat, wenn die
Therapeutperson den Kontakt reflektiert und ob sich damit das Kontaktverhalten bei
der Klientperson positiv verändert. Prozess- und Outcome-Messungen wurden verwen-
det, um die Behandlungsprozesse und den Outcome differenziert zu erfassen. Die
Ergebnisse legen nahe: Die Kontaktarbeit in der kindzentrierten Spieltherapie beein-
flusst die Klientperson im Gebrauch von verschiedenen Kontaktverhaltensweisen und
darin, wie Verhaltensprobleme auftreten. Mögliche Implikationen und zukünftige
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Forschungsansätze werden diskutiert.

Trabalho de Contacto na Ludoterapia Centrada na Criança: um estudo

de caso
Neste estudo, recorreu-se à metodologia de estudo de caso (N = 1) para investigar o
processo de mudança numa ludoterapia centrada na criança realizada com uma criança
que manifestava uma perturbação ao nível do estabelecimento do contacto psicológico.
Recorreu-se a um método analítico da tarefa para avaliar os efeitos do uso das
reformulações de contacto por parte do terapeuta, como forma de reparar o contacto
psicológico do cliente. Foram usadas medidas relativas ao processo e ao resultado para
diferenciar os processos e resultados do tratamento. Os resultados indicam que o
trabalho relacional realizado através da ludoterapia centrada na criança, afetou o
contacto psicológico do cliente e os seus comportamentos problemáticos. São discu-
tidas possíveis implicações e investigação futura.

Introduction
Experts have expressed concern that service providers in the United States are failing to
adequately meet the mental health needs of children with disabilities (United States Public
Health Service, 2001). Many children with intellectual disabilities have a heightened risk
for mental health disorders (Dekker, Koot, Ende, & Verhulst, 2002; Einfeld & Tonge,
1996; Linna et al., 1999). Studies suggest that children between the ages of 4 and 18
designated as having an intellectual handicap are 30–60% more likely than their non-
disabled peers to exhibit symptoms of psychopathology (Einfeld & Tonge, 1996; Holden
& Gitlesen, 2006; Ruiter, Dekker, Verhulst, & Koot, 2007). Linna et al. (1999) investi-
gated emotional and behavioral disturbances among a randomized sample of 5804 8-year-
old children in rural, suburban, and urban regions of Finland. Researchers collected data
about psychiatric and depressive symptoms using parent and teacher reports. Results from
parent and teacher reports indicate that children with intellectual disabilities are three
times more likely to exhibit emotional and behavioral disorders in comparison to non-
disabled children.
Similarly, Dekker et al. (2002) examined prevalence differences of emotional and
behavioral problems between children with and without mental disabilities. When the
investigators gathered teacher and parent reports on 3000 children, they found that
compared to non-disabled children, individuals with IQ scores between 60 and 80 had
greater mean averages on internalizing and externalizing subscales of the Child Behavior
Checklist. The results of the study suggest that children with mental disabilities demon-
strate more internalizing and externalizing behaviors as compared to children without an
intellectual disability.
 Person-Centered & Experiential Psychotherapies 3

An abundance of literature demonstrates that children with an intellectual disability

often manifest symptoms of a mental health disorder through externalized behavioral
problems (Bradley, Summers, Wood, & Bryson, 2004; Einfeld & Tonge, 1996; Holden &
Gitlesen, 2006). Problem behavior among children with an intellectual disability is
characterized by rigid, stereotypic, aggressive, destructive, withdrawing, and self-injurious
behavior (Emerson, Moss, & Kiernan, 1999; Hove & Havik, 2008; Myrbakk & Tetzchner,
2008). Emerson et al. (1999) further conceptualized problem behavior as external func-
tioning “of such intensity, frequency, or duration that the physical safety of the person or
others is placed in serious jeopardy, or behavior which seriously limits the person’s access
to ordinary settings, activities, services, and experiences” (p. 38).
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Beyond examining internalizing and externalizing problems for children with an

intellectual disability, Murphy et al. (2005) speculated that a contact impairment, which
encompasses a lack of social skills, poor communication skills, and stereotyped behavior
could be related to challenging behavior. In their investigation of 141 children aged 2–18,
Murphy et al. (2005) found that behavioral problems decrease as advances are made in
one’s ability to communicate, socialize, and increase awareness of self and the environ-
ment. Therefore, the authors concluded that interventions should target children’s aware-
ness, communication, and social skills. Because contact work in person-centered therapy
tends to advance one’s awareness of their environment and sense of self, (Peters, 2005;
Prouty, 2001), the present authors speculated that contact work in child-centered play
therapy would help increase communication and relational skills and decrease problematic
behaviors for children with an intellectual disability

Theoretical background
Person-centered therapy
According to Cooper, O’Hara, Schmid and Wyatt (2007), person-centered therapy
(PCT) is considered to be one of the leading approaches to therapy. Drawing on
principles inherent to attachment, PCT relies on the therapists’ use of self and an
array of relational conditions to form a treatment alliance and impact change. PCT
integrates experiential and focusing-oriented approaches and is founded on the belief
that people move toward growth and increased self-understanding through a facilita-
tive climate comprised of specific affirming conditions. Paramount to the development
of this growth-producing relationship, Rogers (1957) held that specific conditions
were requisite to the heart of change in the therapeutic process. Specifically, Rogers
emphasized that (a) the client and therapist engage in psychological contact, (b) the
client demonstrates incongruence (c) the therapist demonstrates congruence, (d) the
therapist experiences unconditional positive regard for the client, (e) the therapist
experiences and communicates empathy to the client, and (f) the client receives the
therapist’s use of empathy and unconditional positive regard. Rogers (1957) further
explained that psychological contact, which is defined as the ability to impact another
and possess awareness of such contact, is fundamental to the formation of the
therapeutic relationship. Thus, in the realm of PCT, one exhibits an ability to maintain
psychological contact by exhibiting awareness of self and others, demonstrating
relational interactions, and communicating verbally and non-verbally. According to
Rogers and Prouty (2001), an absence of the aforementioned characteristics is referred
to as a contact impairment, and impaired contact between client-therapist dyads poses
threats to the relationship and obtrudes the five proceeding conditions.
 4 K.L. Swan and A.A. Schottelkorb

