Person-Centered & Experiential Psychotherapies

ISSN: 1477-9757 (Print) 1752-9182 (Online) Journal homepage: http://www.tandfonline.com/loi/rpcp20

Anxiety in childhood person-centered

perspectives
Dagmar Nuding
To cite this article: Dagmar Nuding (2013) Anxiety in childhood person-centered
perspectives, Person-Centered & Experiential Psychotherapies, 12:1, 33-45, DOI:
10.1080/14779757.2013.767746
To link to this article: http://dx.doi.org/10.1080/14779757.2013.767746

Published online: 22 Apr 2013.

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Date: 13 November 2016, At: 15:34

Person-Centered & Experiential Psychotherapies, 2013

Vol. 12, No. 1, 3345, http://dx.doi.org/10.1080/14779757.2013.767746

INVITED ARTICLE
Anxiety in childhood person-centered perspectives
Dagmar Nuding*
University of Education, Educational Psychology, Counselling and Intervention, Schwbisch
Gmnd, Germany
(Received 30 August 2012; final version received 18 December 2012)
This article discusses the basic person-centered (PCE) conflict: working on symptoms versus working on self-structure, and how working on symptoms might
conflict with the idea of non-directivity. Modern person-centered and experiential
therapy needs concepts for dealing with the interaction of structure and symptoms.
The disorder-specific incongruence of childhood anxieties is referred to, as well as
Fner and colleagues therapeutic guidelines for working with children suffering
from anxiety disorders, which are illustrated by a case example. The article
concludes by summarizing the effectiveness of PCE therapies for anxiety in
childhood.
Keywords: anxiety; childhood; guidelines; play therapy; effectiveness

Angst in der Kindheit personzentrierte Perspektiven

Dieser Artikel diskutiert den grundlegenden personzentrierten Konflikt: die Arbeit
an Symptomen versus die Arbeit an der Selbststruktur und wie die Arbeit an
Symptomen mit der Idee von Nicht-Direktivitt konfligiert. Die moderne
Personzentrierte und Experienzielle Psychotherapie bentigt Konzepte, um mit der
Interaktion von Struktur und Symptomen umgehen zu knnen. Die
strungsspezifische Inkongruenz von Kindheitsngsten wird ebenfalls errtert. Auch
die therapeutischen Richtlinien von Fner et al. fr die Arbeit mit Kindern, die an
Angststrungen leiden, werden mit einem Fallbeispiel dargestellt. Der Artikel schliet
mit einer Zusammenfassung ber die Wirksamkeit von PCE- Therapien bei ngsten in
der Kindheit.

Ansiedad en la infancia perspectivas ECP

Este artculo aborda el conflicto bsico centrado en la persona: trabajar con los
sntomas versus trabajar con estructura del self, y cmo trabajar con los sntomas
podra entrar en conflicto con la idea de no directividad. La terapia centrada en la
persona y experiencial moderna necesita conceptos para hacer frente a la interaccin de
la estructura y los sntomas. Trato la incongruencia especfica del trastorno de las
ansiedades de la infancia se refiere, as como los lineamientos teraputicos de Fner y
sus colegas para trabajar con nios que sufren de trastornos de ansiedad, que estn
ilustrados por un ejemplo. El artculo concluye con un resumen de la eficacia de las
terapias ECP para la ansiedad en la infancia.

*Email: nuding@gwg-ev.org
2013 World Association for Person-Centered & Experiential Psychotherapy & Counseling

34

D. Nuding
Anxit dans lenfance PCE perspectives
Cet article examine le conflit au cur de lACP : travailler sur les symptmes ou
travailler sur la structure du self. Il examine aussi la manire dont le travail sur les
symptmes pourrait tre en conflit avec lide de la non-directivit. La thrapie
moderne dans lapproche centre sur la personne et exprientielle a besoin de
concepts pour le travail sur les interactions entre la structure (du self) et les
symptmes. Larticle fait rfrence lincongruence propre aux anxits
spcifiques aux diffrents troubles dans lenfance, ainsi quaux lignes directrices
de Fner et de ses collgues dans le travail avec des enfants souffrant de troubles
danxit, illustrs par une tude de cas. Larticle se termine par un rsum sur
lefficacit des thrapies CPE avec les enfants anxieux.

