!"!THE INTEGRATION OF RELATIONAL PLAY THERAPY INTO INFANT MENTAL HEALTH TREATMENT SERVICES FOR AT -RISK PRESCHOOLERS AND FAMILIES LIVING IN POVERTY By Jennifer L. Farley A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Social Work -Doctor of Philosophy 2015!!!!!!#!ABSTRACT THE INTEGRATION OF RELATIONAL PLAY THERAPY INTO INFANT MENTAL HEALTH TREATMENT SERVICES FOR AT -RISK PRESCHOOLERS A ND FAMILIES LIVING IN POVERTY By Jennifer L. Farley !A mixed -method study was conducted to examine the process of integrating Relational Play Therapy (RPT) into Infant Mental Health (IMH) treatment services for at -risk preschoolers and families livi ng in poverty. Interviews with parents and clinicians highlight the need for tailored treatment interventions an d clinical supportive services to promote protective factors and reduce child and parent risk factors associated with living in poverty . Clini cians and parents reported a variety of RPT and IMH interventions and treatment models that were delivered within a consistent treatment process with four distinctive aspects, all of which heightened parental involvement. RPT interventions were used more often than IMH interventions and significant relationships between RPT and IMH models and o ther tr eatment interventions indicate a need for specialized techniques within Non -RPT treatment models or a need for clinicians to tailor Non -IMH treatment models t o center on attachment reparation. The clinician -parent relationship serve d as a conduit to deliver treatment interventions and c linical supportive services. Within the context of a supportive clinical relationship, parent s reported feeling more confiden t and empowered to advocate for their child to friends and family, which led to improved familial understanding, improved natural supports and fewer feelings of social isolation . Further development of the integrative model along with clinical, research and implications are examined. ! Copyright by JENNIFER L. FARLEY 2015 !!!!!iv This dissertation is dedicated to the preschoolers and families living in poverty that demonstrate resilie ncy each and every day and the clinicians that help them find their voices through unconditional support and advocacy. ! !v ACKNOWLEDGEMENTS I would like to acknowledge and thank my committee chair, Dr. Ellen Whipple, who provided continual support and endless feedback throughout the PhD program , which strengthened my early childhood found ations and provided a path to continue research focused on at-risk young children and families. I would also like to acknowledge and thank my com mittee members, starting with Dr. V ictoria Fitton for her kindness and reassuring support throughout the past four years that enabled my ability find the balance between clinical knowledge and research . I would like to acknowledge and thank Dr. Joanne Rie bschleger for her support and encouragement with qualitative methods that ensured this study captured the voices of participants. I would like to acknowledge and thank Dr. Holly Brophy -Herb for her support and feedback with this study and within early chi ldhood seminars that highlighted the importance of research focused on young children and families. I would like to recognize and thank the School of the Social Work faculty and staff for their benevolence and reassurance for the past four years . In particular, I would like to thank Dr. Rena Harold for her availability and grounding support , which served as a conduit for understanding academia, my role as a future academic, and the importance of achieving a balance between career and family . I woul d also like to thank Julie Farman and Michele Brock for their kindness and limitless support throughout the program and within my teaching journey. In addition, this work would not of been possible without the support and participation of the PYC program . I would like to acknowledge and deeply thank the parents, clinici ans, and program supervisor that volunteered and generously gave their time and energy to this project. I would also like to acknowledge the program clinicians and the program supervi sor for their continually support and flexibility in my research journey. !!!!!vi Finally , I would like to thank my friends and family , especially Dan, my husband and our two kids, Isabel and Henr y for their unconditional love, patience and support over the las t four years. I wou ld also like to thank Grandma Jennie , Grandma Nona, my Great Aunt Shirley and Great Aunt Verlie for modeling perseverance and resiliency throughout my childhood and for their absolute belief in my abilities to help others. !vii TABLE OF CONTENTS LIST OF TABLES ............................................................................................................... x LIST OF FIGURES .............................................................................................................. xi CHAPTER 1: Introduction .................................................................................................... 1 Child and Parent Risk Factors ................................................................................. 1 Similarities and Differences between IMH and RPT..................... .......................... 3 Play u tility and play t echniques. ................................................................ 3 Clinician -parent r elationship....................... ............................................... 5 Supportive clinical s ervices................. ....................................................... 6 Parental i nvolvement ..................... ............................................................. 7 A Common Practice Despite Differences & Limited Studies ................. ............... 8 Definitio ns o f Terms .............................................................................................. 10 CHAPTER 2: Literature Review............... .......................................................................... 18 IMH Treatment Mode ls .......................................................................................... 18 The Concept of Integration of Play Therapy W ithin IMH .... .................................. 21 Future IMH Needs ........................................... ...................................................... 22 RPT Treatment Models .......................................................................................... 23 The Concept of Integration of IMH W ithin RPT............................... ..................... 28 Future RPT Needs ................................................................ .................................. 28 CHAPTER 3: Methodology ................................................................................................. 30 Problem Statement...................................... ............................................................. 30 Research Questions.................................................................................................. 30 Research Procedures .............................................................................................. 31 Parent and clinician i nterviews............................................. ....................... 32 Service provider c hecklist .......................................................................... 34 Methods .............................................................................................................................. 34 Research d esign ...................................................................................................... 34 Agency p opulation .................................................. .................................... 35 Sample ......................................... ................................................................. 36 Measurement ............................................................................................................ 37 Qualitative interviews......... .......................................................................... 37 Service provider c hecklist .................................................. ......................... 39 Data Analysis ........................................................................................................... 41 Qualitative a nalysis ......................................................... ............................ 41 Quantitative a nalysis ............................................................ ....................... 43 CHAPTER4: Results ........................................................................................................... 44 Introduction ............................................ .................................................................. 44 Particip ant Demographics............................................................. ............................ 44 Parent interviews .......................................................................................... 44 !!!!!viii Clinician interviews ......... ............................................................................ 45 Theme Identification ......................................... ...................................................... 46 Research Question 1: Qualitative Results............ ................................................................ 48 The Clinical Decision to Use an Integrative Treatment Model ................................ 48 Continual assessment..................................................................... ............... 48 Willingness and readiness to engage in treatment............ ............................. 50 Flexibility in treatment delivery....................................... ..............................52 Research Question 2: Quantitativ e and Qualitative Results ................................................ 54 Quantitative Results on Spe cific RPT and Non -RPT Treatment Models .................. 54 Service provider c hecklist .......................................................................... 54 Chi-squares............... ..................................................................................... 56 Qualitative Results Regarding Specific RPT and Non -RPT Treatment Models...... . 58 Field observations............ .............................................................................. 58 Play therapy models............................................................................. .......... 59 Play therapy techniques..................................... ............................................ 60 Attachment and psychotherapy......................................... ............................. 62 Uncertainty about the Ògoodness of fitÓ into treatm ent models................... 65 Research Question 3: Qualitative and Quantitative Results..................... ............................. 66 Quantitative Results Regarding Parental Involvement .............................................. 66 Service provider checklist ......................................................................... 66 Chi-squares................................................................................................... 68 Qualitative Results Regarding Parental Involvement .............................................. 70 Check -in, play session, refl ection and post -session activity .......................... 70 Understood treatment process and valued involvement.................... ............ 74 Inclusion of clinical supportive services...................... ................................. 75 Research Question 4: Qualitative Results................. ............................................................ 78 Qualitative Results Regarding the Clinician -Parent Relationship ............................ 78 Attunement, support and availability............................... ............................. 79 Deeper u nderstanding of child behaviors and parenting response s.............. 81 Parental empowerment and confidence............................ ............................. 82 Overall Summary ................................................................................... .................. 85 CHAPTER 5 : Discussion, Limitations and Implications...................................................... 88 Introduction ................................................................................................................ 88 Discussion ................................................................................... .......................................... 89 Limitations ................................................................. .......................................................... 97 Implications and Recommendations .............................. ...................................................... 98 Clinical Implications..................................................................... ............................. 98 Research Implications................................................................... ............................. 100 Policy Implications....................................................................... ............................. 101 Conclusion................................................................................................ ............................ 102 APPENDICE SÉÉÉÉÉÉÉÉ.....ÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ..................... 105 Appendix A : List of Search Words, Data Bases and Specific Journals ............................... 106 Appendix B : Conceptual Map........................................ ...................................................... 108 Appendix C: Consent for Parent Interview ......................................................................... 109 !ix Appendix D: Consent for Clinician Interview ................................................................... 111 Appendix E: Consent for Interview Audio Recording ....................................................... 113 Appendix F: Service Provider Checklist ............................................................................. 114 Appendix G: Clinician Interview Questions ...................................................................... 115 Appendix H: Parent/Caregiver In terview Question s............................................................ 117 REFERENCES ..................................................................................................................... 118 !!!!!x LIST OF TABLES Table 1 Demographics of Parent Interview Participants ................................................. .. 45 Table 2 Main Themes and Subthem es of Parent and Clinician Interviews ........ ................ 48 Table 3 Service Provider Checklist Frequencies and Percentages of PT, IMH and Other Treatment Approac hes Utilized During Home Visits ............................................ 56 Table 4 Significant Chi -Squares and Phi Values Between IMH, RPT and Other Treatment Models ................ .................................................................................. 58 Table 5 Clinical Supportive Services and Freque ncies and Percentages of Parenting, Advocacy and Concrete Needs Assistance .................. .......................................... 68 Table 6 Significant Chi -Squares and Phi Values Between CPP, PP and Anticipatory Guidance and Developmen tal Info rmation ................... ......................................... 70 !xi LIST OF FIGURES Figure 1 : Conceptual Map........................................................................ .................. 108 Figure 2: Service Provider Checkl ist.......................................................................... 114 !1 CHAPTER 1 : Introduction Child and Parent Risk Factors Young children living in poverty are exposed to multiple risk factors that may impede normative behavioral, social, and emotional outcomes (Aber et al., 2000; Morales & Guerra, 2006, Rutter, 1994; Sameroff, Seifer, & McDonough, 2004; Zeanah & Zeanah, 2009 ). Due to the exposure of risk factors, young children living in poverty are more like ly (than children not living in poverty) to experience emotional dysregulation , which can lead to behavioral and relational problems with peers, caregivers, and adults (Zeanah & Zeanah, 2009). Recent studies indicate preschool children living in poverty ha ve a 36% prevalence rate of emotional and behavioral problems (Fung & Fo x, 2014), and 9 % of preschoolers who exhibit emotional or behavioral problems meet criteria for more than two mental health diagnoses (Buffered et al., 2012). Equally concerning is that young children who exhibit these behavioral or emotional symptoms demonstrate moderate stability of psychological symptoms over time (Buffered et al., 2012; Ford et al. , 2007; Lavigne et al., 1998). The long -term consequences of emotional/ behavioral pr oblems and/or symptoms may include parent -child relationship difficulties (Lavigne et al., 1998), lower success rates in earning peer and teacher a cceptance (Raver et al., 1999), achieving academic success in kindergarten ( Emerson, 2004; Isaacs, 2012) and elementary school (Campbell, 1995; Gimpel & Holland, 2003; Lavigne et al., 1998), lower high school graduation rates (Joseph & Schwartz, 2009) and the development of a more intensive mental illness later in adolescence (Nixon, 2002). Parental risk fact ors are also important to mitigate as children grow and develop within the context of a healthy (or unhealthy) parent -child relationship. Parents of young children living in poverty are exposed to high levels of emotional and physical stress ( Lloyd & Ross man, !!!!!2 2005) and daily financial hardships related to food and clothing needs, poor housing conditions, unsafe neighborhoods, and/or unreliable transportation (Broussard & Joseph, 2009). Additionally, paren ts living in poverty are at greater risk of experi encing strained interpersonal relationships with peers and family (Olson & Barnyard, 1993) , therefore it is not surprising that these parents report more family problems, lower parental satisfaction and wellbeing, less competence and social support (Neece, 2013; Olson & Banyard, 1993; Pisula, 2007; Rodrigue et al., 1990; Sanders & Morgan, 1997). Cumulatively, p arents living in poverty are at -risk of developing mental illnesses with particularly high rates of depression and/or substance abuse disorders (Land y, 2000). Consequently, parents with symptoms and/or a mental illness experience higher rates of parental role strain, parental disruption, and child welfare system involvement (Cook et al., 2014). The exposure and potential consequences of multiple ris k factors associated with living in poverty dually influe nce parents and young children and subsequently , the reciprocal nature of the parent -child relationship. If research indicates a healthy parent -child relationship can serve as a protective factor (L uther, 2006) and enhanc e child developmental and behavioral outcomes and help parents gain a sen se of satisfaction, competence and overall wellbeing (Mortensen & Mastergeore, 2014); treatment services for young children living in poverty need a specific an d shared focus on the child, parent, and parent -child relationship. In exploring current treatment services and evidenced -based practices for the wellbeing of young children, parents, and the parent -child relationship; two approaches, Infant Mental Health (IMH) and Relational Play T herap y (RPT) were found to be the most common. Experts in both modalitie s agree that address ing early childhood problems is complex, and require a variety of interventions, includi ng multiple treatment approaches when working with high -risk !3 families ( Gil, 2006; Liebe rman & Van Horn, 2008 ). Therefore, the literature reflected i nfant menta l health clinicians integrating play therapy principles into their practice with toddlers, preschoolers (Benham & Slotnick, 2006; Paradis, 200 2 as cited in Shirilla & Weatherston, 2002; Tuters & Doulis, 2000) and p lay therapists integrating infant mental health concepts into their practice and treatment models with at-risk toddlers and preschoolers (Gil, 2006; Jernberg & Booth, 20 10). Similari ties and Differences between IMH and RPT To understand the process of integration between IMH and RPT , individual treatm ent models within each approach were examined. IMH and RPT both share a focus on the child, parent and parent -child relationship and view the parent -child relationship as the mechanism of change (Landreth, 2002; Zeanah & Zeanah, 2009). IMH provides services to children birth to five years of age, while RPT focuses on children ages two to twelve years . Variability between IMH and RPT cen tered on the utility of play and pla y techniques , parental involvement and the clinician -parent relationship . Additionally, the availability of supportive services (i.e. concrete assistance to meet immediate and basic needs, provider collaboration) were e mbedded within each IMH treatment model, but were only available in one RPT treatment model. These differences are important to consider as they may create barriers in the integrative treatment process. Play utility and play t echniques. In IMH treatmen t models , play is used within the context of child/parental psychotherapy to explore child/parental thoughts and feelings, internal working models of attachment, and to resolve inner conflicts related to past histories , including trauma (Lieberman & Van Ho rn, 2005; 2008; Marvin, Cooper, Hoffman & Powell, 2002 ). Although the utility of play is similar, play techniques within each IMH treatment model slig htly !!!!!4 vary and these differences influence the structure of IMH treatment sessions. Watch, Wait, and Wond er (Lojkasek, Muir & Cohen, 2008 ), an infant or toddler -led psychotherapy u ses non-directive play and spontaneous infant/ toddler activity during parent -child sessions to improve parental sensitivity, a childÕs sense of s elf, and emotional regulation (Lojka sek et al., 2008 ). Child Parent Psychotherapy (Li eber man & Van Hor n, 2005; 2008) uses child -led play and directive play techniques , and reflective developmental guidance within the context of psychotherapy to improve affect regulation and mutuality within the parent -child relationship (which includes reorganizing internal working models of attachment ) to help children (and parents) cope with traumati c events and life stressors (Lieberman & Van Horn, 2005; 2008). Circle of Security ( Marvin et al., 2002) uti lizes parent education on attachment theory, and psychotherapy to assist parents in understand ing their childÕs thoughts, feelings, and behaviors along with their own choices related to attachment -caregiving interactions during clinician -led parent groups. In RPT, p lay and specific play techniques (without a dual application of psychotherapy ) are used to explore child/ parental thoughts and feelings; practice, master and rehea rse adaptive coping skills (Landreth, 2002 ); and/or resolve inner conflicts re lated to past histories or trauma (Gill , 2006). Similar to IMH, the application of specific play techniques varies within RPT models. Filial Play Therapy (Guerney et al. , 1967; Landreth, 2002 ; VanFleet, 1994 ) teaches a parent to implement non-directive pl ay techniques during parent -child sessions to enhance parental observation, attunement, and parent -child communication . Parents eventually conduct play sessions without clinical support, and the clinician serves as a consultant (for up to six months). Integrated Play Therapy (Gil, 2006) uses a combination of non -directive and directive play techniques in combination with art or sand tray techniques to help a child process and cope !5 with trauma, specifically physical, sexual, and/or emotional abuse. Parent s are not involved in child trauma sessions, but part icipate in family play therapy sessions , and/or parenting support groups. In Theraplay (Jernberg & Booth, 2010), directive play techniques are employed during parent -child sessions to foster attachment reparation. Play techn iques focus on child acceptance; and parental ability to set limi ts (which keep the child safe), engage , nurture and support the child in achieving challenging tasks with a dult help (Jernberg & Booth, 20 10). Thematic Play Therapy (Be nedict & Mongoven, 1997) takes a different approach to attachment reparation. Based on themes and metaphors that emerge during individual child play sessions, clinicians use non-directive and directive play techniques to build a secure relationship betwee n the clinician and child in order to repair the childÕs maladaptive inner working model of attachment. Separate parent sessions include support, education, and psychotherapy to examine their parental internal working models of attachment (Mongoven, 1995). Clinician -parent r elationship . The clinician -parent relationship varies between the two treatment approaches. Based on psychoanalytic principles, t he IMH clinician -parent relationship provides a holding (or containing) function for parents to examine unresolved conflicts and reorganize their internal working models, which in turn facilitate growth in the parent -child relati onship (Fonagy & Target, 2003). In other words, IMH clinicians parent the parent so they can in turn parent their child. IMH cli nicians prioritize a positive clinician -parent relationship, in which parents feel nurtured, safe, and protected. The nurturing of caregivers within a clinician -parent relationship enhan ces a parentÕs ability to make behavioral chan ges, and develop a stron g parent -child relationship (Weathersto n & Tableman, 2002). IMH clinicians strive to be consistent, respectf ul, attuned to parental needs, respond with compassion, follow the parentÕs lead, and set limits and respond with empathy (Weatherston, 2000 ). The refore, during sessions, !!!!!6 the role of the clinician is to facilitate the pla y process and monitor play themes but within the context of building a positive clinician -parent relationship. The majority of RPT m odels view the clinician -parent relationship as a collaborative process in which parents gain support through consultation and education on the play process (Landreth, 2001). During consultations , which may occur b efore or after the play session , parents explore concerns about the ir child, and react ions to the play process. Clinicians examine parental reactions and session themes (along with possible meanings), provide Develop mental Information and Anticipatory Guidance, and introduce specific parenting str ategies to address concerns. W ithin this collaborative process, RPT clinicians embrace an empathic attitude, respect parents as the primary change agents (for the child or family), remain open -minded, maintain a positive outlook, focus on parental strengths, and instill h ope (Landreth, 2002 ). Th us, in the majority of RPT models, the clinician -parent relationship provides support and a space where parents can address their concerns and receive education. However, it is not a conduit in which the y can explore past histories or examine the relation ship between their internal working models of attachment and current parent ing responses as this is the case with IMH . The exception is Thematic Play Therapy (Benedict & Mo ngoven, 1997 ), which does examine parental working models of attachment through the use of psychotherapy and education in individual parent sessions. Aside from Thematic Play T herapy, the primary role of the RPT clinician during sessions is to facilitate the play with the use of non -directive and/or directive play techniques while build ing a positive child and clinician -parent relationship. Supportive clinical s ervices . Another variation between the two approaches is the inclusion of supportive clinical services. Within each IMH treatment model , supportive clinical services includ ing concrete needs assistance (i.e. to assist families with gaining resources such as !7 housing, food, clothing, tran sportation, health insurance or legal services ); provider collaboration; advocacy (to ensure stable care for child within the family system a nd/or to reduce barriers with in larger systems such as child welfare or schools ); developm ental information and anticipatory guidance, and the development of a positive support system (Weatherston & Tablema n, 2002; Weatherston, 2000) are provided to at -ris k families . In RPT treatment models, only Integrated Play Therapy (Gil, 2006) provides additional case management services to assist families with concrete needs (i.e. housing, food) and education related to th e court system and potential tri als. It is p ossible that play therapists employing RPT models with at -risk young children may offer supportive services within the treatment process, but the inclusion of these services are only part of the Integrated Play Therapy treatment model (Gil, 2006). Given t he risk factors previously discussed, it seems likely the consistent inclusion of supportive services are needed in order to assist at -risk children and families in reducing the number, and influence of risk factors associated with living in poverty. Par ental i nvolvement . The variability in play utility/ techniques and the clinician -parent relationship shape how parents are involved in IMH verses RPT treatment models. In IMH, parents are viewed as an integral part of treatment and actively parti cipate in the treatment process. Initially, parents provide child and family histories, identify child/ parent difficulties and determine immediate and long -term t reatment goals during a collaborative assessment between the parent and clinician (Lieberman & Van Hor n 2005; 2008). During working phases of treatment, parents participate in the child -led play, or observe the play between the child and clinician during home visits. Additionally, parents participate in the psychoanalytic process (during parent -child sess ions or after play sessions) by exploring internal working models of attachment and how they relate to current parenting responses, and in receiving clinical !!!!!8 supportive services (i.e. assistance with concrete needs , advocacy, parenting guidance ). Throughou t treatment , IMH clinicians provide continual education to parents on the IMH treatment process and its services as a means to engage and sustain parental involvement (Lieberman & Van Horn, 2005; 2008; Weatherston & Tableman, 2002). In RPT treatment mode ls, parents are viewed as change agents and actively participate in treatment services. Similar to IMH, parents participate in the assessment process by providing child/family histories, identifying child/parent diffic ulties or engaging in child observati on during the assessment phase of treatment. Initially, parents receive education on the play process; in p articular why/how play is used as a modality t o address child/p arent concerns (Landreth, 2002). During the working phases of treatment, parents actively participate in child -led play, and within two treatment models (Filial Play Therapy and Theraplay) apply learned non-directive or directive play therapy techniques (Jernberg & Booth, 2010; Landreth, 2002) during child -parent sessions. Parallel to pla y sessions (and to sustain parental involvement) parents receive developmental information or assistance with specific parenting strategies (Landreth, 2002) . Additionally, parents may participate in psychotherapy, however, only one RPT treatment model, Th ematic Play Therapy (Benedict & Mongoven, 1997) is explicit about its use to explore parental internal working models of attachment in individual psychotherapy sessions (Benedict & Mongoven, 1997). Finally, clinical supportive services (i.e. assistance wi th concrete needs, advocacy) would be part of treatment process only if parents were involved in an Integrated Play Therapy (Gil, 2006) model . A Common Practice Despite Differences & Limited Studies Despite the differences within the utility of play and play techniques and treatment components related to parental involvement and the clinician -parent relationship; integration is a !9 common clinical practice. According to the literature, i ntegration increases the scope of clinical services and fulfills a trea tment need within IMH for specialized play techniques, in particular with older toddlers and preschoolers and/or the ability to utilize play -based family sessions (Lieberman & Van Horn, 2008). For RPT, it enhances parental interventions, in particular the ability to address how previous relationships impact current parent responses. Additionally, it ensures supportive services are embedded within each RPT treatment model, which becomes an important aspect when working with families living in poverty. How ever, to date, there are no known studies examining the integration process and outcomes related to the integration success, or the effects of the integration on child outcomes (see Appendix A for a list of search engines, key words , and specific journals ). As a result, little is know n about the clinical decision to implement an integrative model including what types of clinical information is considered (i.e. child/parent behaviors and needs, parent -child relationship difficulties, or need for cl inical supportive services) who is involved (i.e. young child, parent, clinician, clinical supervisor) and how they are involved in the process. Once a clinician decides to implement an integrative treatment model, it is unclear what tene nts of each approach are ( or are not) being utilized, how the integration process impacts parental involvement in treatment sessions , the impact on the clinician -parent relationship and/or the utilization of clinical supportive services. Therefore, research studies regarding the integrative process are needed in order for clinicians and researchers to identify and gain a more explicit understanding of treatment components within the process that do (or do not) align with IMH or RP T treatment approaches and outcomes of th e integr ative treatment process and the effects of the integrative process on child and parent treatment outcomes. This knowledge can strengthen a clinicianÕs ability to make evidenced -informed clinical decisions (Spring & Hitchcock, 2009; Thyer & Pignotti, 2011) !!!!!10 and can serve as a guide for clinicians focused on promoting the parent -child relationship and reducing risk factors of preschoolers and families living in poverty. Given the limited studies and the stat e of Michigan recent ly expanding the definition of IMH to include children ages 4 and 5 years (MAIMH, personal communication, 11 -19-14), it is imperative that future studies prioritize integrative treatm ent models that are inc lusive of at-risk preschoolers and families. Prior to examining an integrati ve treatment process, it is important to consider the concepts behind integration from each treatment approach and understand the efficacy of individual treatment models. Therefore, the following literature review focuses on conceptual literature related to integration process and efficacy studies for individual IMH and RPT or existing integrative treatment models within IMH and RPT specific to 3 to 5 -year -old children living in poverty . This specific age range was chosen because three, four, and five yea r old children have the developmental capacity to utilize symbolic or metaphoric play , which is a key variable in a childÕs ability to process and resolve psychosocial difficulties within the context of relational play therapy approaches . IMH clinicians i dentified the acquisition of this developmental milestone as a primary reason to integrate play therapy into infant mental health (Benham & Slotnick, 2006; Paradis, 2002; Tuters & Doulis, 2000). Since young children ages 0 to 2 do not have the development al capacity to use symbolic or metaphoric play, they were excluded from this study . The determinant of at -risk was included as a criterion, as RPT clinicians viewed it as a primary reason for integr ating infant mental health and play therapy (Benedict & M ongoven, 1997; Gil, 2006). Definitions of Terms The following definitions are included to provide clarity. They are derived in accordance with academic literature. !11 At-Risk: A young child or parent is considered at -risk when they have been exposed to one or more risk factors, which includes poverty. Risk Factor(s): A risk factor is an attribute or experience that may lead to developmental and/or mental health concerns. Risk factors for young children and parents include insecure or disruptive par ent -child attachment relationships, low parental education, parental substance abuse, parental mental illness, poverty, single -parent families, teen mothers, non -employed parents (within the previous year), and residential mobility (changed residences one or more times in a 12 month period) (Robbins, Stagman & Smith, 2012) food shortages and unreliable transportation (Broussard & Joseph, 2009). Infant Mental Health (IMH ): IMH is an inter -disciplinary field rooted in the belief that a health y parent -child relationship is necessary for the optimal physical, social, emotional, and cognitive development of a young child (Weatherston & Tableman, 2002). The parent -child attachment relationship is a central aspect to IMH services as it shapes the c ognitiv e, emo tional, and social context of early childhood experiences. These experiences lead to the development or impairment of cognitive schemas that help a young child org anize and interpret information, self -regulatory skills and the o rganization of behavior fro m a systems perspective (Weatherston & Tableman, 2002; Whipple, 2015). IMH acknowledges the parent -child relationship i s co -constructed and therefore focuses on the reciprocal nature of the secure vs. insecure attachment relationship (Whipple, 2015). Par ents are also an integral part of IMH as their ability to seek and maintain a secure relationship relates to their nurturing style and responses, which are derived from their own childhood experiences and current levels of parenting stress (Weatherston & Tableman, 2002). IMH S ervices: IMH services are relationship -based with a shared focus on the child, !!!!!12 parent, and the parent -child relationship. IMH services are usually intensive, long -term, home -based , preventive, strength -based, and comprehe nsive (Whipple, 2015). The young child and parent(s) are seen together and the parent -child relationship is the focus of treatment. However, all members of the family are encouraged to participate in treatment and this may include siblings, grandparents, or be extended to non -family members such as supportive neighbors, or teachers. IMH services include developmental guidance and parenting, parental empathy and support, concrete assistance with basic and immediate needs (which includes connecting families to community resources), advocacy, encouragement to solve problems and plan ahead, support to dev elop a positive support system and the resol ution of unresolved conflicts (rooted in early childhood experiences) to reorganize internal working models of att achment (Fonagy & Target, 2003) and modify current maladaptive behaviors or parenting responses (Weatherston & Tableman, 2002; Weatherston, 2000). Overall treatment goals include healthy development of the young children, reduction of risks and pathology for the child and parent, and stability of the parent -child relationship (Weatherston & Tableman, 2002; Weatherston, 2000). Concrete Needs Assistance : Clinicians assist families with gaining resources or providing referrals to obtain basic and immediate needs such as housing, food, clothing, transportation, health insurance and legal services . Advocacy : Clinicians advocate on behalf of the child to ensure stable care within the family system and advocate for families within larger systems suc h as court, school (s) , and/or child welfare. IMH Clinician -Parent Relationship : Within IMH, the clinician is responsible for the establishment of a positive clinician -parent relationship, in which parents experience a secure attachment relationship. Th is provides a holding (or containing) function for parents to examine !13 unresolved conflicts and reorganize their internal working models, which in turn facilitate growth in the parent -child relationship (Fonagy & Target, 2003). Thus, a positive clinician -parent relationship enhances a parentÕs ability to make behavioral changes, and develop a strong and secure parent -child relationship (Weatherston & Tableman, 2002). To create a positive and secure clinical relationship, IMH clinicians strive to be consist ent, respectful, attuned to parental needs, respond with compassion, follow the parentÕs lead, set limits and respond with empathy (Weatherston, 2001). Integration of Treatmen t Models: When one or more treatment model s are combined in order to meet the developmental and mental health needs of the young child, parent, and/or family; and within the context of the familyÕs environment and/or cultural needs. Internal Working Model of Attachment: A personÕs cognitive framework that compromises m ental representations for understanding the world, self and others (Bowlby, 1969). For example, a healthy internal working model comes from secure attachment and looks like this: ÒI am lovable, others are trustworthy, and the world is open for exploration. Ó Parent or Caregiver : A parent or caregiver is defined as a person or p ersons who provide basic care for the young child and serve as the childÕs primary attachment figure. Parental Involvement : Occurs when the parent actively participates in discu ssions with the clinician during home visits and either observes or participates in the play during play