Pre-Therapy
Garry Prouty was instrumental in expanding the theoretical notion of psychological
contact in his experiential model that was designated as Pre-Therapy. According to
Prouty (2001), Pre-Therapy represents the practice of psychological contact between
client and therapist and is comprised of therapist use of contact reflections and client
exhibition of contact behaviors. Contact reflections represent concrete, reality-based
reflections that hone in on environmental stimuli, client affect, words, speech patterns,
and bodily movements. This is implemented through the use of five types of contact
reflections: situational, facial, word-for-word, body, and reiterative (Prouty).
Situational reflections are used to mirror one’s awareness of the environment, whereas
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facial reflections are used to echo the client’s expression of affect. Word-for-word
reflections and reiterative reflections are used to emulate the client’s verbalizations,
and body reflections are used to draw awareness to the client’s use of his or her body
in the moment.
In establishing Pre-Therapy, Prouty (2001), Prouty, Van Werde, and Portner (1998),
DeVre (1992), Peters (2005) explained that therapist use of contact reflections increases
the client’s consciousness of the self and world, and enhances communication and
interaction with others. Through this process, Prouty ascertained that contact-impaired
clients would increase awareness of people, places, and things (reality contact), increase
non-verbal and verbal communication (communicative contact), and increase awareness
of emotional states (affective contact). For some client populations, including individuals
diagnosed with disabilities, schizophrenia, or dementia, Pre-Therapy establishes affective
and empathic attunement and fosters one’s innate forward-moving capabilities (Peters,
1999). Research on use of Pre-Therapy indicates that individuals with a range of diffi-
culties have benefited from contact work (Brooks & Paterson, 2011; Prouty, 2001; Prouty
et al., 1998). Specifically, studies suggest Pre-Therapy improves social interaction and
engagement (Brooks & Paterson, 2011), increases reality contact, complex imitative play
behavior (Brooks & Paterson, 2011; Whiten & Brown, 1998), and communicative contact
(Dinacci, 2001; Prouty, 2001).

Theoretical foundation of play

According to Piaget, a pioneer theorist on the role of play in child development, higher
order cognitive development is formed through three primary stages of play: functional
play, constructive play, and symbolic play (Wadsworth, 1989). Through the first year of
life, children engage in functional play characterized by the absence of goal-directed
actions, pretense, or symbolism (Wadsworth). Children’s engagement in functional play
thereby represents control over objects and the pleasure of being in control (Schaefer,
1993). Between the ages of 15 and 24 months, children perform constructive play by
combining sensorimotor actions and grouping objects together. Children also begin to
create artifacts.
By the second year of life, children begin to mentally represent their worlds through
symbolic play (Schaefer, 1993). During this stage of development, children utilize their
cognitive capacity to assimilate their experiences and engage in make-believe or pretend
play (Schafer). Through this assimilative process on which child-centered play therapy is
based, children are able to mentally manipulate their experiences, thoughts, and feelings
for meeting their needs and desires (Landreth, 2012; Schaefer, 1993; Wilson & Ryan,
2005).
 Person-Centered & Experiential Psychotherapies 5

Child-centered play therapy

Virginia Axline, a mentee of Carl Rogers, expanded the application of PCT to children by
developing nondirective play therapy, which is known as child-centered play therapy
(CCPT). Axline (1969) considered children’s stages of development in formulating the
tenets of CCPT. Because children’s acquisition of language skills develops more slowly in
regards to their cognitive skills, play is considered to be the process in which children
communicate (Axline, 1969; Landreth, 2012). According to Garry Landreth, child-
centered play therapy is a:

dynamic interpersonal relationship between a child (or person of any age) and a therapist
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trained in play therapy procedures who provides selected play materials and facilitates the
development of a safe relationship for the child (or person of any age) to fully express and
explore self (feelings, thoughts, experiences, and behaviors) through play, the child’s natural
medium of communication, for optimal growth and development. (p. 16).

Thus, the primary goal in CCPT is to provide a therapeutic environment so children feel
heard, understood, and accepted (Axline, 1969; Landreth, 2012). As a result of this creative
expression and facilitative relationship, children develop control and mastery over their world
and experiences and learn to rely on their own internal locus of evaluation.
With the establishment of the CCPT treatment manual (Ray, 2011), much research has
been conducted on the effectiveness of CCPT with a variety of populations. Empirical
research has shown that CCPT has the potential to improve problem-solving skills, social
skills, and language development (Bratton et al., 2013; Danger & Landreth, 2005),
academic achievement (Blanco & Ray, 2011; Blanco, Ray, & Holliman, 2012), ADHD
symptoms (Ray, Schottelkorb, & Tsai, 2007; Schottelkorb & Ray, 2009), and behavioral
problems (Bratton et al., 2013; Garza & Bratton, 2005; Ray, Blanco, Sullivan, &
Holliman, 2009; Schumann, 2010; Swan & Ray, 2014).
To better understand the overall treatment effectiveness of play therapy, Bratton, Ray,
Rhine and Jones (2005) reviewed results from 93 play therapy outcome studies published
from 1953–2000. In their meta-analysis, Bratton et al. found a large effect size (.80) for
play therapy treatments. In examining outcome differences between humanistic and non-
humanistic approaches to play therapy, Bratton et al. revealed that the mean effect size
for humanistic treatments was significantly higher than non-humanistic interventions
(p < . 03). Further, they detected a large effect size (.90) for studies involving develop-
mental-adaptive outcome measures.