A ansiedade na infncia as perspetivas centrada na pessoa e

experienciais
Este artigo debate o conflito bsico da abordagem centrada na pessoa trabalhar com
os sintomas, versus trabalhar com a estrutura do self e de que modo trabalhar com os
sintomas pode colidir com o conceito de no-diretividade. As terapias centrada na
pessoa e experienciais modernas precisam de conceitos para lidar com a interao entre
a estrutura e os sintomas. Faz-se referncia incongruncia especfica da perturbao,
bem como as diretrizes teraputicas de Fbner e colegas para o trabalho com crianas
que sofrem de perturbaes da ansiedade, ilustradas por um estudo de caso. O artigo
concludo com um resumo acerca da eficcia das terapias centrada na pessoa e
experienciais para a ansiedade na infncia.

PCE

PCE

Working on Symptoms Versus Working on Self-Structure

Each approach to psychotherapy provides a therapeutic guideline with its theory
of personality, maintenance, and development of disorders and their treatments (Behr,
Hlldampf & Steiger, 2012; Wissenschaftlicher Beirat Psychotherapie, 2010). Approaches
to psychotherapy which are trying to understand the client holistically regarding his
symptoms, such as person-centered experiential therapy, psychodynamic therapy and
systemic therapy, reveal the cause of psychological disorders to be in self-structure and
in intra- or interpersonal conflicts. Interventions in these approaches are directed towards
the whole being of the person, his relationships and his self-structure (Behr, Hlldampf, &
Steiger, 2012).
This guideline for the classic concept of the child-centered approach to play therapy
(Axline, 1947; Landreth, 2002) is based on Rogers (1951) theory of personality and his
concept of the helping relationship, and is stated in Axlines eight principles for play
therapy. For the play therapist, they are meant to convey a deep and abiding belief in the
childs ability to make appropriate decisions in the playroom (the trust in actualizing

Person-Centered & Experiential Psychotherapies

35

tendency); to encourage the child to make decisions; to listen actively with tenderness and
concern; to respect the childs capacity for self-direction; to avoid making an attempt to
direct the childs activities or to change the child to meet preconceived expectations or
standards of behavior; and to give the child the freedom to express and explore himself in
an accepting climate of faith and trust.
Influenced by behavioral symptom-focused thinking in psychotherapy and in the
health care system, more and more importance is attached to symptom-orientated therapeutic guidelines. In Germany, for example, symptom-specific effectiveness and efficacy
studies are requested from the evaluation committee to judge a therapeutic method as an
effective approach.
Although representatives of the classic concept of person-centered play therapy, such
as Landreth (2002) or Cochran, Nordling, and Cochran (2010), are in favor of symptomorientated treatment, the classic concept of child-centered play therapy is not symptom
orientated. It focuses on non-directivity and working on self-structure. Younger concepts
of person-centered work, such as Behrs Concept of Interactive Resonance (2003, 2009),
which could be theoretically ranked among constructivist thinking, or Swildens (1988)
Process-Oriented Therapy and Speierers Incongruence Inventory (1994), act on the
assumption that diagnostic categories make sense.
In these concepts it is assumed that the experience and the behavior of humans is
organized by specific cognitive-emotional schemes, and that those schemes can be
allocated to a diagnosis. It is also assumed that clients can be helped faster using this
diagnostic knowledge, because the best treatment is accomplishable. This approach covers
the risk that the attentiveness and presence, as well as the empathy and acceptance, can be
detracted from particularly to the single client. In addition, it particularly allows the use of
understanding for, and the concentration on, the base of the disorder-specific incongruence to facilitate the client to expand his self-concept and to become more congruent. As a
result, modern person-centered therapy needs concepts to work with disorder-specific
incongruence, disorder-specific cognitive-emotional schemes, and with the disorderspecific self-structure.
A group of person-centered child and adolescent therapists (Fner, Dring,
Steinhauser, & von Zlow, 2012) accepted the challenge to create disorder-specific
therapeutic guidelines for the treatment of childhood and youth anxiety disorders without
violating the individuality of the client. In the following, a case will be presented (from
my own therapeutic practice) with regard to the therapeutic guidelines of Fner and
Colleagues (2012).