sessions. Positive Parent -Child Relationship : A parent -child relationship is formed during day -to-day reciprocal interactions, and these interaction s foster the attachment process. Sensitive, and responsive caregiving support a healthy and secure attachment, which is also known as a positive !!!!!14 parent -child relationship. A positive parent -child relationship provides the foundation for optimal emotional , social, and brain development ( Crockenberg & Leerkes, 200 0; Zeanah & Zeanah, 2009 ) including a childÕs sense of self (Tronick & Beeghly, 2011). In contrast, non -positive or problematic parent -child relationships may increase the likelihood of maladaptiv e child out comes (Scheeringa & Zeanah, 2001 ). Poverty : When a familyÕs total income falls below the federal poverty level. In 2012, the federal poverty line was $19, 090 for a family of three (Robbins, Stagman & Smith, 2012). Distinctions within th e federal poverty level include low -income (less than 200% of the federal poverty level), poverty (less than 100%), and extreme poverty (less than 50%) (Robbins et al., 2012). For this study, all three distinctions are included in the definition of povert y. Protective Factor(s): Reduction of the impact of risk factors. For young children, the parent -child relationship is a conduit in which young children experience risk factors (Zeanah, Boris & Scheeringa, 1997), and a positive parent -child relations hip can buffer risk factors young children are exposed to (Luther, 2006; Zeanah & Zeanah, 2009). For example, if parents promote self -regulation and minimize problematic behavioral tendencies, children are less likely to develop maladaptive developmental trajectories (Degnan et al., 2008). Psychotherapy : Is derived from psychoanalytic theory (Freud, 1905) and focuses on the unconscious processes that manifest in a personÕs current behavior . The relationship to the clinician is the focus of therapy, and a personÕs adaption to their environment and past relationships are emphasized (Fonagy & Target, 2003). The therapeutic relationship provides a holding (or containing) function (Bowlby, 1969) for clients to examine unresolved conflicts and reorganize their internal working models; which facilitates continued growth and development (Fonagy & Target, 2003). !15 Relational Play Therapy (RPT) : RPT is an overarching term inclusive of play therapy approaches rooted in attachment , relationship, developmental a nd trauma theories. RPT models are inclusive or solely focus on young children, and parents are actively involved throughout the assessment and t reatment process. RPT t reatment goals are centered on child symptom reduction and enhancing the parent -child relationship. Based on these criteria, RPT includes the following play therapy models: Filial Play Therapy, Theraplay, Integrated, and Thematic Play Therapy. In all of these approaches, the parent -child relationship is viewed as the mechanism for change , and therefore, aligns with two meta -analyses indicating parental involvement is a strong predictor of play therapy effectiveness (Bratton, Ray, Rhine & Jones, 2005; LeBlanc & Ritchie, 2001). RPT M odels : RPT models a re relationship and play -based, and can be applied in a variety of settings including outpatient and/or home -based, schools, and/or hospitals. RPT models do vary in their application of play techniques, and subsequently parental involvement. For example, Theraplay uses directive technique s within parent -child sessions, and Thematic Play Therapy utilizes both non -directive and directive techniques (tailored to needs) for individual child sessions, and psychoanalytic techniques within individual parent sessions. There are differences betwee n intended clinical populations within RPT models. Theraplay, Thematic, and Integrated Play therapy address attachment concerns, but only the latter two focus on resolving interpersonal traumas. Filial Play Therapy is for non -traumatized children, and parents who are stable enough to engage in treatment without their own psychopathology interfering with the process. Other than Thematic Play Therapy (which is solely focused on preschoolers), the majority of RPT models can be utilized with young children u p to age 12, and incorporated into treatment with adolescents, and adults. This can be a strength when addressing the needs of older siblings, parents and/or other family members. Overall goals of RPT include !!!!!16 the reduction of risks for the child and pare nt, reduction of child pathology and stability of the parent -child relationship. RPT Clinical -Parent Relationship : In RPT, the clinician -parent relationship is viewed as a collaborative process in which parents gain support through consultation and edu cation on the play process (Landreth, 2002 ). During consultations ( which occur before or after the play session), parents explore concerns about their child, and reactions to the play process. Clinicians examine parental reactions and session themes (alo ng with possible meanings), provide developmental information and guidance, and introduce specific parenting strategies to address concerns. Within this collaborative process, RPT clinicians embrace an empathic attitude, respect parents as the primary ch ange agents (for the child or family), remain open -minded, maintain a positive outlook, focus on parental strengths, and instill hope (Landreth, 2002 ). Supportive Clinical Services: Supplemental services to parents that include concrete assistance with basic and immediate needs such as housing or food (which includes connecting families to community resources), provider collaboration, advocacy, developmental and anticipatory guidance and the development of a positive support syste m (Weatherston, 2000; Weatherston & Tableman, 2002 ). Metaphoric Play: Play that is inclusive of metaphors in which a child ascribes meaning to one t oy Òas ifÓ it is another object to suggest a likeness or analogy between them . Symbolic Play: When a young child uses a toy or t oys to represent inner thoughts, feelings and/or life events. Also referred to as fantasy play. Thematic Play : Play that produces either verbal or themes within the play. Themes are inferences and are not facts. Treatment Component: Element(s) that are integral t o a specific treatment model, and are !17 need ed in order to obtain fidelity of the model. Treatment Process: Refers the progression of treatment from the assessment to the working phases of treatment, and the end or terminatio n phase . Times within each of these phases depend on the needs of the client/family and specific treatment models. Very Young Child: A child birth to 3 years of age. Young Child or Preschooler : A ch ild between the ages of 3 and 5 years. !!!!!18 CHAPTER 2: Literature Review Prior to examining an integrative treatment process, it is important to understand the concepts behind integration from each t reatment approach . Additionally, the efficacy of individual IMH and RPT models and existing integrative models within IMH or RPT specific to 3 to 5 year old children need to be exam ined. Therefore, the following literature review focuses on conceptual literature and efficacy studies for each IMH and RPT treatment model or integrative IMH or RPT models specifi c to 3 to 5 -year -old children living in poverty. IMH Treatment Models Child Parent Psychother apy (Lieberman & Van Horn 200 5; 2008) is a major treatment model within IMH and centers on helping young children and parents cope with traumatic events and life stressors. Thus far, four randomized controlled studies have been conduced on CPP with young children ages 3 to 5 years old. Sample sizes ranged from 75 to 137 indicating positive outcomes on a variety of standardized measures including the Child Behavior Checklist (Achenbach, 1991), Beck Depression Inventory (Bec k, 1996), Bayley Scales of Development (Bayley, 1989), Ainsworth Strange Situation (Ainsworth, 1978) and SCL -90 Symptoms Checklist (Derogatis, 1994). Outcomes specific to older toddlers and preschoolers include less child resistance and anger, higher leve ls of mate rnal empathy and positive parent -toddler interaction with Latino immigrant mothers (Lieberman, Weston & Pawl , 1991), reduced preschool and parent trauma related symptoms and reduced problematic behaviors (Lieberman, Van Horn, Gosh Ippen, 2005; Ip pen et al., 2011) and positive duration of treatment effects for up to six months (Lieberman, Van Horn & Ippen, 2006). The sample for the latter two studies was ethnically diverse an d included mothers that identified as Bi -racial (38 %), Lati no (28%), Afri can American (14 %), White (9%), and other (2% ). CPP is wide ly accepted as an evidenced -based !19 practice withi n the field of IMH and it has been labeled Òwell supported and efficaciousÓ by the National Child Traumatic Stress Network Empirical Supporting an d Promising Practices (Lieberman et al., 2006). The Circle of Security (COS) is a n IMH treatment model centered on the parent and his/her ability to improve caregiving sensitivity, re cognition and understand ing of overt and covert child cues and caregiv er reflection (Hoffman et al. , 2006). Hoffman, Marvin, Cooper & Powell (2006) conducted a pre -intervention and post -intervention study with 65 toddler or preschool dyads from Head Start and Early Head Start in a group treatment setting. The majority of sample identified as Caucasian (86%). Utilizing the Ainswort h Strange Situation (1978), 69% of participants (which included mothers, fathers, foster parents, and one grandmother) changed from a disorganized to an organized attachment classification. When exploring the efficacy literature, one integrated IMH treatment model was discovered. A randomized controlled trial conducted by Cassidy, Woodhouse, Sherman, Stupica and Lejeuz (2011) integrated a brief version of COS in combination with Video -Based Intervention to Promote Positive Parenting (Velderman et al., 2006) with 174 infants. Four home visits were conducted that focused on enhancing parent observation, recognizing infant signals (to improve sensitivity), attending to attachment and exploratory infant behaviors (i.e. soothing baby cries or slowing down parental response to cries), exploring parental cognitive and affective responses to baby behaviors, and examining the possibility of making changes (Cassidy et al., 2011). The study sample was diverse; mothers identified as Afric an American (43%), White (20%), Bi -racial (18 %), Hispanic (14%), and Asian (2 %). Although the sample was infants, (which is outside the spec ific age range for this study ) this work became of particular interest due to t he integrative components o f the treatment model, and the level of detail within !!!!!20 the methods sect ion regarding session content which provided insight into how researchers developed the integrative model, and applied it to parents. Results from the Ainswor th Strange Situation (Ainsworth, 1978) and the Neonatal Behavioral Assessment Scale (Brazelton & Nugent, 1995) demonstrate d treatment efficacy for highly irritable infants with dismissive biological mothers and for highly preoccupied mothers with moderatel y irritable i nfants (Cassidy et al., 2011) . This study also m arked the only known IMH publication found that integrated two models (COS and VIPPP) that explore d the relationship between the modified model and treatment outcomes. Finally, Watch, Wait a nd Wonder (WWW) focuses on parent -infant or parent -toddler dyads to improve a childÕs sense of self, emotional regulation and the parent -child relationship (Lojkasek , Muir & Cohen, 2008 ). The developers of Watch, Wait and Wonder (WWW) conducted a non -rand omized study with 67 parent -infant dyads that were assigned to either a Watch, Wait and Wonder or an Infant -Parent Psychotherapy treatment group (Cohen, Muir, Lojkasek, Muir, Parker, Barwick & Brown, 1999). The Bayley Scales (Bayley, 1993), Chatoor Play S cale (Chatoor, 1986), and Parenti ng Stress Index (Abidin, 1986) indicated that for both groups (after five months of outpatient treatment) , there was a decrease in infant /toddler problems, parenting stress, maternal intrusiveness, and mother -infant /toddler confli ct (Cohen et al., 1999). Additionally , the Watch, Wait and Wonder treatment group indicated greater shifts towards a more organized or secure attachment, and greater improvements in cognitive and emotional regulation along with higher rates of paren t satisfaction (Cohen et al., 1999). A six -month follow up study was conducted with 58 (out of the original 67) parent -toddler dyads and found that progress was maintained with the Watch, Wait and Wonder treatment group and that both groups continued to show improvements for two years after treatment (Cohen, Lojkasek, !21 Muir & Parker, 2002) . For both of these studies, it was surprising to learn the race and/or ethnicity of the infants or mothers was not reported. Only maternal age (M=32 ) years and educat ion ( M=6 ) years post high school were reported. The Concept of Integration of Play Therapy W ithin IMH As noted earlier, only one study was located th at examined an integrated treatme nt model (Cassidy et al., 2011). The study integrated a brief version of COS (4 sessions) in combination with VIPPP, which indicated treatment efficacy for highly irritable infants with dismissive biological mothers and for highly preoccupied mothers with moderately irritable i nfants (Cassidy et al., 2011). However, as the results indicate, the sample was focused on infants, and was not inclusive of 3 to 5 year olds. Casting a broader net, additional literatur e was found in conceptual literature , and/or case studies. Overall, the integration of multiple treatment interven tions to tailor services to high -risk families was viewed as a necessary and accepted practice (Lieberman & Van Horn, 2005; 2008; Paradis, 2002; Tuters & Doulis, 2000 ). Specifically, the integration of play therapy and infant mental health was proposed to increase the scope of clinical services and fulfill a treatment need within infant mental health for specialized play techniques, in particular within individual sessions with older toddlers and preschoolers and/or the ability to utilize play -based family sessions (Lieberman & Van Horn, 2008). F or play therapists, integration fulfilled a need to focus on parental mental health needs and high -risk families within an ecological (Bronfenbrenner, 1979) and a resiliency -based (Patterson, 2002) framework. Thu s, in a sense, it provides play therapists an overarching treatment model focused on early childhood, and the involvement of parents or additional caregivers into treatment. Within the conceptual writings, it was noted that the use of play was viewed as a natural medium to help facilitate communication and expression in the child -clinician relationship or !!!!!22 within the child -parent -clinician relationship (Paradis, 2002; Tuters & Doulis, 2000 ). The role of play was based on the development of the young chil d and their ability to utilize (or not) symbolic or metaphoric play (Benham & Slotnick, 2006; Paradis, 2002; Tuters & Doulis, 2000). Therefore, play with very young children was utilized to increase ma ternal and paternal sensitivity, while play with older toddlers and prescho olers was used to help the child and parent process their story, and learn additional coping skills . In addition , play therapy was often recommended for individual child sessions (when warranted) and to increase the scope of directive play interventions during parent -child, and/or family sessions ( Tuters & Doulis, 2000 ). However, the details regarding the process of treatment, and the role of the therapist were somewhat vague. It was also unclear if non -directive and/or directive pla y techniques were being utilized in sessions. Further examination of the CPP manual also discovered the use of play specifically to help young children and parent(s) process and heal from their traumas, which included a discussion on toy selection, and ho w to include parents in the play process (Lieberman & Van Horn, 2005). However, play was described as Òjust playingÓ verses play therapy, and again it was unclear what specific non -directive and/or directive play techniques were being utilized. As integr ation is an accepted and common practice (Lieberman & Van Horn, 2008; Paradis, 2002; Tuters & Doulis, 2000 ) with at -risk preschoolers and their families, it is vital that its efficacy is explored . Future IMH Needs In order to fulfill current gap s withi n IMH , future studies need to provide in -depth knowledge about the integrative process and its relationship to specific treatment outcomes . Equally important (for clinicians i mplementing integrative models), future research need s to include details relate d to the implementation of the treatm ent model (i.e. specific constructs from !23 each model and techniques implemented) to ensure treatment fidelity as demonstrated in Cassidy et al. (2011). In terms of design, the continued use of child, parent and relation ship -focused standardized measures is imp ortant, however, data also need to be collected from fathers (even if the mother is present) and/or additional caregivers (i.e. grandparents, extended family, supportive friends and/or neighbors) to increase validit y and reliability of treatment outcomes with a variety of caregivers. The later is innovative, and could lead to deeper understanding of the different systems that influence early childhood and parental mental health including how supportive caregive rs im pact treatment outcomes. Finally, f uture studies also need to examine treatment outcomes at several different intervals in order to measure long -term outcomes (Lieberman, 2008; Moss, Dubois -Contois, Tarabulsy, St. -Laurent, & Bernier , 2011). RPT Treatmen t Models Filial Play Therapy (Guerney & Guerney, 1967) is centered on improving parental attunement, and communication skills with their child during play sessions. Three controlled trials were conducted on the original six -month format of Filial Play T herapy and results from a parental self -report scale (developed by Gurney, Stover & OÕConnnell in 1964) indicated significant child (ages 3 to twelve) and parent relational improvements (as cited in Gurney et al., 1967). One of the trials was a group form at (1971), and additional clinical observations suggest part of the relational improvement related to the increase of self -reflection during play sessions and less parental directive behavior (Gurney et al. , 1967). Utilizing the tenents and treatment go als of the o riginal model, Landreth developed a 10 -week format of Filial Play T herapy (Landreth, 2002). Since this development, several controlled trials have been conducted at the Center for Play Therapy at the University of North Texas. Sample sizes wi thin these trials ranged from 7 to 22 in the treatment groups, and 7 to 21 in the !!!!!24 control groups. The range of children was 3 -10 years of age, which is inclusive of 3 to 5 years olds, but no t specific to young children. The majority of samples were predo minantly White Americans and came from middle class backgrounds. These studies utilized similar measures including the Porter Acceptance Scale (Porter, 1954), Parenting Stress Index (Abidin, 1983), and the Measurement of Empathy in Adult and Chil d Interac tion (Guerney, Stover & DeMerritt, 1968). Results from these controlled trials demonstrate an increase of parental empathy (Bratton &Landreth, 1995; Brown, 2000; Chau & Landreth, 1997; Costas &Landreth, 1999; Glover & Landreth, 2000; Harris & Landreth, 19 97; Jang, 2000; Kidron & Landre th, 2010; Smith & Landreth, 2004 ; Yuen & Landreth, 1997 ; Yuen, Landreth & Baggerly, 2002 ) parental acceptance (Alivandi -Vafa et al., 2010; Kale & Landreth, 1999; Landreth & Lobaugh, 1998; Tew et al., 2002; Topham et al., 2011 ), parental stress (Costas & Landreth, 1999; Glover & Landreth, 2000; Jang, 2000; Kidron & Landreth, 2010 ; Yuen, Landreth & Baggerly, 2002 ), reductions in child problematic behaviors (Alivandi -Vafa et al., 2010; Baggerly, 1999; Beckloff, 1997; Topham et al., 2011), reductions in child anxi ety (Glazer -Waldman et al., 1992 ) an d depression (Tew et al., 2002), and improved child -parent and family relationships (Boyer, 2011). Clinical populations within these studies in cluded children with pervasive developm ental disorders (Beckloff, 1997), learning disorders (Kale & Landreth, 1999), mental retardation, chronic illness -in the hospital (Tew et al., 2002 ), chronic illness -out of the hospi tal (Glazer -Waldman et al., 1992 ), child sexual abuse (Costas & Landreth, 1999), and domestic violence (Kinsworthy & Garza, 2010; Smith & Landreth, 2004 ). Filial therapy has also been examined and demonstrated to be effective with incarcerated mo thers (Harris & Landreth, 1997 ), incarcerated fat hers (Landreth & Lobaugh, 1998), single