Contact work in child-centered play therapy

Contact work in CCPT has not been explicitly developed; however, there are theoretical
and practical elements inherent to CCPT that implicitly form such a foundation.
Particularly, a core component of CCPT is attunement, which is defined by a therapist’s
ability to congruently match a child’s internal dialogue, emotional world, and self-in-
environment. Siegel (2011) explained that attunement is the way “we connect deeply with
another person and allow them to feel felt” (p. 481). To exemplify such an attuned way of
being, child-centered play therapists use a variety of therapeutic verbal responses includ-
ing reflection of feeling, reflection of content, tracking, and esteem building (Ray, 2011).
As a result of reflecting upon moment-to-moment responses, Siegel explained that con-
nection and contact increases, attachment relationships strengthen, and emotional respon-
siveness is enhanced (Siegel).
 6 K.L. Swan and A.A. Schottelkorb

Table 1. Contact work in CCPT and examples.

Verbal responses Contact reflection Example

Tracking Situational, body “You’re pouring that out.”

Reflection of feeling Reflecting facial response “You’re happy, you are smiling.”
Reflection of content Word-for-word, reiterative “Jump” – verbally or physical mirror
Esteem building Situational, facial response, “You did that by yourself.”
and reflection of feelings
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For the purpose of this study, the following framework was drawn from the literature
to conceptually depict contact work in CCPT (see Table 1). As depicted in the model,
contact work in CCPT includes tracking, reflection of feeling, reflection of content, and
esteem building. Tracking responses, which consist of situational and body reflections are
primarily used to reflect the child’s behavior. Reflection of feelings includes mirroring
verbal and nonverbal affect that is stated or exhibited by the child. Reflection of content is
used to echo the child’s verbalizations and includes word-for-word reflections and reitera-
tive reflections. Moreover, esteem-building reflections are used to acknowledge a child’s
intrinsic worth and may include verbal responses that mirror a child’s affect and effort in
completing tasks.

The present study

Empirical evidence demonstrates CCPT is an effective approach for children with a range
of emotional, behavioral, and developmental difficulties, however, an investigation into
the use of contact work in CCPT for children with an intellectual disability has not been
conducted. Thus, in this study, the researchers utilized a case study method to investigate
the impact of the process and outcome of contact work in CCPT with a child identified
with clinical levels of hyperactivity and irritability, as rated by a parent or teacher. We
hypothesized that the model of contact work in CCPT would produce growth toward
contact reparation as captured by increased use of contact behaviors. We further hypothe-
sized that the client’s irritability and hyperactivity behaviors would decrease across
treatment.

Method
A case study research design was used to examine the contact impairment resolution
process that emanated between a child and therapist in CCPT. Each session was construed
based on Greenberg’s (2007) case study method, whereby client and therapist relational
responses are analyzed during the play therapy process. According to Pascual-Leone,
Greenberg, and Pascual-Leone (2009), case study interpretation involves two stages:
discovery and verification. In the discovery stage, a clinical observation (contact impair-
ment) and treatment environment (CCPT) is identified and fully described. Next, a model
of change is constructed and in-treatment performances are defined. Proceeding from the
discovery stage, one moves to the validation stage, whereby one’s in-treatment behaviors
are compared with the model and finally, treatment processes are related to identified
outcomes.
To examine the effect of contact work in CCPT on behavioral outcomes, we examined
changes in the child’s behaviors across the relationship-building phase (A; sessions 1–3),
 Person-Centered & Experiential Psychotherapies 7

working phase (B; sessions 4–12), and termination phase (C; sessions 13–15. We utilized
visual analysis, the primary method for assessing single case effectiveness data to examine
changes in the level, trend, and variability within and across phases of CCPT. Similarly,
we employed visual analysis to examine contact reflections and contact behaviors across
each phase of CCPT.

Procedures and ethical considerations

Prior to beginning the present study, approval to conduct research was attained from a
university Institutional Review Board. Participants were recruited from an elementary
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school in the Southwest United States. Parents and guardians of children in a self-
contained special education classroom received a letter inviting their children to partici-
pate in this play therapy research. The first author met with interested parents/guardians
and reviewed consents, purpose and eligibility requirements, and information regarding
permission to participate, including consent to videotape each play therapy session. The
following criteria were noted as eligibility requirements: (a) educational placement in a
self-contained classroom, (b) borderline or clinical scores on at least one behavioral
subscale of the Aberrant Behavior Checklist (ABC; Aman, Singh, Stewart, & Field,
1985) as rated by the teacher or parent/guardian, and (c) formal diagnosis of intellectual
disability from school records, and (d) presence of a contact impairment as identified by a
severe speech impairment. In this study, 1 participant qualified for participation based
upon borderline scores on the Irritability and Hyperactivity subscale of the ABC. The
participant’s name was changed to protect his confidentiality.
Additionally, to collect observational data from two sources, the child’s classroom
teacher and aide were invited to participate in the study. The first author trained observers
to administer the ABC. In complying with specified procedures in the manual (Aman
et al., 1985), observers received a description of measured behaviors and scale
demarcation.