Case
Sara the ladybird girl with short antennae
Sara was 5 years and 2 months old when she first came to play therapy. Her parents
were searching professional help after being advised by a kindergarten teacher who
recognized the girls problems regarding contact with other children. The main concerns the parents reported were that their daughter does not have any friends in the
kindergarten group and is treated like an outsider. They also indicated that the girl does
not assert herself, refuses herself, is overextended and easily distracted, and has a lack
of concentration.
The girl, especially in situations where she was asked to carry out a task, was
unable to communicate or act, and instead froze and did not react to either her
kindergarten teacher or to her mother if she was present. Due to this behavior of not

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D. Nuding

reacting, which occurred more frequently if there were other children around her, the
parents presumed hardness of hearing. As a result, a medical check up was carried out
that did not lead to any diagnostic findings.
In Kindergarten, the other children in the group refused to play with her and the
kindergarten teacher became increasingly unable to integrate her into the group or find
playmates for her.
My tentative diagnosis was social anxiety disorder of childhood (F 92.3) because
the child was of normal intelligence, the chief symptoms were a fear in social
situations of a degree that is outside the normal limits for the childs age, and it is
associated with clinically significant problems in social functioning.

Anxiety disorders in childhood

Since anxiety is part of nearly everyones life, anxiety disorders and anxieties requiring
treatment need to be well defined. In psychopathology, there is hardly any disorder in
which anxiety does not take a major part (Dpfner & Lehmkuhl, 2002; FrhlichGildhoff & Rnnau-Bse, 2012; Ihle & Esser, 2002; Ravens-Sieberer et al., o.J.). A
high proportion of diffuse anxiety, situation- or object-related phobias qualifies as
clinically-significant anxiety syndromes. Anxiety disorders requiring treatment in childhood include: Separation Anxiety Disorder, Specific Phobia, Social Phobia,
Agoraphobia, Panic Disorder, Generalized Anxiety Disorder, and School Phobia (for
diagnostic criteria see the American Psychiatric Association, 2000 or the World Health
Organization, 2008).

Prevalence
A prevalence of anxiety disorders between 710% in childhood and youth is already
rather high, and as a result in such a sensitive developmental phase anxiety disorders
prove to be the most widespread psychopathological phenomenon (Frhlich-Gildhoff,
2007). Studies have also shown that girls have rates of anxiety disorders that are two to
four times higher than those of boys. Social phobia ranks second in the number of anxiety
disorder diagnoses.

Person-centered, experiential understanding of anxiety

Anxiety disorders develop in conjunction with conflicts originating in the development of
self-concept, due to an inert drive of autonomy on the side of the child, however
misunderstood and/or not accepted by his caretakers. This usually happens with a history
of an insecure attachment style. If the child does not have the ability to distinguish
between internal and external, between real and imagined dangers, and because children
are so defenceless and vulnerable, they have difficulties integrating anxiety in their selfconcept.
Fear is a basic emotion that is eminent to every human being with signal function. It
needs to be integrated in self-concept, and therefore attachment figures need to recognize
this emotion and react in an appropriate way to facilitate the child in learning to regulate
his emotions (Crittenden, 2005; Dring, 2011). Anxiety is typical for childhood and