parents (Bratton & Landreth, 1995) and !25 recently in combination with a neuro -sequential model to high -risk preschoolers (Barfield, Dobson, Gaskill & Perry, 2012). Filial Play Therapy has also demonstrated effectiveness in increasing parental empath y, and reducing parent stress with homogenous samples focused on specific cultures including Native Americans (Glover & Landreth, 2000), Korean Americans (Jang, 2000; Lee & Landreth, 2003), Israeli familie s (Kidron & Landreth, 2010), Chinese America n famil ies (Chau &Landreth, 1997; Yuen & Landreth, 1997; Yuen, Landreth & Baggerly, 2002), and parenting acceptance with Iranian families (Alivandi -Vafa & Ismail, 2010) . Additionally, a case study indicated improved parent -child relationships and positive family interactions with a Native American family (Boyer, 2011). Qualitative studies of the FPT 10 -week model have also been conducted and indicate improvements in child problematic behavior , parental understanding, positive perceptions of the parent -child re lationship (Bavin -Hoffman, Jennings & Landreth, 1996; Edwards, Ladner, & White, 2007; Foley, Higdon & White, 2006; Kinsworthy & Garza, 2010; Solis Meyers & Varjas, 2004; Wickstrom, 2009), improved partner communication (Bavin -Hoffman et al., 1996), and improved martial relations and family functioning (Wickstrom, 2009). To date, no outcome studies have been completed on the 20 -session format (VanFleet, 1994). Theraplay (Jernberg & Booth, 2010) centers on the parent -child dyad and attachment reparation. There are a total of four controlled studies examining the efficacy of Theraplay (Jernberg & Booth, 2010) , however, only one study focuses on young children ( Wetting, Coleman & Geider, 2011) . The lat ter study utilized a sample of 167 children ages 2 to 6 t hat presented with a language disorder and were either shy or withdrawn (Wetting et al., 2011). Results from the Clinical Assessment Scale for Children and Adolescent Psychopathology !!!!!26 (Doepfner, Berner, Flechtner, Lehmkuhl & Steinhausen, 1999 as cited in We tting et al., 2011 ) indicated children in the Theraplay treatment group demonstrated improved assertiveness, self -confidence, trust, and expressive and receptive communication along with a decrease in social withdrawal when compared to the control group (W etting et al., 2011). These results were maintained over a two -year period. Recently, Therapla y has been awarded an evidenced -based status from the California Evidence -Based Clearinghouse (2009) based on the results from the Wetting et al. (2011) study, its publication of a manual which was recently revised (Jernberg & Booth, 2010) and an extensive training certification program. To date, no known outcome studies have been conducted on Integrated Play Therapy (Gil, 2006) but Gil has outlined a compr ehensive treatment approach to children who have exper ienced varying levels and degre es of physical, sexual, and/or emotional abuse (2006). Interventions include a variety of modalities and are tailored to help the child and/or family process the many asp ects of trauma and may include individual play -based therapy inclusive of expressive therapies such as art, play, or sand tray work; group therapy consisting of structured short -term groups for children, family th erapy; psychopharmacology ( if needed); pare nt-child therapies including filial play therapy, or parent -interaction therapy; and parent support groups (Gil, 2006). Supportive services are inclusive, but are specific to child maltreatment. These supportive services include advocacy, support and Deve lopmental G uidance to parents, case management as needed, and education focused on navigating court and legal proceedings. Similar to IMH, this model supports tailored treatment services, use of empirically supported theories and neurobiological concepts. These aspects do increase the design validity of this integrated approach, however, studies need to examine its treatment effectiveness with at -risk young children. !27 Thematic Play Therapy (Benedict & Mongoven, 1997) is the final pl ay therapy approach included within RPT. Thematic Play Therapy seeks to individually repair a child and parentÕs maladaptive inner working model of attachment. To date, two studies have been conducted using aspects of Thematic Play Therapy. Snow, Hudspeth, Gor e and Seale ( 2007) utilized two case studies to explore connections between play themes and child behavioral outcomes. Utilizing Thematic Play Therapy Thema tic Codes (Benedict & Hastings, 2002 ) and the Childhood Behavior al Checklist (Achenbach, 1991) results indicated a relationship between play themes in play sessions, and the reduction of externalizing behaviors and aggressive behaviors outside of play sessions (Snow et al., 2007). However, generalizability of findings is limited due to the low number of case studie s used (Snow et al ., 2007). Holmberg, Benedict and Hynan (1998) reviewed 33 records of children with attachment concerns to explore gender differences within play themes. Utilizing Thematic Pl ay Therapy Codes (Benedict & Hastings, 2002 ), results indica ted both girls and boys held themes related to aggression, failed and positive nurturing, instability, safety, ambivalence, and doing and undoing . Positive nurturing was the most frequent theme for both genders. Girls demonstrated higher rates of positiv e self -nurturing , fixing, control and constancy (Holmberg et al., 1998). Boys that were exposed to violence had higher levels of aggressive themes , and girls exposed to violence had higher rates of faile d nurturing, and broken characters in which figurine s were sick, hurt or need ed repair (Holmberg et al., 1998). Although these studies further examine the validity and clinical utility of the thematic codes, generalizability is limited due to the small sample size, and the use of the Thematic Play Therapy Code (Benedict & Hastings, 2002 ), which is a non -standardized measure (Snow et al., 2007). !!!!!28 The Concept of Integration of IMH W ith in RPT Many RPT treatment models have been developed from the integration of theories and corresponding clinical interventi ons specific to young children. Therefore, it is not surprising two RPT models, Integrated Play Th erapy and Thematic Play Therapy, utilize similar infant mental health theories (i.e. attachment, developmental, psychoanalytic and trauma) and principles (Be nedi ct & Mongoven, 1997; Gil, 2006). On the other hand, Theraplay is closely related to infant mental health , in particular due to its use of parent -child sessions (Jernberg & Booth, 20 10). Filial Play Therapy utilizes similar relational concepts by usin g the parent -child relationship as the mechanism for change. Similar to IMH, many RPT models recommend the integration of treatment models, and/or additional play techniques to tailor treatment services (Benedict & Mongoven, 1997; Gil, 2006). In addition , supportive clinical services are recommended to meet the needs of high -risk families (Gil, 2006). However, these recommendations stem from either conceptual writings and/or the corresponding treatment manuals and to date, no outcome stu dies have been co nducted focusing on the integration of play therapy into a RPT or non -RPT treatment model. Future RPT Study Needs Future studies are needed that focus on the integration of play therapy into an infant mental health approach specific to 3 to 5 year olds who are living in poverty . Moving forward, it is important to keep in mind RPT research critiques while designing future studies . For example, the majority of quantitative RPT studies focus on two-parent families with middle to higher incomes (ranging f rom $30,000 to $60,000) . One study attempted to address this limitation, and focused on recruiting single parents, which led to 41% of the sample having an income of below $20,000 (Topham et al., 2011). Results from this study demonstrated RPT effectiven ess as !29 evidenced by greater reductions in child behavior problems, improved parental acceptance, and parent communication of this acceptance during parent -child play (Topham et al., 2011). However, the sample size was relatively small (N=27), which limits the generalizability of the study to low -income families. Thus, there continues to be a need to examine RPT efficacy with larger samples of low -income families. Similar to IMH, data needs to be collected from a variety of caregivers ensuring fathers are also represented in samples. RPT studies used a variety of measures, however, some were not standardized which imp acts the validity of the study and leads to a variety of related outcomes. In order to build a more supportive literature base with higher l evels of validity and reliability, standardized measures focused on similar relational constructs (i.e. the parent -child relationship) need to be incorporated into new studies along with the continued use of multiple measures. !!!!!30 CHAPTER 3: Methodology Problem Statement Although each approach has efficacious treatment models rooted in randomized or non -randomized studies, curren t evidence does not include specific knowledge about the process of integrating RPT i nto IMH; outcomes related to int egrative process of RPT into IMH for young children living in poverty; or the effects of the integrative process on child and parent outcomes. This is concerning as this int egrative model receives support within both field s as an acceptable practice . Howe ver, the integrative model is not yet rooted in evidence d-based practices or research specifically with at -risk 3 to 5 year olds and their families living in poverty . The refore, the following study aims to contribute to this knowledge gap by providing an in-depth examination of the integrative proc ess, and its influence on treatment components . Research Questions To gain an understanding of an integrative treatment process, the experiences of those involved in the integrative process need to be examined. Therefore, research questions center ed on the experiences of parents with at -risk preschoolers involved in an integrative treatment process, and clinicians providing integrative treatment services with an emphasis on th e similar but diffe rent treatment components between RPT and IMH treatment models (See Appendix B for a Conceptual Map). Qualitative methods examine the first and last research question, whereas both qualitative and quantitative methods explore the second and third research questions (which will be further discussed in the methods section) . To provide a foundation for understanding the different treatment components between IMH and RPT, the first research question explores how clinicians deci de to integrate treatment modalit ies. Research question two focuses on what RPT and Non -RPT models clinicians chose to integrate into an IMH approach. !31 The third question focuses on parental involvement as this treatment component varies between IMH and RPT treatment models. Finally, th e last research question focuses on the variability within the clinical relationship, and how an integrative treatment process influences this specific relationship. Research Question 1. How do clinicians decide to integrate play therapy within an IMH t reatment approach with at -risk 3 to 5 year olds and their families? Research Question 2 . What RPT models vs. Non -RPT are clinicians utilizing within an IMH treatment approach for at -risk 3 to 5 year olds and their families? Research Question 3 . How are parents involved in th e treatment process when play therapy is integrated into an IMH approach with at -risk 3 to 5 year olds and their families? Research Question 4. How does the clinician -parent relationship impact the integrative treatment p rocess? Research Procedures This program evaluation started on February 13, 2012 with an agen cy program that integrates play therapy interventions within the context of infant mental health approach with at -risk preschoolers and their families. A needs assessment was completed in collaboration with the co -primary investigator (Ellen E. Whipple, PhD, ACSW) and the agency program supervisor. A proposal was then s ubmitted and approved by the agency research team on December 5, 2012. Confidentiality st atements were signed by this researcher, the co -primary investigator, and an undergraduate research student (s) assisting on the study and sent to the agency research team. An application was also submitted to Michigan State UniversityÕs Ins titutional Revie w Board (IRB). The IRB determined the study Ò non-regulated research Ó because the evaluation would not !!!!!32 contribute to generalizable research (i041509/x13 -023e) and therefore is not regulated by the IRB under section 45 CFR 46.102(d). No further action was r ecommended or needed per the IRB. Data collection started with the inter views on April 2, 2013 and end ed with the completion of the Service Provider Checklists on March 27, 2013. Parent and clinician interviews. A program meeting was held to detail th e program evaluation to clinicians, and to answer any questions related to the first phase of the study, which focused on the interviews. Following CMH research procedures, clinicians were instructed to ask each parent on their caseload if they wanted to participate in interviews. Specific approaches to e ducate parents about voluntary participation, and confidentiality were reviewed during the meeting. Parents could contact researchers if needed, and that informat ion was provided to clinicians, which was included in the Informed Consent Form (see Appendix C ). If parents were willing to participate, they were given a stamped envelope and the Informed C onsent Form detailing their voluntarily participation, interview procedures, and confidentiality. They c ould sign the Informed C onsent Form and return it to their assigned clinician or mail it in at a later time. If parents signed the Informed C onsent Form , clinicians turned them into the program super visor who kept them in a locked drawer in her office . The program supervisor contacted this research er who picked up the Informed Consent Forms . Per agency research procedures, only the first name and phone numbers of the parents were available to view (the program supervisor had blacked out the last name of the participant). The researcher called parents, and home visits were scheduled to conduct the interviews. If home visits were not preferred or scheduling became problematic for parents, they were offered a phone interview. Interviews with parents were co nducted between April 2, 2013 through June 31, 2013. !33 Clinicians were asked to participate in interviews during the same meeting time that parent interviews were discussed. The researcher provided info rmation on basic procedures, reinforced pa rticipatio n was voluntarily and confiden tiality would be maintained. The researcher opened the floor for questions, and also provided contact information if they wanted to ask quest ions at a later time. Informed Consent F orms were given to the clinicians (See Appe ndix D) following the q uestion and discussion period. Clinicians could either return the Informed Consent Forms (if they wanted to participate) after the meeting, or m ail them to the researcher (the agency provided envelopes and stamps to cl inicians). A master list was developed with names of six program clinicians and identification number s were assigned using a letter (C for clinician) and numbers (1 -6). After receiving the Informed Consent F orms, clinicians were contacted via phone to set up interview s. Clinicians were giv en the choice if they wanted the interview to take place at the program office or an alterative location. All of the c linicians chose to have interviews at the program office . Prior to the interviews, t he master list was updated with clinician contact information, date/time of the interview and p referred interview location. Interviews were conducted between March 26, 2013 and April 9, 2013 in a confidential meeting room at the program office. Prior to conducting interviews, paren ts and clinicians were asked permission to audiotape the interview, and if they agreed, they signed an additional consent form (See Appendix E). Parents and clinicians were also informed that once the interview was transcribed, and confirmed by three rese archers (the researcher and two undergraduate student researchers) , the audiotapes would be deleted. Parents and clinicians were offered a $25.00 Visa, Target, or Meijer gift card for their participation. Gift cards were given at the end of interviews, a nd if phone interviews were conducted, gift cards were mailed to the participantÕs home. Once the interviews were !!!!!34 conducted, the researcher updated the master list with the date; length and location of the interview along with indicating the participant signed the Informed Consent Form, the audio consent form, and received a gift card. Service provider c hecklist. Clinicians were asked to fill out a Service Provider Checklist after each home visit for t wo months (See Appendix F ). The researcher attende d a staff meeting two weeks prio r to the implementation of the Service Provider Checklist to provide support and detail the procedures. At the staff meeting, copies of the checklists and a codebook were provided to each clinician and the pr ogram superviso r. Although clinicians were aware of the majority of terms on the Service Provider Checklist, the codebook was reviewed and each item on the checklist was defined. Q uestions pertaining to the definitions were answered during the meeting, and c larificatio n on the overall process of completing a checklist for each home visit and the collection of the checklists was established through clinician questions and open discussions. Checklists were collected for a period of two months between January 27, 2014 thro ugh March 27, 2014 . The accumulating checklists were kept in a locked office at the agency . Methods Research Design Using a pragmatic perspective, which values both objective and subjec tive knowledge (Morgan, 2007), a mixed -method program evaluation was chosen to explore the integration of play therap y into infant mental health specific to at -risk preschoolers aged 3 to 5 years of age and their families living in poverty. A mixed -method approach allows an in -depth understanding of the integration process f rom multiple perspectives, examination of the integrative process in relation to treatment outcomes and the ability to triangulate results (Klassen et al., 2012). Therefore, intentiona lly using both qualitative and quantitative methods seeks to maximize the !35 strengths and weaknesses of both approaches (Thyer, 2001). Additionally, t he combination of qualitati ve and quantitative methods also provide s a meta -inference or purposeful conside ration of the total evidence (Green, 2007), which can identify contradictory and confirmatory evidence leading to a fuller understanding of the integrative treatment process. The qualitative and quantitative methods in this study utilized a cross -sectional research design and a non -probability purposive sample. To gain in -depth understanding of the process from multiple perspectives, qualitative methods included parent and clinician interviews. In order to triangulate the interview data and increas e va lidity (Creswell, 2013), a Service P rovider Checklist was incorporated to further examine the scope and frequency of treatment modalities . Agency p opulation. A mental health program within a Community Mental Health (CMH) agency in the Midwest was asked to participate in this study because their treatment approach includes the integration of play therapy within an infant mental health context . The program provides home -based mental health services for 3 to 5 year old children who display significant emot ional, s ocial, and psychiatric distress, are at risk of preschool expulsion due to behavioral problems, have medical problems, disabilities, or developmental delays which cause distress in the family system (PYC , 2000). To qualify for services, children n eed to be between the ages of 3 and 5 years of age, low -income, uninsured, or have Medicaid or MI -Child insurance , and meet either the CMH established criteria for a Serious Emotional Disorder (SED) and /or a DSM -IV diagnosis (program is still using the DSM -IV). The majority of families experience high levels of stress related to unresolved traumas, parent -child attachment distributions, problematic and intensive child behaviors, interpersonal violence, financial str ains, and systemic barriers ( PYC, 2000). The p rogram services an average of 100 families per year (PYC, 2000) and there are a total of six masters -level clinicians with a degree in cli nical social !!!!!36 work, and training in infant mental health, play therapy, specialized trauma and attachment inter ventions with at -risk families. Clinicians do