The client
The client, referred to as “Andrew” for the purpose of this study, was 7 years old, male,
and enrolled as a first-grader. He was Mexican-American, met diagnostic requirements for
an intellectual disability (ID) and was placed in a self-contained classroom environment.
Data from the Vineland Adaptive Behavior Scale (Sparrow, Cicchetti, & Balla, 2005) and
DSM-IV-TR (American Psychiatric Association, 2000) indicated the presence of a mod-
erate intellectual disability. Results from the Picture Vocabulary Test, third edition
([PPVT-3], Dunn & Dunn, 1997) showed he had a severe speech impediment. Andrew
received speech therapy services and adaptive physical education services as part of his
Individual Education Plan (IEP). In addition, Andrew’s teacher and biological mother
rated his behavior in the clinical range on hyperactivity and irritability subscales of
the ABC.

The therapist
The first author was the play therapist in the present study. At the time of the study, the
play therapist was a doctoral student in counselor education, had completed 5 courses in
play therapy instruction and supervision, possessed a teaching certificate in special
education and a professional counseling license.
 8 K.L. Swan and A.A. Schottelkorb

Treatment
CCPT is a developmentally appropriate treatment modality for working with children. The
primary goal in CCPT is to provide a therapeutic environment so children feel heard,
understood, and accepted (Axline, 1969; Landreth, 2012). As a result of experiencing a
unique and accepting relationship, children access their own inner resources and ulti-
mately increase independence, problem-solving skills, and social skills (Landreth, 2012;
Rogers, 1957). During the course of this study, the therapist facilitated child-centered play
therapy three days per week for 30 minutes across the relationship-building phase (A;
sessions 1–3), working phase (B; sessions 4–12), and termination phase (C; sessions 13–
15). The therapist adhered to the treatment protocol and completed a treatment concep-
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tualization specific to play therapy at the end of each play session (Ray, 2011).
Additionally, a separate and private playroom was created in a portable building on school
campus grounds. The playroom space was created in accordance with Landreth’s (2012)
recommendations and included the following play materials: real-life toys, acting out and
aggressive toys, and creative expression materials. The progression of the use of contact
work in CCPT is as follows.

Relationship phase
This phase accounts for the development of the therapy relationship, wherein the therapist
provides a permissive and accepting environment and uses tracking responses, reflection
of feeling, and reflection of content. The client demonstrates difficulty in connecting and
maintaining contact with the world and self, and the child’s play behaviors are unfocused,
lack pretense, or function (Baron-Cohen, 1987; Lewis & Boucher, 1988).

Working phase
During the working phase, the play therapist works to bring about the client’s contact with
self, world, and others through use of therapeutic reflections. The child’s exhibition of
contact behaviors increase and the child’s play becomes functional and/or constructive
(Thorp, Stahmer, & Schreibman, 1995).

Termination phase
Child’s contact with self, others, and the world is restored and the child’s play behaviors
remain functional and/or constructive. Symbolic play behaviors may begin to emerge
(Kasari, Freeman, & Paparella, 2006).

Treatment integrity
As a measure of appraising treatment integrity, all play therapy sessions were recorded
and an independent reviewer used the Play Therapy Skills Checklist (PTSC; Ray et al.,
2009) to review 10% of all play therapy recordings. During the course of this study, the
reviewer was an advanced play therapist working toward a doctoral degree in counselor
education. The following verbal and non-verbal responses were appraised: (a) appearing
interested in the child, (b) using tone congruent with child’s affect, (c) appearing relaxed,
(d) demonstrating appropriate forward-leaning posture, (e) tracking behavior, (f) reflecting
content and feeling, (g) facilitating responsibility, and (h) enlarging the meaning of play.
 Person-Centered & Experiential Psychotherapies 9

Percent agreement for CCPT verbal responses was 99%, indicating treatment fidelity was
optimal. Caution is warranted in interpreting results of this integrity appraisal because to
date, the PTSC has no established reliability or validity.

Measures
Process measures
Play therapy sessions were videotaped and transcribed to facilitate coding of therapist use
of contact reflections and client use of contact behaviors. The measurement tools devel-
oped for this study were based on the work of Landreth (2012), Prouty (2001) and Brooks
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and Paterson (2011). In order to code contact reflections specific to CCPT, we decided to
collapse contact reflections under the following primary reflections used in CCPT: track-
ing, reflection of feeling, esteem building, and reflection of content. Tables 1 and 2 depict
the framework for contact reflections and contact behaviors that were specifically
designed for this study. At the conclusion of this study, play sessions were transcribed
and two graduate students rated the therapist’s use of contact reflections and the client’s
exhibition of contact behaviors. At the time of this study, both raters were working
towards completing their master’s degree in counseling and had completed one semester
of internship. To assess the agreement among raters in this study, we calculated a Cohen
kappa for scores on contact reflections and contact behaviors, yielding a kappa of 0.80,
and a kappa of .81 respectively. Scores suggest that there was substantial agreement
between the raters on appraising contact reflections and contact behaviors.

Outcome measures
Aberrant behavior checklist (ABC)
The ABC is a 58-item checklist designed to evaluate informant’s perceptions of proble-
matic behaviors exhibited by children with disabilities. The ABC is considered one of the
best instruments for evaluating treatment interventions for children with disabilities, is
sensitive to slight changes in children’s behaviors, and can be completed by teachers,
parents, or caregivers. The ABC has five subscales, each related to behaviors common to
children with disabilities: irritability, lethargy, stereotypy, hyperactivity, and inappropriate
problem behaviors. Completing the checklist requires informants to rate participant’s
behaviors on a scale of 0 (indicating no problem) to 3 (severe problem). Studies indicate
internal-consistency reliability for the five subscales is between .86 and .95, and test-retest
reliability falls within .96 and .99 (Aman et al., 1985). Overall, results examining validity

Table 2. Examples of contact behaviors.