Person-Centered & Experiential Psychotherapies

37

youth, considering the amount of developmental and adaption tasks required. Normal
childhood development consistently forces the child to give up familiar terrain, and
therefore securities, and turn to unfamiliar and at times threatening terrain. Children
develop anxiety whenever they cannot cope with their living conditions due to limited
experience. These are circumstances that would demand skills such as self-confidence and
autonomy. However, being helpless in the face of their circumstances, as well as having
no coping mechanism at hand, the children develop anxiety.
Coping would need the help and assistance of caretakers, without being overprotective, controlling, not accepting or even deprecating towards their effort to
conquer the new and unknown. If the child is left unsure of his conduct and in his
experience inhibited, self-efficacy, competence and autonomy cannot be integrated in
the childs self-concept and a stagnation in the development of autonomy follows.
In the long run, a self-concept of weakness, dependency and self-victimization will
result. The actualization tendency of the child is inhibited (Jaede, 2002). On the one hand
the child finds itself in a state of incongruity between his wish for development, autonomy
and experiencing self-efficacy as part of the desire of actualization tendency, and on the
other his self-concept of dependency and inability to act on his own.
An anxious child is unable to perceive and take in experiences to further his independence. If the significant others have shown little empathy for the childs needs of
autonomy and individual growth, the childs efforts towards more independence will not
be supported. This leads to a self-concept of fighting the need for independence and also
contesting the experience of power and competence in the child. As a result, the child will
experience himself as weak, dependent and incompetent in an environment that is
potentially dangerous and overwhelming. Thus, the child looks for safety and security
in his significant others.
A child with such a self-concept cannot attempt, experience, or live autonomy of the
organism. Developmental tasks, which always lead to more autonomy and independence,
will not be experienced and lived by this child. This child has fewer experiences that
prove his self-competence, efficacy or autonomy. Experiences that lead to encountering
the need for autonomy and independence have to be averted, since they cannot be
integrated in the self-concept (Teusch & Finke, 1999).
Significant others who do not understand a childs need and goal for autonomy, and
therefore do not support them and are, moreover, afraid of letting go of the child only
further the impact of anxiety on the child. The child fears that gaining autonomy will, at
the same time, mean losing the significant people in his life, along with safety and
security. On the other hand, a child who had to become too independent too early on
and was therefore completely overwhelmed by the task, may also develop a concept of
himself as being weak and helpless. Early on, this child is left on his own to master
separation anxieties and his needs for support. This child also may develop an inhibited
experience of self-efficacy and may not be able to reconcile this with his self-concept.
This child will experience his separation anxiety as threatening, because it will also
threaten the childs self-concept and therefore inhibit the development of autonomy. A
child will develop anxieties if his attachment to significant others is threatened. The
significant other supplies the child with safety and security, and if lost, will cause
substantial anxiety. This will happen if the attachment figure is not present at a time
needed, threatens to leave, or is otherwise threatened. A child will always avoid developmental tasks that risk separation with the attachment figure. The child will suppress
organismic impulses that will lead to such a separation. Having these desires alone may be
the cause for anxiety (Fner et al., 2012).

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D. Nuding

Implications for person-centered, experiential treatment of childhood anxiety

From the person-centered and experiential theory of the development of anxiety disorders
for their therapeutic guidelines, Fner and colleagues (2012) concluded that:
An extension of the classical concept from Axline is necessary.
A specific way of contact is needed for children with anxiety disorders.
Process-directive steps are useful.
Objectives
As objectives for the treatment, the establishment of a realistic positive self-concept, the
knowledge about personal strengths and difficulties, and the ability to accept them and
deal with them are suggested (Dring, 2011; Fner et al., 2012; Goetze, 2002;
Weinberger, 2005).
Further objectives include the facilitation of experiencing individual competencies and
the efficiency of ones own activity. The goal is to have the child encounter being in
control and experiencing competencies during play. Therefore, the therapist can arrange
experiences of self-assurance. Self-enforced behavior can be detected and attempted. Fear
should be known as a useful emotion. The ability to realize, handle and accept emotions
should be created. It may also be helpful to further realize previously having coped fearful
situations as success. This way, situations or objects that trigger anxiety may be viewed
from a different perspective and may as such be newly defined. Also, self-instructions,
which summon bravery, can be helpful. In addition, it is important to process acute
pressure or life burdens. The clarification of their reactions to situations causing anxiety
is most important in the work with significant others.
Stages of treatment
It makes sense to divide person-centered experiential treatment for children with anxiety
disorders into three treatment stages, of which all require a specific behavior from the
therapist: the beginning, the middle stage, and the end of therapy.