receive reflective supervision weekly or bi -weekly (depending on need). There is also a family service worker (FSW) who provid es support to the clinicians as necessary (i.e. attends sessions to complete an acti vity with the child if clinicians need a one -on-one parent session). The tri -county CMH agency and Medicaid fund the program. Key stakeholders in the program are the 3 to 5 year old children and their families , program clinicians and staff, program super visor, CMH senior management team, and the CMH board of directors. IMH t reatment i nterventions utilized by clinicians include parent -child therapy, parental empathy and support, collaboratio n with other systems providers, concrete needs assistance, anti cipatory guid ance, parent skill training, crisis resolution and if ne eded families are referred for a psychiatric evaluation and/or consultations (PYC , 2000). Additionally, play therapy is identifie d as an intervention for the program , and integrated into the established IMH treatment approach. Treatment services are provided in the home, and occasionally in the community (i.e. at a school or childcare setting). Sample . Participants in the sample were eith er parents/caregivers of children enrolled in the program, or clinicians providing direct clinical services to t he families enrolled in the program. In order to maximiz e the number of participants , a non -probability purposive sample was utilized for the paren t and clinician interviews, and the collectio n of the Service Provider Checklists . This method yielded 20 parent interviews, and 4 clinician interviews conducted from April 2, 2013 to June 6, 2013. For two months, program clinic ians completed a Service Provider Checklist after each home visit with young children and families. A total of 361 Service Provider C hecklists for a total of 81 families were collected from January 27 to March 27, 2014 . !37 Measurement Qualitative i nterviews . The interv iews with parents and clinicians were semi-structured such that a basic set of questions were ask ed to each participant; and the respons es to the questions were open -ended and utilized standard replies (Grin nell, Gabor & Unrau, 2010). A total of 12 questions for the clinicians (See Appendix G ), and a separate set of 12 questions for the parents (See Appendix H ) were asked during interviews. However, only clinician questions 2, 3, 4, 5, and 6 , along with parent questions 4, 5, and 7 pertain to this study whereas the remaining questions will be explored within p rogram evaluation findings . To explore the first research question, which centers on exploring how clinicians decide to int egrate treatment models, c linicians were asked how they determine treatment modalities (interview question 2 ). The second researc h question focuses on what RPT and Non -RPT models clinicians chose to integr ate. Therefore, clinicians were asked during interviews what play theories, models and play therapy techniques they applied along with what IMH principles or models they incorpora ted into sessions (interview questions 3, 4, and 5). Research question three focuses on the variability of parental involvement and to examine this aspect, clinicians were asked how they involved parent s (interview question 6) while parents were asked if t hey were involved in sessions, how they were involved, and what they thought about the process of the sessions. Finally, the last research question focused on the variability within the clinical relationship, and how an integrative treatment process influ ences this specific relationship. During the interviews, parents were directly asked to describe their rela tionship with the program clinician (interview question 7). Establishing t rustworthiness is an important aspect of qualitative research. It seeks to ensure da ta is accurate and dependable (Creswell, 2013) . Creswell and Miller (2000 ) use the !!!!!38 term validation (not verification) to ensure the process is accurate. Eight strategies are recommended which include prolonged engagement and persistent field observation; triangulation of multiple sources, methods, investigato rs and theories; peer reviews, debriefing, and/or negative case analysis ; clarifying researcher bias based on past experiences, prejudices, and orientations that have shaped study design or analyses; member checking; external audits, and providing rich, thick descriptions whe n describing a case or theme. Creswell and Mil ler (2000) also recommend a number of reliability activities to enhance dependability that include detailed field notes, recording and transcribing interviews to indicate trivial pauses and overlaps; and inter -coder agreement between multiple coders to analyze transcripts. For this s tudy, the following procedures were used to strengthen the trustworthiness of the data. In terms of validation techniques (Creswell, 2013), m ultiple sources (pare nts and clinicians), multiple methods (interviews and Service Provider Checklist s) and multiple investigators (this researcher, and two undergraduate student researcher s) were used in order to triangulate the data . The first undergraduate student researcher transcribed the interview data, while a second undergraduate student during the following school year re -checked the transcriptio ns and participated in the data analysis for the in terviews. From this point, participation from an undergraduate student researcher denotes the second student involved in this study. In addition to multiple sources, methods and investigators, d ebriefing between the research er and undergraduate student researcher occurred regarding the identification of significant state ments and codes, code meanings, and code assignments. Negative case analysis was also completed to search for contrasting data. Ad ditionally, researcher bias was examined through bracket ing; and r ich, thick descriptions are provided to elicit detailed descriptions that !39 will enable the reader to determine if information can be transferred to other settings (Creswell, 2013). In terms of reliability activities (Creswell, 2013), field note s were taken, and interviews were audio recorded. Audiotapes were transcribed by a student researcher, and then re -checked by two additional researchers (the researcher and a different undergraduate student researcher) . During a series of meetings betwee n April 1, 2015 and April 10, 2015, c onsensus was reached on the identification of significant statements, the code label , and its definition . A codebook detailing this information was developed to ensure the researcher and the undergraduate student resea rcher process the data in a similar manner (Salda Œa, 2013). Following the completion of the codebook, significant statements were indepen den tly reviewed and coded by the researcher and the undergraduate student researcher, which yielded an 83 % inter -coder agreement. Outside experts Joa nne Riebschleger, Ph D and Victoria Fitton, PhD review ed the codebook, and other trustworthiness procedures. The undergraduate student researcher was trained through multiple meetings and readings focused on qualitative met hods and analysis. Spe cific qualitative software was not be used, rather, editing tools within Microsoft Word and Excel were used to compile significant statements, codes, cod e meanings and assignments. Service provider c hecklist. To triangulate the d ata, and explore patterns of service use (Thyer, 2001), a Service Provider C hecklist was developed. The chec klist log s the freque ncy of treatment interventions, and supportive clinica l services used during each home visit. The items on the Service Provid er C hecklist were identified first by researchers via the interview data , and then reviewed by the program supervisor and clinicians. The final version had 53 items that asked clinicians to identify the leng th and modality of the session; parental partici pation; specific treatment and parenting interventions; supportive services focused on concrete needs or !!!!!40 advocacy, and/or coordinati on with medication management se rvices, school or court systems (see Appendix F ). In each of the areas, there was an Òother Ó line provided to ensure clinicians were able to document all of their services. The Service Provider Checklist focuses on research question two and three. Research question two explores what RPT and Non -RPT treatmen t interventions clinicians are usin g within an integrative treatment approach for young children and their families. Therefore, the specific RPT (Non -directive, Non -Directive and Directive , and Directive Play Therapies), and IMH (Parent Psychotherapy and Child -Parent Psychotherapy) treatmen t models were incl uded (items 17 -23). In addition, program staff identified using Cognitive Behavioral Therapy (CBT) and Trauma -Focused CBT (TF -CBT) , art therapy, safety planning, bibl iotherapy, and social skill or sensory integration treatment models (it ems 24, 25, 26, 27, 28, 29). Research question three explores how parents are involved in an integrative treatment process. Therefore, the length and modality of the session (i tems 3 -16) were included in the Service Provider Checklist to explore if and how often parents were involved in treatment sessions, and if a relationship ex ists between length and modality and specific treatment interventions. Supportive clinical services (i.e. developmental or anticipatory guidance, concrete need assistance, advo cacy, or collaborations with medical, school, or court systems) were included (items 30 -53) to explore the frequency of these services, and if a relationship exists between the occurrence of supportive clinical services and length and modality of parental involvement , and/ or specific treatment interventions. Clinicians completed a Service Provider Checklist after each home visit for two months yielding 361 completed checkl ists on a total of 81 families between January 27, 2014 through March 27, 2014 . As th e Service Provider C hecklist !41 was developed for the purpose of this study, reliability and validity of the measure is unknown . Data Analysis Qualitative analysi s. To gain an in -depth understanding of an integrative treatment process, the experiences of parents with at -risk preschoolers involved in an integrative treatment process, and clinicians providing integrative treatment services were examined. An integrated qualitative phenomenological approach (Creswell, 2013) was implemented. This approach int egrates a psychological perspective (Moustakas, 1994), which emphasizes participant textu al and structural descriptions and a human scienc e orientation (van Manen, 1990) that focuses on interpretations between the meanings and the meanings of the lived exp eriences (van Manen, 1990). The psychological perspective (Moustakas, 1994) also emphasizes the concept of epoche or bracketing, in which the researcher attempts to set aside (as much as possible) their experiences in order to take a fresh perspective tow ard the phenomenological under examina tion (Creswell, 2013). This relates to the philosophical nature of epoche (Husserl, 1859 -1938 as cited in Creswell , 2013) which contends research should suspend judgments about what is real until they are founded on a more certain basis; reality is not divided into subjects and objects but instead the nature of both subjects and objects as they appear in conscience; and the reality of an object is only perceived within the meaning of the experience of an individual (pp. 76-83). The first step in an integrated phenomenological analysis includes bracketing personal experiences related to the phenomena (Marshall & Rossman, 2010). In this study, experiences were documented and explored with a research team member (co-primary investigator or undergraduate research student) related to individual clinicians within the program, the program supervisor, and the program itself . The next step included the identification of significant statements that addressed the phenomena of p arents of at -risk preschoolers involved in a CMH !!!!!42 program, and clinicians providing direct serv ices. The researcher and the undergraduate research student independently identified significant statements. Following this, a final list was comprised to ensur e significant statements did not overlap. Next, significant statements were coded using a two-cycle coding process. Salda Œa, (2013) recommends an initial cycle of coding, and a second coding cycle that requires more in -depth analytic skills. During th e first cycle, a method called themeing the data ( Salda Œa, 2013) was implemented. Significant statements were used to identify t hemes throughout the intervie ws. Themes were labeled u sing phrases that represent the identity and meaning of the recurrent ex periences (DeSantis & Ugarriza, 2000). This method allows participants to construct the meaning of the phenomenon being studied (Kvale & Brinkmann, 2009; Rubin & Rubin, 2012; van Manen, 1990). Once themes were identified independently, the researcher and the undergraduate student researcher came to a consensus regar ding the name of the theme , its definition and how the theme was used to code the data. A codebook detailing this information was developed to ensure the researcher and the undergraduate resea rch student process the data in a similar manner (Salda Œa, 2013). In the second cycle of coding, efforts centered on deciding what content belonged under each theme. The researcher and the underg raduate student researcher complete d the process independen tly, and m et to reach a consensus on theme and content a ssignments. Once a consensus was reached, d ata were analyzed to explore processes, explanations, causes, consequences, and/or conclusions (Rubin & Rubin, 2012 as cited in Salda Œa, 2013). Following th is, negative case analysis was completed to examine contrasts within the data. Following the coding process, in -depth textural (i.e. what happened) and structural descriptions (i.e. ho w it was experienced) according to each theme was completed . These !43 descriptions are a key aspect of phenomenological analysis, as the y give richness and voice to the participants (Creswell, 2013). Finally, a composite description blending the textural and structural descriptions was completed . This description, cal led t he essence, is intended to represent the culminating aspects of the phenomenon (Creswell, 2013). Quantitative analysis. The Statistical Package for Social Sc iences (SPSS), Version 22, was employe d for the quantitative analysis. Each item on the Service Provider C hecklist was coded and entered into SPSS. Descriptive statistics were calculated including the mean, mode, standard deviations, and frequencies of each of the categories on the service provider checklist. Chi-square test s examine d if IMH and RP T are independent or if a relationship exists between them. Additionally, relationship s betwee n the applications of IMH and /or RPT to treatment modality, session length, and each subgroup of supportive clinical services (i.e. developmental or anticipatory guidance, concrete need assistance, advocacy, or collaborations with medical, school, or court systems) were examined . !!!!!44 CHAPTER 4: Results Introduction As previously stated in the literature review, there are limited studies focused on the integration of RPT into IMH for at -risk preschoolers and their families. To gain a better understanding of the integrative treatment process, the experiences of those involved within an integrative process with parents of at -risk preschoolers and clinicians providing directive treatment services were examined. This chapter outlines the results of the qualitative (parent and clinician interviews) and the quantitative (Service Provider Checklist) methods. It begins with demographic information from the paren t and clinician interviews followed by a description of the identified themes. The final section examines both quantitative and qualitative results according to each of the four research questions. Qualitative methods examined research question one, whic h asked how clinicians decide to integrate treatment models. Both qualitative and quantitative methods examined research question two or what RPT and Non -RPT models clinicians utilize in an integrate treatment model; and research question three which exam ined how parents are involved within an integrative treatment approach. Finally, qualitative methods examined research question four or how an integration treatment process influences the clinician -parent relationship. Participant Demographics Parent interviews. To examine parental perceptions, a total of 20 interviews were conducted and audio -recorded with parents. The majority of interviews 17/20 (80%) were conducted in the parentÕs home by the researcher, and 3 (15%) were audio -recorded and conduc ted over the phone by a student researcher. The average time of interviews was 45.37 minutes ( SD=27.22). The average age of the child in the program was 4.77 years ( SD=. 92) and !45 the majority of families 65% (13/20) had more than two children in the house hold (including the child in the program). The majority of participants (75%) identified as Caucasian , while 10% identified as African American, 5% identified as Cuban American, 5% identified as Biracial, and 5% identified as Native American (see Table 1) . Half of participants were biological parents (10), while 4 (20%) were foster parents, 3 (15%) adoptive parents, and 3 (15%) were grandparents . Two father figures participated in interviews and included 1 biological father, and 1 grandfather. Table 1 !!Demographics of Parent Interview Participants N % Race Caucasian 15 75% African American 2 10% Cuban American 1 5% Native American 1 5% Biracial 1 5% Gender ! Female 17 85% Male 3 15% Parenting Position ! Biological Parent 10 50% Foster Parent 4 20% Adoptive Parent 3 15% Grandparent 3 15% Note. N =20 Clinician interviews. To explore perspectives of clinicians providing direct services, a total of 4 out of 6 (67%) interviews were conducted and audio re corded by the researcher in an office setting with program clinicians. Two clinicians were unavailable for interviews due to a medical and maternity leave (there are a total of 6 program clinicians). The average length of interviews was 52.34 minutes ( SD=15.01). All four clinicians identified as Caucasian and female. Each clinician holds a master level degree in either psychology or social work. !!!!!46 Theme Identification Data from parent and clinician interviews were blended together to identify a tota l of four main themes and s ubsequent subthemes (See Table 2 ). Themes were blended due to the reciprocal experiences of parents and clinicians. The first theme relates to how program clinicians tailored treatment modalities and interventions based on init ial and continual assessments utilized to identify child, parent and/or family maladaptive behaviors, salient childhood experiences (child or parent) or problematic parent -child or family attachment or relationship patterns. However, prior to beginning a t reatment modality or intervention, clinicians assessed the willingness and readiness of the child/parent to engage in treatment. If a child/parent was not willing or ready to begin the proposed interventions, clinicians adapted treatment modalities and in terventions to focus on child/parental areas of concern. Clinicians and parents reported that flexibility in the delivery of treatment interventions was an important aspect to addressing continuous family needs and maintaining a supportive clinical relat ionship with the child and parent. The second theme relates to the presence of RPT models (Filial Play Therapy and Theraplay) and techniques (Non -Directive, Directive, and a combination of Non -Directive and Directive) along with IMH theories (Attachm ent) and models (Child Parent Psychotherapy, Parent Psychotherapy and Circle of Security) clinicians blended and implemented simultaneously. Field observations noted clinicians seemed less comfortable when discussing theories and models, which was support ed by clinician reports of uncertainty if their treatment approach or techniques utilized fit into an established treatment model. The third theme was a consistent treatment model that was identified by clinicians and parents. The treatment process incl uded a check -in period in which the clinician explored with !47 the parent the previous week, parenting concerns and/or stressors. Next, a play session was conducted between the parent, child and clinician or the child and clinician (parent observed the play) . Following the play session, a reflection period occurred between the clinician and parent and play me anings, parenting responses and /or previous childhood experiences were examined. Finally, clinicians assigned a post -session activity to practice feelin g identification/expression or coping skills in -between