Contact behavior Example

Reality (awareness of Child plays in a functional or constructive manner; sifts sand,

environment/others) looks in mirror, observes the therapist, responds to the therapist.
Affective (awareness of self) Child reflects feelings, demonstrates feelings, responds to the
therapist.
Interactive (relational) Child verbally/non-verbally motions for therapist to engage in
play.
Communicative Child looks at the therapist, talks or makes non-verbal motion
(non-verbal/verbal)
 10 K.L. Swan and A.A. Schottelkorb

of the ABC suggests there is well-established content and concurrent validity

(Karabekiroglu & Aman, 2009).
In this study, the teacher and classroom aide used the ABC to rate the child’s
behaviors during school hours on three alternate days per week for 5 weeks. Observers’
scores on the hyperactivity and irritability subscales were combined to produce a mean
score for each observation. Scores on the lethargy, stereotypy, and inappropriate problem
behaviors fell in the normal range, therefore data from those subscales were not examined.

Data analysis
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Using visual analysis, we examined changes in level (mean), trend (slope), and variability
(difference between trend and each data point) for hyperactivity and irritability variables
within and across the relationship phase, working phase, and termination phase.
Specifically, we compared the level, trend, and variability across the relationship phase
(Phase A) working phase sessions 4–11 (Phase B), and termination phase (Phase C;
sessions 12–14). In a similar fashion, we performed a visual analysis of contact behaviors
and contact reflections to assess relationships between therapeutic processes and client
responses. Accompanying this analysis, we reviewed the therapist’s treatment notes for
analyzing emergent play themes, play behaviors, interactive responses, and affective
changes.

Results
Outcome measures
Visual analyses for ratings of Andrew’s hyperactivity and irritability behaviors show
substantial improvement (see Figure 1). As indicated across all phases, visual analysis
shows Andrew demonstrated decreased mean levels of hyperactivity behaviors from the
relationship-building phase (53.6) to the termination phase (47.6). Further, the data for
hyperactivity behaviors suggest a decreasing trend and low levels of variability across
treatment. Andrew’s exhibition of irritability behaviors across phases of CCPT showed

Figure 1. Andrew’s hyperactivity and irritability behaviors across phases of CCPT.

 Person-Centered & Experiential Psychotherapies 11

similar patterning. Specifically, visual analysis illustrates decreased mean levels and
decreasing trends for irritability behaviors from the relationship-building phase (Phase
A; 52) to termination (Phase C; 45). Analysis further revealed moderate levels of
variability within and across phases of CCPT.

Process measures
To further identify patterns between therapist’s use of contact reflections and the client’s
exhibition of contact behaviors, we examined data collected from raters’ appraisement of
in-session behaviors. Visual analyses for contact behaviors and contact reflections across
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all phases of the study are presented in Figure 2. Visual analysis depicts increased mean
levels and accelerating trends for therapist use of reflection of feeling and esteem building,

Figure 2. Contact reflections and contact behaviors across phases of CCPT.

 12 K.L. Swan and A.A. Schottelkorb

indicating that as the relationship progressed, the therapist demonstrated increased use of
reflection of feeling and esteem building responses. Analysis further demonstrated mod-
erate levels of variability for both therapeutic processes. Examination of tracking
responses reveals a decrease in the level and a slight downward trend across CCPT
phases, suggesting that the therapist’s use of tracking decreased across time.
Analysis of Andrew’s exhibition of contact behaviors revealed moderately
increased trends and accelerating levels for affective and interactive behaviors, indi-
cating that Andrew began to exhibit an interest in the relationship and showed
increases in affect across phases of CCPT. Visual inspection of reality behaviors
further shows a marginally increased level and trend, and moderate variability across
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phases of CCPT, suggesting that Andrew’s play behaviors and awareness of his
environment remained fairly stable through CCPT. Further examination of commu-
nicative behaviors shows low variability, and slightly increased trend and level,
indicating that his communication improved slightly.

Play behaviors
In this study, the therapist used Ray’s (2011) treatment form to identify play themes,
use of reflections, and progress in session. During the relationship-building phase of
CCPT, the therapist noted that Andrew’s play behaviors were characterized by the
absence of goal-directed actions, pretense, or symbolism. The therapist’s notes
revealed that Andrew often displayed an interest in observing himself in the mirror
and engaged in simple cause-effect motor movements. Analysis of treatment during
the working phase revealed that Andrew began to engage in functional play as
exhibited by pouring sand into containers, and rolling cars around a track. During
the termination phase, Andrew continued to demonstrate functional play behaviors,
and during two sessions, he engaged in constructive play; creating pictures with paint,
crayons, and glitter.

Qualitative evidence
Following collection of the data, Andrew’s teacher, classroom aide, and mother were
asked if they thought play therapy was effective for reducing problem behaviors and
they were asked to describe noted changes. Andrew’s teacher and aide reported that he
followed directions better and was more willing to cooperate with students and staff
members. They also stated that Andrew was calm and happy after each play session.
The follow-up interview with Andrew’s mother revealed that she thought Andrew
seemed more independent and self-controlled as a result of participating in play
therapy. Andrew’s mother reported that she thought play therapy was helpful and
indicated wanting to learn CCPT-based strategies for assisting her son with his
problem behaviors at home.