The beginning of play therapy for Sara

At the beginning of play therapy and during the first sessions it is important to leave
the control over the situation in the hands of the child without overstraining them with
too many gaps and phases of inactivity.
When Sara first came to play therapy, accompanied by her mother and her father,
I met a shy, insecure girl who did not directly look at me and tried to hide behind her
mother. I introduced myself and explained to her that I do not exactly know what her
parents told her about me and about what we will do together, but that my understanding is to provide her a special time during which she can play and do nothing
wrong. Since I asked her if she would like to come with me into the play room and she
tried to hide herself even more behind her mother, I suggested that we all could go
together into the play room and that she could have a look at things together with mum
and dad. I asked her if that would be OK for her, and her parents also tried to make her
feel comfortable with it. She did not say a word, but moved towards the open door of
the playroom. In the playroom she walked into the middle of the room and stood there,

Person-Centered & Experiential Psychotherapies

39

inactive. I verbalized that she is in a new room now at a place where she has never
been before and that she does not really know what to do and that it might feel
especially strange for her that there are three adults who seem to wait for her to do
something. She did not say anything, but Im sure she understood every word I said,
and that she felt understood in her feelings. Her mother might have also felt as insecure
as Sara, because she started to look around and describe what toys she was able to see.
I allowed Sara to walk over to the toys she wanted to play with and said that she could
take her mum or dad as a helper who could get the things she wanted to play with.
After this invitation she walked to the wooden play animals and gave them all to her
father and her mother, who helped her display them on the floor. I asked her if
she wanted me to bring her the wooden stable for the animal to play with. She told
me, no those are free animals. After saying that, she started a role-play in which
she symbolized her individual situation.
The animals were roaming the country on a big migration. A little donkey
suddenly fell down and hurt itself. The other animals just moved past it. I verbalized
that the little animal is now lying there and the other animals just move on without
taking care of it. Sara explained that the other animals had not noticed that the little
donkey was feeling bad. When I suggested that the little animal could call for help, she
replied that the little animal was unable to do so and that it was very sad and
frightened. After a while the herd noticed that the little animal was missing. Two
animals went back. However, they could not help the little one because they did not
understand what was wrong with it and the little one could not explain the problem.
Even its parents, who went back too, were unable to help because they too did not
understand what was wrong and even worse, there were no humans in the scene that
could have helped. In my perception, the little girl was symbolizing her own situation
and suffering with this sequence. It displayed how she experienced her incapacitation
in frightening situations, with no one being able to help her or understand her plight.
At the end of the play session a sandbox was the destination of the journey. All
animals could have jumped in and would have been safe, but not all animals knew and
trusted in this ability. When I told her that our playtime is over now she stood up and
walked in the direction of the door. I told her that I would be happy to see her again
and that I hoped she would like to come again for another play session.

Beginning
At the beginning of therapy with anxious children, the focus is on creating a therapeutic
relationship with empathy and unconditional positive regard; the therapist is open towards
the childs being and acts in a calm manner. A balance between giving security and
leaving space has to be found. If a child is blocked, the therapist helps and creates an
anxiety-free area.
It is important to explain the context of the playtime, how long it is and the place
where the mother is waiting. Long silences and inactivity are avoided. The therapist can
show the room and the play material and offer to play a game after the child seems to be
interested in it. In this stage of therapy it is very important to pay attention to the childs
needs regarding closeness and distance.
During the beginning, the child is leading and controlling the situation in order to feel
secure. Later on, success and experiences of self-efficacy are verbalized and the child

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D. Nuding

copes with anxiety in role-play therapeutic stories and creative media can be used. As an
add-on, differential play experiences can be offered through painting a picture of anxiety
or forming an anxiety sculpture. In this way, the anxiety becomes tangible and at the same
time a distance will be created between the child and his anxiety. The child can actually do
something with his anxiety. Another possibility would be enacting a talk show with
puppets. A dialogue could be generated between the anxiety and courage, and the child
could learn that both are equally important (Weinberger, 2005). Using therapeutic stories,
the child might hear a story in which fear converts into strength. In such a story a child
might succumb to his fear and is led to its resources, all serving as a model to the afflicted
child. It is also possible to write a therapeutic story for the child that helps to understand
the individual situation and allows a symbolizing experience through the identification
with the protagonist.