home visits. Parents reported appreciation for this particular treatment process and valued the play and active involvement within it. Parents and clinicians reported involvement in the delivery of clinical supportive services including concrete needs assistance with basic and immediate needs (i.e. referrals or assistance with paperwork to obtain services) anticipatory guidance, developmental information, provider collaboration and advocacy (i.e. to gain additional resources) and assistance in creating a positive support network. The fourth theme, a supportive clinician -parent clinical relationship was identified by parents. Parents reported clinicians were consistently available and attentive t o parental feelings and needs (both during and in -between home visits). Clinicians reported within the context of the supportive relationship, parents were willing to explore child behaviors, and current parenting responses. As a result, parents reported a deeper level of understanding about their childÕs behaviors/symptoms and their own parenting reactions and responses. With this knowledge, parents felt empowered and more confident in making parent -related decisions, employing new parenting strategies and advocating on behalf of their child with friends and family. !!!!!48 Research Question 1 : Qualitative Results The Clinical Decision to U se an Integrative Treatment Model During interviews, clinicians were asked how they chose treatment modalities and/or interventions for at -risk preschoolers and their families. Clinicians reported t reatment modalities and interventions were tailored to meet child, parent and family needs. Treatment was tailored based on initial and continual assessments utilized to identify child, parent and/or family maladaptive beha viors or relationship patterns, and the willingness and readiness of the child and parent to engage and participate in treatment interventions. Additionally, flexi bility in treatment delivery was reported by clinicians and parents to be an important aspect to tailoring treatment in order to meet ongoing family needs. Continual assessment . To determine treatment modalities and/or interventions, each clinician 4/4 ( 100%) discussed the importance of conducting an initial and continuous assessment focused on multiple factors including child, parent and/or family maladaptive Table 2 !Main Themes and Subthemes of Parent and Clinician Interviews Theme Subtheme 1.Tailored Treatment Services Continual Assessment Focused on Child, Parent and Family !Read iness and Willingness to Participate Flexibility in Treatment Delivery 2. Blend of Treatment Models/ Techniques RPT Models and Techniques and IMH Theories and Models !Uncertainty about 'Goodness of FitÕ into Treatment Models 3. Consistent Treatmen t Model Chec k-in, Play Session, Reflection and Post -Session Activity !Parent Understood and Valued Treatment Process !Delivery of Clinical Supportive Services 4. Supportive Clinician -Parent Relationship Attunement of Parental Needs and Consistent Ava ilability !Deeper Understanding of Behaviors and Parent Responses !!Parental Empowermen t and Confidence !49 behaviors, salient childhood experiences (child or parent) or problematic parent -child or family attachment patterns. Assessment s provided clinicians with knowledge related to child/parent symptoms or pathology and child -parent relationship difficulties, and this knowledge was utilized to determine treatment modalities and interventions. The follow ing are remarks from a clinician discussing how she utilized multiple assessments along with the nature of child symptoms/diagnosis to determine modalities and interventions. In going in initially, I will look to see what's going on with the family, with the information that they've given to me, and what I've observed. And sometimes over time, different situations come up and evolve. Sometimes, I am t hinking it is the child who is identified as the client, but sometimes it turns out the parent is the one who is in greater need of help or direction. Whether it's parenting skills, attachment, fine -tuning what's going one with them emotionally. It's just based on symptoms of the child, experiences, what happened in utero. I might have a different modalit y and intervention for someone who has FAS than I would someone who does not have FAS. In addition, clinicians assessed the permanency of the caregiver (i.e. foster care or adoption) to determine treatment duration and subsequently treatment modalities or interventions. For example, a clinician remarks on the importance of considering the experiences of grandparents and permanency of the placement in order to determine if she would use psychotherapy to address potential inner conflicts related to raising their grandchildren. It's a little different; you take into consideration what's going on for the grandparent. But if it's a temporary one, I am not as willing to do that because I wonÕt be there as long but If I can help an adoptive mom or an adoptive grandma, !!!!!50 deal with another layer there, the remorse and the regret and the things they are feeling about their own child, and now they're raising their grandchild. I f we can process some of that stuff and get it on the road to resolution, I'm not say ing w e always get it resolved, b ut at least it ends up helping the parenting of thi s child as opposed to being stuck i n this mode of "I didn't do it right the first time, how could I do it right now." Helping t hem sort through that so that they can be the best parents they can right now to this chi ld. Willingness and readiness to engage in treatment . Within assessments, all clinicians remarked on the utility of play to examine what the child is willing to do and/or what they can do. Thi s in t urn, assisted c linicians in determining specific modalities and interventions they were going to be able to implement within treatment sessions. This was particular ly important with foster or adoptive children with or without cognitive delays due to the limited informat ion that was available during the initial assessmen t period. A clinician remarks on the assessment process and the use of play to determine what modalities and/or interventions a child can or is willing to do within treatment sessions . So it's interview ing, it's getting a really good history as mu ch as you can. That's always a work in progress with foster children and adopted children. An d it's a little frustrating at times. And so you try to get a good history, you find out w hat brought them to treatmen t, or what the recommendations were. And you do s ome interviewing and you start working with that. I've had kids that I have begun to play with to find out what they're able to do or willing to do, or even intelligence -wise, a nd it's a little trickier, to see what am I going to be able to do. !51 In addition, clinicians considered the parentÕs readiness to engage in tre atment and/or explore underlying issues when deciding treatment modalities and interventions. A different clinician remarks on the need to a ddress the familyÕs immediate treatment needs, while planting seeds for more long -term interventions. Its tricky I think. There has to be a readiness on the childÕs point of view and as well as where the parent or family is. If the family is feeling overwhelmed by behaviors and they really need you to do something a little more immediate, then we might go there first. If the immediate goals, it is kind of goal -driven. I can suggest some things or talk, see if they're interested in this right now. But I can also paint a picture for the future. Plant some seeds saying, okay we can do this now, we can work on some basic behavioral things or self -regulation issues or this or that interventions. But I'm really thinking that if we address the trauma that some of that will go down in time as it's just not going to be a good fix. But if you want me to do this now we can, but I don't think that that's going to fix it. So basically, I don't do anything quickly. I tell people I retired my magic wand about ten, fifteen years ago when I realized it didn't work. I jokingly say there's not a quick fix. Parents reported clinicians listened and addressed their areas of concern with specific interventions. A parent remarks on how she felt when clinicians listened and addressed her concerns with a behavioral intervention. All of the things I said to them at the very beginning we focused on, they reall y listened to my concerns I had, and addressed all of them starting with the one I wanted . It was surprising. My big thing was what do I tell them about what I !!!!!52 really want, you k now and they actually listened. We started with bubbles and play dough to help him calm down which helped to stop the fits. Clinicians reported the readiness and willingness of the child o r parent to be an important aspect in building a good working alliance or clinical relationship, however, they also remarked on how this can be a frustrating process because it can limit a clinicianÕs ability to use interventions and at times requires a lo t of patience. There's a lot of things you can't do until you have a goo d working relationship and you don't know how long that's going to take. Especially with a grandma that has raised nine children and Òwhat are you going to tell me?Ó and so you j ust sit there and kind of wait until you can because its that important . I shouldn't say wait, you're not waiting , youÕre actively building are a re lationship until you can get that opportunity to make an interventi on go. One that you might have known six months ago, but now they 're ready. That's hard because you don't always know that in six months they're goi ng to be ready, you can always hope. Flexibility in treatment d elivery . Flexibility in how clinicians delivered treatment modalities and interventions was reported by clinicians and parents to be an important aspect to tailoring treatment to meet shifting and/or growing child/parent/family needs. A clinician remarks on how she structures a home visit based on child/parent treatment needs and contextual factors within the home. So say mom's got more than one toddler or more than one child and she is trying to manage. I don't expect her to sit for a whole session and be available for play if the child wants to play sort of thing. But um, I work with famil ies in different ways. Some of them, like, this one case that I have, Mom and I talk ahead of time, !53 she's got a baby, so she Õs dealing with a lot of postpartum stuff and she's going back to work. So I deal with her a lot on that level and then the child ju st really needs me to be there for her and help her through ADHD stuff. SheÕs five and so it's a little bit different, I don't feel like Mom needs to be there but then there are pieces that I do where I include step -Dad or Mom and I make a connection at least, so it may not be the 50 -minute hour or anything like that, but everyone is included, so sometimes I do work with kids through their own play and Mom might be tending to the baby or might be having the baby there and not completely focused on what is g oing on. So it's kind of contextual as far as that goes, what we're dealing with. A different clinician remarks on the need for flexibility due to the presence of siblings who may (or may not) participate in treatment sessions and how this can relate to treatment retention . And there's families where the only way I'm going to get this done is to tell one chil d that I want to work with [child] alone for twenty minutes but then I'll set the timer and the last fifteen you can come in and play too. And tha t's what I do a lot so that the older child can come play. Because if I don't, most likely the family is not going to have me back because I would cause a disturbance with the older one. They're not going to allow me to come if it's going to do that. So it 's not orthodox but that's how we get our work done sometimes. Otherwise I don't know that anything would get as far as seeing truly what the child has going on without doing that. And there are so many areas for corruption as far as home -based and !!!!!54 there i s no Ô true formula. Õ But you also see a lot that way too and I think that's partially how we get back in because if we're going to cause a big stir they're [parents] not going to want to have u s back. Remaining flexible and tailoring interventions within home visits was also an important aspect to parents. The following is a parent who remarks on the process and a clinicianÕs ability to adjust interventions based on current need(s) while maintaining a f ocus on long -term goals. We're going to talk about this [during the session] and something happens and things change and then the next session changes, but then we'll always go back to what we were going to do. So I like the fact that it's not just, you know, oh this is what we're going to do today. ItÕs tailored to u s, you know, that what we need. In summary, tailored treatment services were accomplished by initial and continual assessments that examined the child and parentÕs willingness and readiness to engage and participate in modalities and inter ventions; and in maintaining flexibility when employing proposed tailored modalities and interventions to meet the shifting needs of families. Research Question 2: Quantitative and Qualitative Results Quantitative Results on Specific RPT and Non -RPT Tre atment Models Service P rovider Checklist. To further explore specific R PT and Non -RPT models , Service Provider C hecklists were completed after each home visit for two consecutive months by program clinicians, which yielded a total of 349 checklists on 81 families. Checklists documenting a cancellation ( N=18) or a no -show ( N=4) by clinicians were dropped leaving a total of 327 checklists for analysis. The a verage length of home visits was 1.20 hours ( SD=. 35). !55 Parent -child dyad sessions were conducted 5 2% of the time whereas family sessions with the parent, child and sibling(s) were held 20% the time. I ndividual child o r parent sessions occurred 18% of the time. In terms of treatment interventions , results indicate that within a two -month time frame, clinicians were utilizi ng play therapy interventions (Non -Directive; Directive and Non -Directive; and D irec tive Play Therapy) a total of 49 % of the time, and IMH modalities (Child P arent Psychotherapy and Parent Psychotherapy) 34 % of the time (See Table 3 ). Cumulatively, there is a higher percentage of play therapy, however, when the individual modal ities are examined , clinicians report using C hild Parent Psychotherapy (CPP) (20%) and Trauma -Focused Cognitive Behavioral Therapy (TF -CBT) 20% of the time. T his finding highlights the need for trauma -based interventions and the possibility clinicians are integrating specific play therapy techniques as needed within the CPP or TF -CBT model. Other treatment approaches were identified, and surprisingly, Biblioth erapy was rated the highest at 24% although this specific intervention also classifies as a form of Directive Play Therapy (DPT) suggesting the frequency of DPT may be higher. Additionally, clinicians are utilizing psychotherapy with parents 12% of the ti me indicating a need to address parental mental health . Speaking to the intensity of this at -risk population, clinicians are also implementing safety plans 14% of the time due to severe aggressive behaviors and/or self -harm ideations or plans. !!!!!56 Tabl e 3 Service Provider Checklist Frequencies and Percentages of PT, IMH, and Other Treatment Approaches Utilized During Home Visits PT Frequency % Non -Directive (NDPT) 50 15.3 Non -Directive & Directive PT (NDPT & DPT) 58 17.4 Directive PT (DPT) 52 15.9 Total PT 160 48.9 IMH Child Parent Psychotherapy (CPP) 68 20.8 Parent Psychotherapy (PP) 39 11.9 Circle of Security (COS) 3 0.91 Total IMH 110 33.6 Other Treatment Approaches Bibl iotherapy 79 24.2 CBT/TF -CBT 67 20.4 Sensory Integr ation 49 15.0 Art Therapy 34 10.3 Safety Planning 47 14.3 IMPACT (Social Skills) 7 2.1 Total Other Treatment Approaches 283 86.3 Note . N=327; Treatment approaches self -reported by clinicians; One checklist was completed per home visit; Check lists were c ollected for 2 consecutive months on a total of 81 families. Chi-squares . Multiple chi -square tests of independence were performed to examine the relationships between IMH and RPT treatment interventions. Phi values were also calculated t o measure effect size or strength of the relationship . Results indic ate a significant relationship between CPP and the combination of NDPT and DPT, !2 (1, N=327) =9.975, p=. 003 (See Table 4). The phi value was .169 ( p=. 002) indicating a small to medium effect (Engel & Schutt, 2009) . Thus, c linicians are more likely to use CPP with NDPT and DPT than using CPP without NDPT and DPT techn iques. Chi-squares examined the relationship between CPP and the remaining RPT models, DPT or NDPT and were non -significant. N on-significant relationships were found between the other IMH models (PP or COS) and RPT models (NDPT or DPT, NDPT, or DPT); !57 whic h may relate to PP and COS primarily being centered on paren ts verses the parent -child dyad. Relationships between IMH and RPT with Other Treatment Services were explored with Chi-squares. Results indicate a significant relationship betwee n CPP and TF-CBT, !2 (1, N=327) = 4,443, p=. 035 indicating clinicians are more likely to use CPP and TF -CBT than CPP without TF -CBT. However, the phi value was .113 ( p=. 03) indicating a small effect (Engel & Schutt, 2009 ). Results also indicated a significant relationship betwee n Art Therapy and DPT, !2 (1, N=327) = 6.257, p=. 012 and a significant relationship between Bibl iotherapy and DPT, !2, (1, N=327) = 5.007, p= .025. This indicates clinicians were more likely to use Art Therapy and Bibliotherapy with DPT than using Art Therapy and Bibliotherapy without DPT. However, as mentioned earlier, it is p ossible clinicians view art or B iblotherapy as DPT techniques. The phi value for Art Therapy and DPT was .134 ( p=. 012) and Phi for Bibliotherapy and DPT was .12 0 (p=. 025) indicating small effects (Engel & Schutt, 2009 ). !!!!!!!!!58 Table 4 Significant Chi -Squares and Phi Values of Relationships Between IMH, PT and Other Treatment Models PT and TF-CBT CPP !!!Observed Expected !2 " NDPT & DPT 20.0 11.3 9.975** 0.169 Non -NDPT & DPT 47.0 38.0 !!TF-CBT 2.0 32.0 4.443* 0.113 Non -TF-CBT 6.6 27.4 Other Treatment Models DPT !2 " !Observed Expected !!Art Therapy 10.0 5.1 6.257** 0.134 Non -Art Therapy 24.0 28.9 !!Bibliotherapy 18.0 11.8 5.007* 0.120 Non -Bibliotherapy 61.0 67.2 !!!!Note. N=327; *p< .05, **p< .01, ***p<. 