Confounding factors
Moderator variable
In assessing characteristics of the client that may have affected the process of therapy, we
hypothesize that Andrew’s severe speech impairment may have affected his communica-
tive contact and consequently the therapist’s use of contact reflections.
 Person-Centered & Experiential Psychotherapies 13

Mediator variable
In analyzing therapeutic processes that appear to have been particularly helpful to the
client, we hypothesize that the therapist’s training in special education may have served as
a mediator variable. During the course of the study, Andrew ran throughout the school
building and playground on his way to the playroom and often sat in the middle of the
hallway on his way back to the classroom. During these instances, the therapist used
pictures for communicating with Andrew. For example, the therapist used a 2 × 2 picture
of a computer to explain to Andrew that he could play on the computer if he walked back
to his classroom. The use of combining words with symbols seemed to help Andrew and
we speculate that the therapist’s training in special education served as a mediator
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variable.

Discussion
We conducted this case study to examine components of contact work in CCPT that affect
contact behaviors and behavioral changes. This study raises questions regarding the
intervening process between contact reflections and contact behaviors and illuminates
the saliency of tracking, reflection of feeling, and esteem building. Analysis of in-session
contact behaviors revealed that reality, affective, and interactive behaviors were displayed
with greater frequency across phases as compared to communicative contact. This case
also highlighted that the therapist’s use of tracking was most prevalent during the
relationship phase and decreased during the working phase and termination phase of
CCPT. We speculate that as the relationship progressed between the client and therapist,
the therapist began to use tracking with decreased frequency and began to use meaningful
reflections that include esteem-building, reflection of content, and reflection of feeling.
We further hypothesize that as Andrew gained awareness of self and his environment,
play behaviors became organized and as a result, the therapist began to increase her use of
esteem-building responses and reflection of feeling. Additionally, we speculate that
therapist-client attunement was enhanced through esteem building and reflection of
feeling responses and consequently, Andrew’s sense of “feeling felt” was displayed
through increased levels of contact behaviors (Siegel, 2011, p. 481).
Regarding results of the outcome measure, Andrew’s exhibition of hyperactivity and
irritability behaviors decreased significantly and steadily from the relationship-building
phase to termination, suggesting that Andrew exhibited changes over the course of
therapy. The evidence seems to support the possibility that Andrew’s increasing use of
contact behaviors resulted from the use of contact work in CCPT. However, there is a
need to further explore how mediator and moderator variables influence the process of
contact work in CCPT and the mechanisms of change, particularly as related to the client’s
degree of impairment as well as the therapist’s level of training in working with children
with disabilities.
In CCPT, psychological contact is fundamental to establishing a therapeutic alliance,
and for clients with contact impairments, the process of contact work in CCPT may
facilitate client growth. The improvements in Andrew’s behaviors seem to suggest that he
benefited from the model of contact work used in this study. Surprisingly, we found that
Andrew’s play behaviors shifted from being disorganized and lacking pretense to becom-
ing functional, constructive, and organized. Considering play is a child’s natural vehicle
for communication, we conclude that the changes in Andrew’s play behaviors are an
expression of his increased contact with himself, his environment, and others.
 14 K.L. Swan and A.A. Schottelkorb

An additional explanation for changes in Andrew’s behaviors across conditions is

related to effect of teacher expectancy on the teacher-child relationship. Given that the
classroom teacher and aide had knowledge of the intervention, it is plausible that
expectancy of change affected the teacher-child relationship as well as their perception
of Andrew’s behaviors, consequently, influencing their ratings on the ABC.

Limitations and recommendations for future research

A limitation of the present study is the potential influence of the first author as both the
therapist and researcher. Although the first author was not part of collecting the data, the
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first author was involved in critically analyzing the data; therefore it is plausible that the
report contains inadvertent bias. We hope that the use of independent raters who were
unaware of the therapist’s identity has militated against any potential bias. Another
limitation of this study is in reference to the long-term effects of contact work in CCPT.
We did not continue to collect data after therapy was concluded, therefore there is no
evidence to support whether the client maintained improvements or if behaviors worsened
once the child did not have contact with the therapist. Future researchers are encouraged
to collect longitudinal data regarding the effect of contact work in CCPT on child
behaviors over a specified period of time.
In interpreting case study research, readers are cautioned about generalizing the
applicability of findings (Kazdin, 1982). From a clinical perspective, improvements in
Andrew’s behaviors are encouraging, however, an experimental design is necessary for
confirming treatment effects. Thus, researchers are encouraged to conduct a single case
design with the inclusion of an experimental and control phase. In addition, contact work
in CCPT has not been investigated; therefore researchers are encouraged to further
examine the practicality and efficacy of this particular model.
An additional limitation and implication for future research is the utilization of
multiple instruments. The ABC, a behavioral rating assessment, was the only method
for analyzing outcome data; therefore multiple sources of data could have strengthened
the results. Further, because play therapy is a holistic intervention, multiple informants
and self-assessments should be involved in assessing the utility of particular treatment
conditions (Shirk & Karver, 2003). Additionally, both observers that used the ABC to rate
the participant’s behavior had knowledge that the client was receiving CCPT; therefore
their ratings may have been biased. Researchers are encouraged to include independent
observers that are blind to treatment and control groups.

Conclusion
In CCPT, psychological contact is fundamental to establishing a therapeutic alliance, and for
clients with contact impairments, contact work in CCPT may facilitate client growth.
Although generalizations cannot be drawn from this study, preliminary evidence indicates
that contact-impaired children may benefit from contact work in CCPT. The findings of this
study further highlight the need for researchers to study how relational conditions, including
contact work impact attunement and client growth and change (Prouty, 2001; Wyatt, 2007).