A therapeutic narrative for Sara

Years ago a ladybird man and a ladybird woman lived together with their son in a
lovely meadow. They all loved each other very much, so much that they wanted to
have a ladybird girl. Finally, one day their little daughter was born. The whole family
was very happy. The little ladybird girl had five fantastic black spots and a sixth spot
that reflected beautifully in the sun when it was wet. The family flew together every
day from blossom to blossom and nibbled nectar. Usually they had a bath at the nearby
stream and admired the girls glittery spot. The whole family was very happy being
together and life was good for them. The little ladybird girl was looking forward to her
first school day and asked her mummy every evening before going to bed when she
could finally go to ladybird school and play with other children there.
Finally, the first school day came and all ladybird children and their parents met
under the big tree in the middle of the lovely meadow. The girl was very happy to see
all those ladybird children so happy that she felt butterflies in her stomach. Finally,
the school started. Now she would meet other children every day to play with.
After one week the children went on their first excursion with their teacher to
collect mushrooms. The teacher explained to the children which mushrooms taste the
best and exactly how they have to fly to find them. They all met again and the teacher
wanted to look at the mushrooms collected. However, the little ladybird girl with
the glittery spot did not have a single mushroom, although she did exactly what
the teacher said. All the other children had five or even more mushrooms. Since the
other children saw that the girl had not even one mushroom they started laughing at
her and badmouthing her. They said things like she was stupid because she did not find
a mushroom. The girl recognized how her little ladybird heart was beating and was
very sad that she did not find any mushrooms. She felt ashamed. She wished to be
invisible.
When the teacher asked her why she did not collect any mushrooms she felt very
hot and cold at the same moment. She fought back her tears, put her head down and
wasnt able to say a word any more. She really wanted to explain it, but she was
unable to. The other children laughed even louder and shouted: Now she doesnt even
say anything, the stupid girl. The girl felt how her belly cramped. She became even
sadder and was unable to hold her tears back. She started to cry.
When she came home from school that day she was still unhappy, because all the
other children were laughing at her and did not want to play with her anymore. Her

Person-Centered & Experiential Psychotherapies

41

mum wanted to know why she was so unhappy, but as much as she tried to she was not
able to tell her.
Because of that, her mum decided to fly with her into the forest to the wise owl.
Her mum said to the owl, Im very sorry Owl to wake you up, but I desperately need
your help. My daughter is so sad and I dont know why. The wise owl asked the
ladybird girl to fly on his beak to see her better. First, the girl was afraid because she
did not know the owl, but after watching her for a little while she saw that the owl
looked very friendly, so she carefully flew on the owls beak. After the owl looked at
her and talked to her for a long time, she said, Its because of her antennae. They are
different than on other ladybirds. Thats the reason that she sometimes has problems
doing things. But you can train it with her and she will be fine.
The next day the ladybird mum and the girl went together to school and told the
teacher about the girls antennae. The teacher explained to the other children why the girl
sometimes has problems doing things. The other children thought, Oh, we did not
know that, we thought she was just stupid. And some of them felt bad because they
were so mean. From this day on, the other children liked playing with her again. The girl
was so happy. And do you know what else happened? If it was raining all the children
loved to watch the girls glittery spot. And the girl had learned how to find mushrooms.
She realized that it is much easier if she just flies a little deeper than the other children
and she understood that she was able to find any other thing if she wanted to.
Together with the child, a storybook may be created. With the use of imaginary
journeys the child can face his anxiety directly and diminish it. A fearful animal might
be fed or the child is celebrated as a hero. A fantasy figure could be created and installed
to serve as a companion. Guiding angels or worry dolls or dream catchers might be used,
as well as picture books about fears.