001 !!! Qualitative Results Regarding Specific RPT and Non -RPT Treatment Models During interviews, c linicians were asked what RPT theo ries, models and techniques and what IMH theories or models they utilized when working with at -risk p reschoolers and their families, which provided explanatory knowledge to Service Provider Checklist data. Thus, the second theme relates to the presence of RPT treatment models (Filial Play Therapy and Theraplay) and techniques (Non -Directive, Directive, and a combination of Non -Directive and Directive) along with IMH theories (Attachment) and models (Child Parent Psychotherapy, Parent Psychotherapy and Cir cle of Security) clinicians blend and implement together. When discussing theories and models, clinicians reported uncertainty on whether or not their approach fit into an established treatment model. Field Observations. When interviews focused on theor ies, the researcher observed the clinicians to be less comfortable (i.e. nervous laughter, less eye contact, more silence). No theories were identified while discussing RPT models and techniques, however, attachment !59 theory was acknowledged as an important piece of IMH tr eatment models. Clinicians seemed a bit more comfortable discussing treatment models (i.e. less silence, more eye contact) however, all four clinicians reported uncertainty if their techniques Òfit intoÓ a treatment model. When discussing techniques clinicians seemed the most relaxed (i.e. ta lkative, direct eye contact) . The following outlines what RPT and IMH treatment model s and techniques cli nicians utilized within the program. Play therapy m odels. Clinicians identified the use of tw o RPT treatment models, Filial Play Therapy (Guerney & Guerney, 1967) and Theraplay (Jernberg & Booth, 2010). Clinicians reported Filial Play Therapy (with or without modifications) to be a beneficial intervention to children and parents. The following r emark is from a clinician regarding how she modifies Filial Play Therapy based on child/parent readiness. I use filial play therapy where IÕm trying to get the parents and children on the same page and sometimes, thatÕs a rough match. You have to de pend on the parent and the child a bit more, but it can be a good model to get them on the same page. Sometimes I don't do the whole thing, sometimes I just do parts of it that I think they can actually master without resisting. Or if they resist, I might present the whole thing then say let's just try this and this. You do have to have a good enough relationship to start this . There are a lot of things you can't do with filial play therapy until you have a relatio nship at least with the parent. Therapl ay was also identified as a treatment model in which an attachment game was used to engage and strengthen attunement within the parent -child dyad. We do, actually we do a lot of that in the beginning, especially with attachment stuff. These kids look to be born, I roll them up in a blanket like a burrito and !!!!!60 their heads are sticking out and I'll pick them up of the floor and I'll place them on their parent's lap. And they love that but then I slowly pull the blanket off their feet while their parents hol d their upper body. You should see what happens to these kids, they want to do it over and over and over again. I mean, they'll do it 15 times until I can't pick them up anymore because I'm exhausted. And they'll do it over and over and over again. It is t he coolest thing. Another clinician remarks on Theraplay , an attachment -based RPT model and the use of an engagement activity in which a parent and child blow a cotton ball a cross a pillow to elicit play and eye contact. We can play games that strengthe n the attachment between the parent and child. When they are both trying to blow the cotton bal l across the pillow, they are making eye c ontact with each other and having fun , which is a mutual goal for both of them. Play therapy techniques. Clinicians reported a variety of non -directive and/or directive play therapy techniques along with art, B ibl iotherapy, and sensory -based play techniques. A clinician remarks on her application of directive techniques based on the young childÕs experiences and sympt oms. I have different directive techniques, whatever you want to use them, based on the experiences, symptoms of the child that's coming in. I migh t use more physical activities for a child that may have sensory issues. For a child tha t presents with trauma and has identified with trauma I would use more traditional play therapy whether it's dolls, a family of pets. Sometimes we can do writing, drawing, I'm trying to thi nk. And also maybe some B iblot herapy, some books. Maybe thereÕs a !61 concern about att achment, to work on that. Or if there was sexual abuse to work on tha t piece, if there was domestic violence to work on that piece too. Kind of like a social story about that child's experience. In addition, sensory -based play therapy techniques were rep orted by clinicians and parents to help the child learn additional calming techniques. The following is a remark from a clinician using sensory -based techniques followed by a parentÕs remark on how these techniques helped her child learn how to be calmer. Clinician: I will do sensory -motor type stuff where you do play dough or there's a thing where you wrap the child. They sit in a blanket and they get that deep pressu re around them. So it's like sensory integration techniques that can help them to calm down. I do a lot of that and some of that will work even if you're not totally addressing a deeper issue at that time, just different ways to give them options when they're having a struggle. Parent: Well, I now realize when you rub certain parts of the body or [use] brushing how it calms him [child]. I used to have to brush him but now he likes to just be tickled. They showed me how to massage him a little bit too to calm him down. The bubbles calm him, he loves running wit h scarves tied together, tha t c alms him and he has learned some breathing techniques as well. Clinicians also reported how they adjusted clinical techniques based on treatment phases and/or the need to establish safety . A clinician remarks on the different circumstances in which she applies non -directive and directive play techniques and the importance of ensuring safety during treatment sessions. !!!!!62 I may become more directive depending on where the child is and wh ere they are in the process of therapy, like if they are in trauma resolution I may reinforce safety so the child can feel safe . For example, I had a child recently who just amazed me. Out of nowhere she presented what happened to her and it's just an amazing piece to go with that, and it usually comes from the child fe eling safe and the literal holding environment you create with the family so that everybody, Mom, Dad, the child feels safe. And it's just huge, it' s amazingly huge is what it is. Clinicians also discussed selecting toys as a directive technique. A clini cian remarks on using specific toys to help the child process feelings related to transitions; and leaving the toys or books in the home in -between home visits. I use a lot of house play or houses if there's a t ransition going on , where you kind of have the toys represent their feelings. I use different interventions where we read a book and act out the book. In one case, we act out a book with an owl puppet that is usually a judge. So it's been really interestin g because the owl puppets are available to the little guy [child] even when I'm not there [clinician leaves them at the home in -between sessions] . Those issues play themselves out because he's now getting t o the point where he's saying, Ò how could it be different? Ho w could it have gone differe nt?Ó Attachment and psychotherapy . Clinicians were asked what IMH theories and models they applied during treatment sessions with at -risk young children and families. When asked this question, all 4/4 (100%) clinicians identified the importance of atta chment theory and the use of psychotherapy to help children feel safe and parents to process past experiences and current !63 parent ing responses. For example, a clinician remarks how psychotherapy helps create feelings of safety, improve parental sensitivity and parental self -care. The attachment piece I find very important, especially with children who have been in out-of-home placements. In working on feeling safe, secu rity, and trust for day -to-day functioning and allowing the parents to be able to loo k at it from the child's perspective. How the parents' behaviors and feelings can affe ct the child, that could be an intervention in and of itself so the parent can recognize that they either need to do a poker face and not be so reactive, or maybe be more reactive an d more responsive so the child knows that they're available. So that comes in play and I also talk about the parentÕs families and how important it is for them to take care of th emselves and I kind of do this triangle thing, because if you're n ot here it's hard for yo u to have anybody else be there where they need to be. You really need to take care of yo urself. And that's part of the daily scheduling of the parenting piece, I kind of connect them together. Clinicians also remarked on the use of psychotherapy to explore parental early childhood experiences and how they relate to current parent responses. For example, a clinician remarks on this process and how play elicits a parentÕs ability to explore their own childhood experiences. I like the psycho therapy piece as far as, some parents are more apt to talk about that on their own and some parents you really have to get a drill and dig for it. Like asking what did your parents do, or did you think that was a good idea, or how did you k now you wanted to do things the same way or how did you know you wanted to do things different because some parents don't want to talk about it and en d up being the dismissive ones that kind of walk the line between !!!!!64 contrasting what t hey say with what they do. For example, what they say they don't want to happen and then they'll say well that's how it was when I was young and we did okay. They kind of f lip flop according to what the question is you're asking because they want it to go away. And so sometimes I have to work that in while we're playing so we're not really fo cusing necessarily on the play therapy is more sometimes a good time to talk to parents about that. You know, because the dad might say Ôoh if my d ad saw me playing wit h that, he'd whip my b uttÕ or something like that. How did you know that you didn't want to be raised like that or how did you know that would be okay if you played with thatÉthat sort of thing. Another clinician remarks on the need for psychotherapy to help parents process t heir childhood losses in order to improve attachment relationships and caregiving responses. In these remarks, the clinician discusses the need to have additional support during session s in to address individual child and parent needs. I think I do a lo t of parent psychotherapy. Becau se, again, if it's a permanent situation, if we can resolve some of that or explore some of that, so at least they are aware. Some of that is put in a context then I think if they're going to be all the more able to be attac hed and better caregivers to the little ones. I can 't do much with the child if I don't have mom or dad or parents in a better place. So sometimes we use a FSW [family support worker who accompanies the clinician to home visits ] like for instance right no w, I have an FSW doing a coloring book of good touch -bad touch while I'm over here dealing with mom who has had !65 multiple losses and in and out of her foster care all through growing up and is terrified of losing little one. So weÕve got layer upon layer of things. Uncertainty about the Ògoodness of fitÕ into treatment m odels. When identifying RPT treatment models and the use of attachment theory and psychotherapy, all clinicians seemed uncertain if their treatment approach Ò fit into an established evidence -based treatment model .Ó When asked about RPT treatment models, a clin ician remarked [while laughing], ÒumÉ if I had a manual I could choose which models I use.Ó After the researcher reassured that there were no right or wrong answers, the clinician remar ked on a case where she is working on self -regulation but is unsure if her approach fits into an established treatment model. I can't help this little guy as much, he has fetal alcohol syndrome. His receptive language is lower than his expressive, which is not typical. So he sounds like he's really doing much, understanding more than he is. And so his frustration tolerance is really low, so if I can get him to cope or communicate, one or the other. Like I said, I know what I'm trying to do, but I'm not su re if it fits in a model. Another clinician remarks that she is not good talking about theories or models, but is able to identify different types of play therapy techniques. I know IÕm not very good at talking about theories and models. I am reall y not [the researcher validates clinicians and lets her know there are no right or wrong answers and the cl inician continues] well, I use B ibl iotherapy, I use quite a bit of different types of non -directive and directive, art, I throw it all together and c ome up wit h something [clinician laughs]. Similarly, another clinician remarked on her uncertainty related to the goodness of fit between techniques utilized and existing clinical treatment models. !!!!!66 I use non -directive and directive techniques, IÕm ju st kind of all over the place and IÕm not really describing the clinical book treatments or models, but these are the kinds of things I do and the seem to work for our kids. In summary, clinicians reported using the blend of RPT and IMH treatment models and techniques to tailor treatment services along with uncertainty if their treatment approach fits into an established treatment model. Q uantitative results indicate clinicians are utilizing RPT models/techniques a total of 49% and IMH treatment models a total of 34% and chi -square results indicate significant relationships between CPP and NDPT/DPT; CPP and TF -CBT; Art and DPT; and Bibliotherapy and DPT. These findings suggest clinicians are integrating specialized play techniques, in particular within CPP, TF -CBT, Art Therapy and Bibliotherapy. Research Question 3: Qualitative and Quantitative Results Quantitative Results Regarding Parental Involvement Service Provider Checklists. In addition to treatment interventions, parents were involved in clin ical suppo rtive services, which included Anticipatory Guidance, Developmental Information, specific parenting curriculums, concrete needs assistance and advocacy. Clinicians reported using anticipatory guidance a total of 65% ( N=214) of the time and devel opmental information 55% ( N=179) of the time (See Table 5 ). Specific parenting training models L ove and Logic (Cline & Fay, 2006 ) (12%) and Parent Management Training Oregon (Forgatch et al., 2004) 12% of the time. Clinicians repo rted advocacy focused on school -based interventions a total of 20% of the time including child classroom observation, consultation with teachers and principles and attendance at Individual Education Plan (IEP) meetings. Mental health advocacy occurred 9% of the time and included phone collaboration with the psychiatrist and attendance at medication reviews. Health advocacy, which included collaboration with providers and !67 transportation to medical appointments, also occurred 9% of the time. Collaboration centered on the court sys tem occurred 2% of the time and included education to families about the court process and attendance at trials. Finally, concrete needs focused on gaining access to housing wait lists and bill re -payment plan s (i.e. gas, electric, heat) 4 % of the time wh ereas referrals to gain access to insurance or assistance in filling o ut needed paperwork occurred 4 % of the time. Concrete needs focused on legal aspects of custody o r child visitations occurred 2 % of the time. Finally, food referrals or assistance wit h paperwork, transportation referrals or providing bus tickets occu rred less than 1% of the time. !!!!!68 Note . N=327; Treatment app roaches were self -reported by clinicians; One checklist were completed per home visit; Checklists were c ollected for 2 consecutive months on a total of 81 f amilies. Chi-squares . Multiple chi -square tests of independence were performed to examine relationships between IMH and RPT treatment interventions and Clinical Supportive Services (Anticipatory Guidance, Developmental Information and Concrete Needs Ass istance). Phi values were also calculated to measure effect size or strength of the relationship. Results indicate a significant relati onship between an IMH approach, Child Parent Psychotherapy (CPP) !!Table 5 Clinical Supportive Services and Frequencies of Parenting, Advocacy and Concrete Needs Assistance Parenting Frequency % Anticipatory Guidance 214 65.4 Focused on client 133 40.6 Focused on family 57 17.4 Other 24 7.3 Developmental Information 179 54.7 Focused on client 106 32.4 Focused on family 53 16.2 Other 20 6.1 Love and Logic 39 11.9 Parent Management Training Oregon 37 11.3 Advocacy School (observation, consultation, IEP meetings) 64 19.5 Mental Health (psychiatrist collaboration, med review s) 29 8.8 Health (collaboration w/providers, transportation to appts.) 28 8.6 Court (e ducation on process, attending t rials) 8 2.4 Total Advocacy 129 39.4 Concrete Needs Food (referrals, assistance with paperwork) 3 .009 Housing (accessing wait lists, bill re -payment plans) 12 3.6 Transportation (referrals, providing bus tickets) 2 .006 Insurance (referrals, assistance with paperwork) 13 3.9 Legal Services (custody pl ans, visitations schedules ) 8 2.4 Tot al Concrete Needs 38 11.6 !69 and Anticipatory Guidance (AG) focused on the child X2 (1, N=327) =7.878, p=. 005 and a significant relationship between CPP and AG focused on the family, X2 (1, N=327) =8.329, p= 004 (See Table 5) . Thus, clinicians were more likely to use CPP with AG focused on the child or family than CPP without AG. Chi -square values were higher when AG focused on the family verses the child; however, the phi values were similar between a focus on the child (.150, p= .005) and family (.154, p=. 004). Additionally, results indicate a significant relationship between CPP a nd Developmental Information (DI) focused on child, X2 (1, N=327) =9.246, p=. 002 and CPP and DI focused on the family, X2 (1, N=327) =10.668, p=. 001. Therefore, clinicians are more likely to use CPP with DI verses CPP without the use of DI. The phi val ue for CPP and DI focused on child is .163 ( p=. 002). The phi value for CPP and DI focused on family was .175 (p=. 001) indicating small effects (Engel & Schutt, 2009 ). Results also indicated significant relationships with another IMH treatment m odel, Parent Psychotherapy (PP) and AG focused on the child X2 (1, N=327) =4.610, p=. 032 and a significant relationship between PP and AG focused on the family, X2 (1, N=327) =9.287, p=. 002. Therefore, clinicians are more likely to use PP and AG focused on the child or family than PP without AG. The phi value for PP and AG focused on the child is .115 ( p=. 032) and .163 (p= .002) for PP and AG focused on the family, which indicates a slighter higher phi value when AG is focused on the family. In additi on, results indicate a significant relationship between PP and DI focused on the family, X2 (1, N=327) =5.778, p=. 01 and a non -significant relationship between PP and DI focused on child, X2 (1, N=327) =3.627, p=. 057. Phi values for PP and DI focused on family is .129 ( p=. 016) and PP and DI focused on the child is .102 ( p=. 057) indicating small effects (Engel & Schutt, 2009) . Finally, no significant relationships were discovered between RPT models and AG or DI !!!!!70 meaning the occurrence of RPT was independent of AG or DI. No significant relationships were discovered with IMH or RPT treatment models and other Clinical Supportive Services including Mental Health, Health, Court Advocacy or Concrete Needs Assistance. Table 6 Significant Chi-Squares and Phi Values of Relationships between CPP, PP and Anticipatory Guidance and Developmental Information CPP Anticipatory Guidance Observed Expected !2 " Child Focus 36 25.9 7.878* 0.150 Non -Child Focus 97 107.1 Family Focus 19 11.1 8.329*** 0.154 Non -Family Focus 38 45.9 Developmental Information Child Focus 21 20.7 9.246*** 0.163 Non -Child Focus 19 10.3 Family Focus 19 10.3 10.668*** 0.175 Non -Family Focus 34 42.7 !PP Anticipatory Guidance Observed Expected !2 " Child Focus 21 14.9 4.610** 0.115 Non -Child Focus 112 118.1 ! Family Focus 13 6.4 9.287*** 0.163 Non -Family Focus 44 50.6 !Developmen tal Information ! Child Focus 17 11.8 3.627* 0.102 Non -Child Focus 89 94.2 Family Focus 11 5.9 5.778** Non -Family Focus 42 47.1 0.129 Note. N=327 ; *p>.05, **p>.01, ***p>.001 Qualitative Results Regarding Parental Involvement Check-in, play session, r eflection and post session -activity . During interviews, parents provided explanatory data related to the context of parental involvement . Parents were asked how they were involved in treatment sessions and what they thought about their level of involvement. Results indicate most of parents 19/20 (95%) were actively involved within a !71 consistent treatment process, which included a Òcheck -inÓ period for the parent, child, and clinician to explore the weekÕs events and/or concerns, a nd prepare for the parent -child -clinician play session. For 2/20 (10%) of parents, the preparation for the play session included role -plays in which the parent led a directive play activity. The remaining 16/20 (80%) parents reported verbally reviewing t he play agenda (i.e. directive an d/or non -directive techniques) or plans for play observation . During the pl ay session, parents were actively invol ved in the play process or observed the play in close proximity between the child and clinician. Following the play session, clinicians allotted time for parents to reflect on the process of the play session and their own reactions, which may (or may not) be related to their own experiences as a parent. During this time, children were often given a special toy or an art activity to complete. Parents also reported a post session activity (i.e. blowing bubbles for deep breathing , reading a feeling book) clini cians assigned to the parents to complete with their child in-between home visits . The following are rema rks from parents about their involvement within this process. [Clinician] comes in and talks to me before she [child] gets off the bus so that we can have our time to talk and go over different options of discipline . When she [child] comes in, she [clin ician] will say, you know I heard you had a good week. And then she'll sit down and talk with her [child] and they'll get out the toys and play and we've been doing the play sessio n where we let her [child ] be in charge. It lets her be in charge and she ta kes control if she wants us involved in the play or we'll draw together and stuff like that and we have this paper where I write down questions. Then she [clinician] turns around and at the end and we'll talk about things whatÕs on the paper and what happ ened during the play . Another parent remarks on this process and how her family is involved in treatment !!!!!72 sessions. We, as far as like all fi ve of us, meet together at first. What happens is she [clinician] would normally come in, touches base, read us a book, and we'd talk about it, which typically deals with feelings. And then the children [identified client and two younger sibs] would play with her [clinician] and us afterwards. Then, he [child] goes to school, which he isn't now becau se he's off [on school break] b ut he would get on the bus, and she [clinician] would come back in and stay with us and talk to us in general what's going on wi th the family or my husband. A clinician remarks on this process and how she includes an ending ritual (i.e. stickers for the child and a post session activity for the parent). So I'll ask m om how things have been going, sometimes I'll ask what went well this week, al l that kind of stuff. And then mom will tell me, or d ad or whoever is there, will tell me what's been going on. And most times they know we'll talk at the end and if it's something the child sho uldn't hear and then I'll say, Ò alright it looks like it's time to ask for thumbs upÓ because thumbs up means they can get their toys out, but I have to give a thumbs up and they have to give a thumbs up. The parents first, then me . If mom isn't done she'll go, Ò nope, n ot ready to give the thumbs upÓ then when thumbs up is given, the children get the toys out and we all kind of switch gears. So th e parent is kind of put in charge and I think they like that piece and they know that they'll be heard that way. And I always check in with the parent at the end too, and I talk about any insights that I've gained from !73 the play that's gone on, Òdid you not ice this?