References
Aman, M. G., Singh, N. N., Stewart, A. W., & Field, C. J. (1985). Psychometric characteristics of
the Aberrant Behavior Checklist. American Journal on Mental Deficiency, 89(1985), 492–502.
 Person-Centered & Experiential Psychotherapies 15

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed. text rev). Washington, DC: Author.
Axline, V. (1969). Play therapy. New York, NY: Ballantine.
Baron-Cohen, S. (1987). Autism and symbolic play. British Journal of Developmental Psychology,
5, 139–148. doi:10.1111/j.2044-835X.1987.tb01049.x
Blanco, P. J., & Ray, D. C. (2011). Play therapy in elementary schools: A best practice for
improving academic achievement. Journal of Counseling and Development, 89(2), 235–243.
doi:10.1002/j.1556-6678.2011.tb00083.x
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. doi:10.1037/a0026932
Bradley, E. A., Summers, J. A., Wood, H. L., & Bryson, S. E. (2004). Comparing rates of
Downloaded by [World Association for Person-Centered ] at 09:11 28 November 2014

psychiatric and behavior disorders in adolescents and young adults with severe intellectual
disability with and without autism. Journal of Autism and Developmental Disorders, 34(2),
151–161. doi:10.1023/B:JADD.0000022606.97580.19
Bratton, S. C., Ceballos, P. L., Sheely-Moore, A. I., Meany-Walen, K., Pronchenko, Y., & Jones, L. D.
(2013). Head start early mental health intervention: Effects of child-centered play therapy on
disruptive behaviors. International Journal of Play Therapy, 22(1), 28–42. doi:10.1037/a0030318
Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A
meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice,
36(4), 376–390. doi:10.1037/0735-7028.36.4.376
Brooks, S., & Paterson, G. (2011). Using contact work in interactions with adults with learning
disabilities and autistic spectrum disorders. British Journal of Learning Disabilities, 39(2),
161–166. doi:10.1111/j.1468-3156.2010.00643.x
Cooper, M., O’Hara, M. O., Schmid, P. F., & Wyatt, G. (2007). Preface. In M. Cooper, M. O’Hara,
P. Schmid, & G. Wyatt (Eds.), The handbook of person-centered psychotherapy and counseling
(pp. xxi–xxiv). New York, NY: Palgrave Macmillan.
Danger, S., & Landreth, G. (2005). Child-centered group play therapy with children with speech
difficulties. International Journal of Play Therapy, 14(1), 81–102. doi:10.1037/h0088897
Dekker, M. C., Koot, H. M., Ende, J., & Verhulst, F. (2002). Emotional and behavioral problems in
children and adolescents with and without intellectual disability. Journal of Child Psychology
and Psychiatry, 43(8), 1087–1098. doi:10.1111/1469-7610.00235
DeVre, R. (1992). Prouty’s Pre-Therapy (Master’s Thesis). Department of Psychology, University of
Ghent, Belgium.
Dinacci, A. (2001). Objective evaluation criterion for the Pre-Therapy interview. International Pre-
Therapy Review, 1(1), 21–30.
Dunn, L. M., & Dunn, L. M. (1997). Peabody picture vocabulary test (3rd ed.). American Guidance
Services Publishing. Retrieved from http://www.pearsonassessments.com/HAIWEB/Cultures/
en-us/Productdetail.htm?Pid=PAa12010&Mode=summary
Einfeld, S. L., & Tonge, B. J. (1996). Population prevalence of psychopathology in children and
adolescents with intellectual disability: II epidemiological findings. Journal of Intellectual
Disability Research, 40(2), 99–109. doi:10.1111/j.1365-2788.1996.tb00611.x
Emerson, E., Moss, S., & Kiernan, T. (1999). The relationship between challenging behavior and
psychiatric disorders in people with severe developmental disabilities. In N. Bouras (Ed.),
Psychiatric and behavioural disorders in developmental disabilities and mental retardation
(pp. 38–47). Cambridge: Cambridge University Press.
Garza, Y., & Bratton, S. C. (2005). School-based child-centered play therapy with Hispanic children:
Outcomes and cultural considerations. International Journal of Play Therapy, 14(1), 51–80.
doi:10.1037/h0088896
Greenberg, L. S. (2007). A guide to conducting a task analysis of psychotherapeutic change.
Psychotherapy Research, 17(1), 15–30. doi:10.1080/10503300600720390
Holden, B., & Gitlesen, J. (2006). A total population study of challenging behaviour in the county of
Hedmark, Norway: Prevalence, and risk markers. Research in Developmental Disabilities, 27,
456–465. doi:10.1016/j.ridd.2005.06.001
Hove, O., & Havik, O. E. (2008). Mental disorders and problem behavior in a community
sample of adults with intellectual disability: Three-month prevalence and comorbidity.
Journal of Mental Health Research in Intellectual Disabilities, 1, 223–237. doi:10.1080/
19315860802269198
 16 K.L. Swan and A.A. Schottelkorb

Karabekiroglu, K., & Aman, M. G. (2009). Validity of the aberrant behavior checklist in a clinical sample
of toddlers. Child Psychiatry & Human Development, 40, 99–110. doi:10.1007/s10578-008-0108-7
Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young children
with autism: A randomized controlled intervention study. Journal of Child Psychology
Psychiatry, 47(6), 611–620. doi:10.1111/j.1469-7610.2005.01567.x
Kazdin, A. E. (1982). Single-case research designs: Methods for clinical and applied settings. New
York, NY: Oxford University Press.
Landreth, G. L. (2012). Play therapy: The art of the relationship (3rd ed.). New York, NY:
Routledge.
Lewis, V., & Boucher, J. (1988). Spontaneous, instructed and elicited play in relatively able autistic
children. British Journal of Developmental Psychology, 6, 325–339. doi:10.1111/j.2044-
835X.1988.tb01105.x
Downloaded by [World Association for Person-Centered ] at 09:11 28 November 2014