Middle stage of therapy

In the middle stage of therapy it is important for the therapist to be attentive to the
feelings of fear and anxiety and to validate them, as well being open to feelings of
courage and anger and the childs need for self-government. An important experience for
the child includes a therapist trusting in the childs own abilities, particularly someone
who is present as a person and allows the child to make new relationship experiences.
Again, it is also important in this phase to leave control up to the child, to pick up on
the childs perception of his own needs and emotions, and to let this be experienced. The
therapist goes along verbalizing the experience and thus making it more profound for the
child. He might address the experience of successes and the feeling of efficacy on a
physical, emotional or cognitive level, as well as on a behavioral level, bringing them
into the childs awareness. In role-play, the therapist verbalizes feelings of anxiety and
possibilities to overcome them by simply speaking his thoughts and ideas out loud while
the child acts. Likely, the child should experience the role of the hero. In games that are
based on a fixed set of rules the child will encounter success and efficacy as he wins.
The child should be given the possibility of testing his strength and competing with the
therapist. The same goes for fighting games. Even construction games or creative work
allow the child to experience self-efficacy, successfully letting some structure take shape
in the childs undertaking. On the level of relationship the therapist shows interactive
resonance.

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D. Nuding

Sara experiencing strength as Pippi Longstocking

In this stage of therapy the girl had the experience of being very strong, playing Pippi
Longstocking. This was a lot of fun for her and she got plenty of opportunity to test her
capacities. At one time, for example, I had to push her in the swing chair so hard that it
could become dangerous. At the end of the first session in which she was Pippi, she
refused to take off the costume and wanted to take it home. She explained that she
wanted to feel as strong as Pippi Longstocking at home, as well as in Kindergarten.
Therefore, I took a picture so she could always look at it and remember how it feels to
be Pippi, reactivating the feelings of strength.

End of therapy
At the end of therapy the therapist communicates trust in the childs competencies of selfgovernment, activates coping with failure and is attentive for the childs subject of
farewell. The therapist initiates farewell and supports the transfer of the experiences
from therapy into the daily routine. In board games or construction games the child
should have the experiences that he does not succeed. Symbols that bridge between
therapy and daily routine, such as power-stones, can be given to take home.

Collaboration with parents

In play therapy in Germany we usually also work with parents, not as their therapists, but
conducting therapy support meetings with them. At the beginning of therapy it is
important to establish a good relationship that is based on empathy and appraisal of the
parents. The therapist has to be open towards parents negative feelings and validations of
the child. It is important to relieve and unburden the parents by normalizing the situation
without making it trivial, and to facilitate self-acceptance. It is also imperative to show
empathy and recognition for the strain the parents are under and to facilitate the experience the parents are having empathetically and with acceptance. Furthermore, it is
important to reduce any rivalry between parents and therapist, and to let the parents
know that the therapist is not trying to be the better mother or the better father. In this
stage, parents can be asked how, in their opinion, the child should act and feel after the
therapy. They are informed about the therapeutic framework and a therapy agreement is
formulated. In addition to therapy, parent meetings can be used to gain information about
the child, including his resources and strengths, and how the parent-child relationship is
defined. It is interesting to know how much pressure the parents experience from their
childs afflictions. Also the explanation the parents have for the anxiety disorder is
interesting for the therapist, who might help them in finding a rationalization that
makes sense.
During the middle part of therapy the therapist should be supportive, encouraging and
facilitative, instead of being confrontational! He has to be open for the negative feelings of
parents towards themselves and towards their child. The goal is to establish a beneficial
relationship between the parents and the child.
In the parent meetings it can be worked through with the parents on their resonance to
the problems of their child and their basic feelings towards the child, such as anger or
helplessness. They can be supported in accepting the emotions they experience towards

Person-Centered & Experiential Psychotherapies

43

their child and in learning how to deal with them. Together, we can analyze the parentchild interaction in a distinct situation that is triggering anxiety in the child. Ways can be
worked out to supply their child with safety and security, as well as approaches to
regarding the childs need for attachment, while at the same time respecting and facilitating his tendencies towards autonomy. Information about anxieties and the ways they are
displayed in a childhood are supplied. Parents are supported in accepting their own
anxieties in order to facilitate the acceptance of the anxieties of the child. It is worth
trying to involve the parents own insecurities, as well as their own need for safety and
security. Parents are encouraged and supported to have confidence in their child and to
allow their child to experience self-efficacy.
At the end of therapy the appraisal of the positive developments in child and family is
communicated to the parents. One topic discussed is the parents way to deal with the
farewell. And the therapist is open for the parents questions and worries concerning the
childs future.
In a recap session, it is reflected together with the parents on the developmental
progress of the child and confidence in the abilities of the child is encouraged, using
precise everyday examples. Together with the parents, experiences of difficult situations
involving anxiety that the child mastered successfully can be collected. And everyday
examples of successfully implemented empathy for the feelings and needs of the child and
the encouragement of autonomy can be reflected. Typical examples for facilitating
experiences of self-efficacy and instances for facilitating the childs individual handling
of frightening situations can be recalled. Also with the parents, the appropriate ending date
is determined possibly there will be a farewell celebration of some sort with the family.
Once more the resources of the child and those of the family are evaluated and a plan for
relapse prevention is worked out. Finally the possibility of renewing the contact if
necessary is offered (Fner et al., 2012).
Effectiveness of person-centered, experiential treatment of childhood anxiety
There are several meta-analyses published on child and adolescent psychotherapy.
Three of them can be evaluated as particularly clarifying for the person-centered
approach: the meta-analysis of Bratton, Ray, Rhine, and Jones (2005), who identified
73 humanistic, non-directive play therapy studies, with an average effect size of 0.92;
the meta-analysis of LeBlanc and Ritchie (2001), who identified 42 play therapy studies,
with an average effect size of 0.66; and the meta-analysis of Beelmann and Schneider
(2003), who identified five controlled person-centered effectiveness studies, with an
average effect size of 0.55. As the findings from those studies do not give information
about disorder-specific effectiveness, Hlldampf, Behr, and Crawford (2010) conducted a
review that included 83 outcome studies on person-centered child and adolescent
therapy, assigning the evaluated studies to diagnosis as defined in the DSM-IV
(American Psychiatric Association, 2000) and in the ICD-10 (World Health
Organization, 2008). They found that person-centered therapy is effective for a wide
range of psychological problems in childhood and adolescence, with a mean effect size
0.45 (Hlldampf, 2012).
The pool of research Hlldampf, Behr, and Crawford (2010) used includes 28 studies
using a measurement concerning anxiety or fear. Eleven different measures were used in
primary studies to evaluate anxiety as an outcome of therapy (APAT Anxiety Scale,
RCMAS Revised Childrens Manifest Anxiety Scale, STAIC State-Trait Anxiety
Inventory for Children, Young Persons CORE, Anxiety sub-test of Burks Behavior

44

D. Nuding

Rating Scale, PFK-VS-4 subscale social anxieties, Connors Teacher Rating Scale
Subscale Anxiety, DYSIPS-KJ Diagnostic System for psychological disorders in childhood and youth anxiety, KAT Child-anxiety-test, SASC-R-D Social Anxiety Scale for
Children Revised, neurotic behavior, neuroticism). Calculated with pre- and post-data of
these tests, the total effect of person-centered and experiential psychotherapy on reducing
anxiety as an outcome is g =.383***. Four studies concern children with anxiety disorders; the overall effect size among these studies is g =.729***.
Elliot (2012) found that the measured effects are larger if the therapists are thoroughly
committed to the approach of therapy they are applying, the studies are recent, and the
newest developments of the therapeutic approach are applied. A similar effect can be
shown for a study conducted by Frhlich-Gildhoff and Rnnau-Bse (2012), who investigated the effectiveness of Fner and colleagues therapeutic guidelines for personcentered and experiential therapy (2012) with children suffering from anxiety disorders.
For this study, a mean effect size of d = 1.224** was calculated. It can be assumed that
research studies applying the most modern developments of person-centered and experiential treatments will continue to have better results.
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