Linna, S. L., Moilanen, I., Ebeling, P. J., Kumpulainen, K., Tamminen, T., & Almqvist, F. (1999).
Psychiatric symptoms in children with intellectual disabilities. European Child & Adolescent
Psychiatry, 8(4), 77–82. doi:10.1007/PL00010704
Murphy, G. H., Beadle-Brown, J., Wing, L., Gould, J., Shah, A., & Holmes, N. (2005). Chronicity
of challenging behaviours in people with severe intellectual disabilities and/or autism: A total
population sample. Journal of Autism and Developmental Disorders, 35(4), 405–418.
doi:10.1352/0895-8017(2005)1102.0.CO;2
Myrbakk, E., & Tetzchner, S. (2008). Psychiatric disorders and behavior problems in people with
intellectual disability. Research in Developmental Disabilities, 29, 316–332. doi:10.1016/j.
ridd.2007.06.002
Pascual-Leone, A., Greenberg, L. S., & Pascual-Leone, J. (2009). Developments in task analysis:
New methods to study change. Psychotherapy Research, 19(4–5), 527–542. doi:10.1080/
10503300902897797
Peters, H. (1999). Pre-Therapy: A client-centered/experiential approach to mentally handicapped
people. Journal of Humanistic Psychology, 39(4), 8–29. doi:10.1177/0022167899394002
Peters, H. (2005). Pre-Therapy from a developmental perspective. Journal of Humanistic
Psychology, 45, 62–81. doi:10.1177/0022167804269404
Prouty, G. F. (2001). The practice of Pre-Therapy. Journal of Contemporary Psychotherapy, 31(1),
31–40. doi:10.1023/A:1010226814792
Prouty, G., Van Werde, D., & Portner, M. (1998). Prae-Therapie. Stuttgart: Klett-Cotta.
Ray, D. C., Blanco, P. J., Sullivan, J. M., & Holliman, R. (2009). An exploratory study of child-
centered play therapy with aggressive children. International Journal of Play Therapy, 18(3),
162–175. doi:10.1037/a0014742
Ray, D. C., Schottelkorb, A., & Tsai, M. -H. (2007). Play therapy with children exhibiting symptoms
of attention deficit hyperactivity disorder. International Journal of Play Therapy, 16(2), 95–111.
doi:10.1037/1555-6824.16.2.95
Ray, D. E. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child
practice. New York, NY: Routledge.
Rogers, C. R. (1957). Client-centered therapy: Its current practice, implications, and theory.
Oxford: Houghton Mifflin.
Ruiter, K. P., Dekker, M. C., Verhulst, F. C., & Koot, H. M. (2007). Developmental course of
psychopathology in youths with and without intellectual disabilities. Journal of Child
Psychology and Psychiatry, 48(5), 498–507. doi:10.1111/j.1469-7610.2006.01712.x
Schaefer, C.E. (1993). What is play and why is it important? In C. E. Schaefer (Ed.), The therapeutic
powers of play (pp. 41–64). Northvale, NJ: Jason Aronson.
Schottelkorb, A. A., & Ray, D. C. (2009). ADHD symptom reduction in elementary students: A
single-case effectiveness design. Professional School Counseling, 13(1), 11–22. doi:10.5330/
PSC.n.2010-13.11
Schumann, B. (2010). Effectiveness of child-centered play therapy for children referred for aggres-
sion. In J. Baggerly, D. Ray, & S. Bratton (Eds.), Child-centered play therapy research: The
evidence-base for effective practice. Hoboken, NJ: John Wiley.
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(3), 452–464. doi:10.1037/0022-006X.71.3.452
Siegel, D. J. (2011). The whole-brain child. New York, NY: Delacorte Press.
 Person-Centered & Experiential Psychotherapies 17

Sparrow, S. S., Cicchetti, D. V., & Balla, D. (2005). Vineland adaptive behavior scales (2nd ed.).
Retrieved from http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/enus/Product
detail.htm?Pid=Vineland-II
Swan, K., & Ray, D. (2014). Effects of child-centered play therapy on irritability and hyperactivity
behaviors of children with intellectual disabilities. Journal of Humanistic Counseling, 53(2),
120–133. doi:10.1002/j.2161-1939.2014.00053.x
Thorp, D. M., Stahmer, A. C., & Schreibman, L. (1995). Effects of sociodramatic play training on
children with autism. Journal of Autism and Developmental Disorders, 25(3), 265–282.
doi:10.1007/BF02179288
United States Public Health Service. (2001). Report of the surgeon general’s conference on
children’s mental health: A national action agenda. Washington, DC: Department of Health
and Human Services.
Downloaded by [World Association for Person-Centered ] at 09:11 28 November 2014

Wadsworth, B. (1989). Piaget’s theory of cognitive and affective development (4th ed.). New York,
NY: Longman.
Whiten, A., & Brown, J. (1998). Imitation and the reading of minds: Perspectives from the study of
autism, normal children, and non-human primates. In S. Braten (Ed.), Intersubjective commu-
nication and emotion in early ontogeny (pp. 260–281). Cambridge: Cambridge University
Press.
Wilson, K., & Ryan, V. (2005). Play Therapy: A non-directive approach for children and adoles-
cents (2nd ed.). London: Elsevier.
Wyatt, G. (2007). Psychological contact. In M. Cooper, M. O’Hara, P. Schmid, & G. Wyatt (Eds.),
The handbook of person-centered psychotherapy and counseling (pp. 140–153). New York, NY:
Palgrave Macmillan.