Ó or Ò you seemed to do this mo re than once, did you see that?Ó or Ò I noticed this last time and it happened again, what do you think that's about?Ó and all that kind of stuff, so then you kind of draw that reflective capacity a little bit as far a s thinking and "what do you think you might doing by that?" And then, I do my ritual motion and stickers and all that stuff and then I give parent things to do, like to read Don't Feed the Monster on Tuesday (Moser, 1991) because he [child] i s, uh, a perfe ctionist and lots of time he tries to control things. That's part of what we're working on, trusting the adults enough to realize you're safe and all that kind of stuff, so the parents can read the book to him during the week when I am not there and after that. After all that, I am on my way [done with visit]. Limited involvement was reported by 1/20 (5%) of the parents. Participation was reported in the check -in process but not within the child -clinician play session and reflective time with the cli nician was not identified nor reported to occur. Additionally, play therapy was not viewed as helpful as one parent remarked, ÒI think [she] was trying to see with play therapy [explore the childÕs past history] but it was very unclear and it didnÕt seem to help. Ó In addition, resistance to parenting suggestions was reported as one parent remarked, ÒWhat [she] wants me to do is go around the house all day long and say you were good, let me give you a sticker but then I cannot get anything else done!Ó The latter could be attributed to the level of parent stressors, and/or the stage of the clinician -parent relationship as this same parent reported dissatisfaction with the clinician. !!!!!74 Understood treatment process and valued i nvolvement . Specific to the pla y process, the following two parents remark on being direct ly involved in sessions, and as a result, understanding how they are contributing to his [child] treatment progress. [Parent 1] We all play together, listen to her story together. There's a story . Play a game together. And then at the end we'll let him watch TV and we'll sit down and talk to her [clinician] if we have questions. [Parent 2] And the reason why that is this way is because of the Reactive Att achment. He wants the bondÉwe want the bond. [Parent 1] With the previous therapist, we just didnÕt understand (held individual play sessions) but now itÕs more like weÕre really helping him because this is wha t we know and this is what we [P arent 2 points to herself and partner] are doing with her [clinician]. You know what I mea n. Additionally, a foster parent remarks how her direct involve ment in the play and reflects about how the play assisted in her in processing her reactions to her foster childrenÕs previous childhood experiences. So the y were very helpful in finding the words. I would read the bo ok or she [clinician] would read the book. We had bunnies, little puppets that went with the book to help with figuring out words for us. It meant a lot to me because you know as a Mom myself, I couldnÕt imagine what she [the biological mother] was experiencing without her kids and I wanted t o be able to help . Human to human, I was so emotionally wrapped up in how she [biological mother] felt too. I gotta protect the boys, but I want ed to protec t her, and I felt bad and then thereÕs a part of me that was going Òhow could she do this?Ó You know what I mean? It was !75 just nice to have that person to bounce that kinda stuff off after the play especially because that was a very emotional time. Inclusion of clinical supportive services. Within home visits, parents reported involvement within clinical supportive services, which were delivered in the check -in or reflection parts of the treatment session. Parents and clinicians reported the use of clinical supportive services such as concrete assistance with basic and immediate needs (i.e. referrals or assistance with paperwork), provider collaboration and advocacy within school systems (to gain additional resources for child) , developmental and ant icipatory guidance and the development of a positive support system. The following is a clinicianÕs remark on concrete assistance and its importance in building relationships and Òpaving the wayÓ to address other family needs. I do a lot of concrete ass istance to begin with. And it's one of my relationship builders because if they have a basic need like i f they are missing some food or clothing, well they can get it, its not totally missing but I come in and say, Òoh, its coming in on summer, you know we have this tiny little clothes closet, would you like me to see if there are some clothes? Are you doing good with that?Ó Then they will say , Òoh yes, she wears a 3T.Ó And I that just kind of seems to pave the way of taking care of other child or parent needs . Parents commonly reported clinical advocacy with teachers and administrators to improve their childÕs successes in school. In the following, a grandparent remarks on her experiences within the school system and the importance of having advocates t o obtain the appropriate level of supportive services. After I explained to them [school administrators] his medication regim e, and some of the emotional in -balance, they took another look, and they decided he !!!!!76 should stay in the p rogram so now he is gett ing he [child] will get hallway help next year , extra help with math, extra help with reading, speech and language services so I am hoping those services will take him to the top. She [clinician] was there with me the whole time , and she knew what to say, she knew what, I have been out of the loop for awhile, I have not worked since 2008 and I am not as knowledgeable about the right approaches and the clinical terms for this and that. [Clinician] knew it all and she helped convenience them it was a really need for [child]. Not only that but [child] Õs teacher said Ò I am not signin g it, I will not sign this IEP, mom to m om, he needs it.Ó She [clinician] is al so going to the eye care doctor with me. Just to see what we can get [child] enrolled in. Right n ow [child] is also enrolled in the respite program, which is great. That is such a nice thing for us; it gives us some nice time away sometime. You need a dvocates, having them in your corner because not everyon e is going to listen to me. Nobody is going to listen to him [points to grandfather] or me [shakes her head side to side three times]. All clinicians 4/4 (100%) reported the use of Development Information and/or Anticipatory G uidance, during the check -in or reflection portion of treatment session s. A clinician remarks on the process and how it can help the child and parent address transitions to new situations. Anticipatory guidance, I think, is everything from the justification , to helping with new situations. One kid pops out when we talk abo ut this, I was working with a family who had a new situation, the little guy was saying he was scared about camping this summer. And originally mom was saying, Òyou're scared?Ó and I !77 [clinician] l ooked at her [mom] like ÒDo you know what to do?Ó and she's like, ÒOh, some little boys and girls get sca red, but then once you're there you will be ok.Õ But she was nÕt abl e to tell him that ÒW hen you feel that way, you can come close or ask questions or ask mom to go on a walk with you around the campsite so you don't have to feel afraidÓ so we worked on that. Just different things like that, with this kid, the d entist was very challenging. School was pretty challenging. There were a lot of things that were pretty challenging. And sometimes anticipatory guidance i s half the battle. A parent remarks on how the involvement in treatment with extended family has improved her ability to use family as natural supports, which is part of the IMH model of supportive clinical services. She's [clinician] done play therapy and therapy with him, with his dad, with my mom, with my step -dad, with my grandma, so. It's been here, at my Mom's before, at the school. One time we met at McDonald's because something came up last minute for us and we called and she [clinician] said, Ò Well, I'm over here if you want t o meet me at this McDonald's.Ó Talking to her has been helpful , because especially my step -dad and my grandma, they 're very old school. And very , ÒW ell if he's not g oing to listen just spank him.Ó So it's been a big, big h elp, what I've learned and what I've taught my mom how to deal with him, my step -dad has picked up on. It's pretty much changed our whole family. T hrough what I've learned from [clinician] and passed on to everybody, my sister has kind of picked up with t hat as well, itÕs changed my whole family, its changed a whole lot !!!!!78 of what we do. I am more able to call my mom and say, ÒL ook, this is what is going on, what do you think I should do?Ó rather than calling [clinician] twice a day. She [parentÕs mom] is m ore open and my grandmother and her h ave read different book that the [clinician] has suggested. In summary, nearly all of the parents 19/20 (90%) were actively involved in a consistent treatment process, which included a parent check -in, play session, p arental reflection and a post -session activity. Additionally, parents received Anticipatory Guidance (65%), Developmental Information (55%), Advocacy (44%) and Concrete Needs Assistance (12%). Chi -squares results indicate significant relationships betwee n CPP and Anticipatory Guidance and Developmental Information focused on the child or family, along with PP and Anticipatory Guidance on the child and family, but only Developmental Information when focused on the family (verses the child). Research Ques tion 4: Qualitative Results Qualitative Results Regarding the Clinician -Parent Relationship During interviews, all clinicians identified a trusting clinician -parent relationship as a key aspect of treatment and nearly all of the parents 19/20 (90%) desc ribed the clinician -parent relationship as supportive, consistently available (during and in -between home visits) and attentive to parental thoughts/feelings and needs. Within the context of the supportive relationship, parents reported a deeper understand ing of difficult child behaviors and their own parenting responses. As a result, parents felt empowered and more comfortable making parent -related decisions, employing tailored parenting strategies and advocating on behalf of their child to friends/family and reported improved natural supports and f ewer feelings of social isolation . !79 Attunement, support and a vailability . A parent remarks on a clinicianÕs level of attunement, support and encouragement during treatment sessions. I like how they come ou t and they really listen to my concerns. And they don't just write it off, like maybe it's just a change of the season, no they really listen to my concerns and help me and give me ideas of what to do. And I think even though being a young parent, because I'm only 23, they give me the breakdown and tell me what's normal and what's typical. And like, they tell me that certain things are typical at this age too. And it's not just a disorder that's taking over, because that's what I was worried about, the bigg est thing. That it would take over everything. I just like how they're so involved with us, they really are. And they listen, they sit down and listen to me, and they listen to my significant other. She has concerns, they just really listen. And then too, sometimes when I was crying, [clinician] would be crying too and would be like , Òyeah, I know it's a bit much for y ou, but we will get through it.Ó She is very encouragin g. A parent remarks on the constant support and availability of the clinician and how the support contributes to feeling less isolated from others. So she's [clinician] there. She's there for me and she's gone to the pediatrician with me when we're trying to figure out meds. She's been to all the IEP meetings we've had throughout the year s, so she's been there a lot. For everything that we're going through. Because I think she knows, you know, we don't have family help around here. So she knows emotionally I need the help, I mean, cause it's hard. So I just like the fact that if she doesn 't know then she'll ask a coworker. She'll ask !!!!!80 her supervisor, sh e'll find the answers for me, I think it's been a really good help for us. It's kind of opened our eyes to different disabilities that are even out there. I think it's been really helpful jus t to know, you kn ow, that he isn't the only one, so it make s us feel like we aren't alone and there are other kids out there going through this and other f amilies. Another parent describes how the clinician has built a positive relationship with the child but is equally attuned to her [parent] dai ly experiences or stressors, which the parent finds surprising. If you donÕt trust the person you are counseling with, you are not going to tell them how you really feel so she [child] reaches out to [clinician] and says things to her that she [child] wouldn't of said to me, so I think it's a good relationship and she han dles her really well and the [clinician] offers me more support than my family does, and she is always helpful. If I make mention of something, she asks , ÒHow are you? Ó ÒYou seem sad ,Ó and stuff like that and sometimes she offers me solutions sometimes or some resources to help out with things and she does sheÕs really wonderful. I would categorize her as a pro fessional friend. I like that sh e is certified i n child development so if [child] is doing something, I am like is this normal? And she is like, Òyeah. Ó And sheÕs so helpful to our family, and I really appreciate everything, because she does things that are not even technically her job really. She comes here for [child], and she doesnÕt come here to listen to me to gripe out my job because how badly it stresses me out, you know. SheÕs really great. !81 Deeper u nderstanding of child behaviors and parenting responses. The following are remarks from an adoptive parent and how her insight into child behaviors/ symptoms deepened her understanding, ability cope with frustrations and adapt parent responses. ItÕs just really helped me learn to look at things differently and approach thing s. My daughter, instead of immediately interpreting something one way, looking at it and understanding it comes from somewhere else . When she [child] first came [adopted child] I was frustrated, I was a frustrated parent. I didn't understand what was going on and if it wasn't for her [clinician] at the beginning helping us understand what fetal alcohol syndrome was and how to deal with the behaviors and such, I'm not so sure we could have made t he other transitions so easy. And so [clinician] has helped me to understand her better and in turn, it's helped me to understand and adapt myself and my reactions. And to be able to cope with frustrations . So she [clinician] has helped us deal with those things and when you have a less frustrated parent, you have a less frustrated child. Another parent remarks on a similar experience and how support and a deeper understanding contributed to modifying parental reactions. Talking with her [clinician] has really helped me to understand my [child] and not to t ake the things personal. B ecause at first I'd feel like, Ò you know maybe it is my fault wha t he doesÓ and she'd [clinician] would say like , Òyou have to step back and just now that it 's not you, this is a disorder.Ó And she used to give me, well she sti ll gives me a lot of praise for how far [child] has come because where we were back in August was a whole different kid from where we are now. !!!!!82 Parental empowerment and confidence. To understand feelings of empowerment, it is important to note that prior to treatment services, parents reported intense stress and frustration related to child difficult behaviors/symptoms. The following is a remark from a parent regarding her frustration about parenting. His [child] episodes would last an hour to a n hour and a half where I had to physically restrain him and it was happening three or four times every single day. And then he wouldn't be safe in the car, like he would unbuckle his seat belt and dash to the front of the car and at one point, he open ed the door because I forgot the child locks. And when I looked at him, he was not there, it was not like him, he was not my son and I didnÕt know how to manage it. I was stressed every day, literally crying everyday. Parents also reported isolation f rom friends and family who made quick judgments and blamed the parent for child behaviors/symptoms. A parent remarks, My father -in-law has a brand of discipline [spanking] he thinks we should use on our child. And if that doesnÕt work, you just need to do it harder. No, thatÕs not a solution, and itÕs frustrating because you get advice from a lot of people that donÕt get the whole thing. Once involved in treatment services, parents reported feeling empowered by the knowledge they learned about the ir childÕs behaviors/symptoms and their own parenting responses. As parents were able to implement new parenting strategies, they felt more confident in making parent -related decisions, using positive coping skills as needed, employing new parenting strat egies and advocating on behalf of their child with friends and family. A parent remark s how a supportive clinical relationship has influenced her own anxiety, ability to manage !83 child behaviors/symptoms and find words to help friends and family understand her [child] better. I just feel more comfortable in my decision -making after talking to her [clinician] because, you know, it helps to have somebody to talk to about it. And, without it I already have a lot of anxiety, so I feel a lot better if I can talk to her about things and discuss them with her, so that helps a lot. I like the consistency of it, that you know, sheÕs here and she comes once a week and itÕs, you know, we continue on where we left off. Having her [clinician] to talk to and expl ain things to me to make me feel, you know, like I understand her [child] better. She [clinician] has explained you know like the right side of the brain and the left side of the brain and how it works, and now I understand more about you know, how kids a ct. Cause I didn't realize that there was so much in there, some of the ideas that she [clinician] gave me to work with her have specifically helped [child] and given me words to use with my friends and her [child] family so they get her more. I feel I h ave gotten a valuable education to help her [child]. Another parent remarks on how she has learned triggers to her child behaviors and how she felt more confident managing his behaviors in the community. It was like we were in prison in our own home a nd that was what it felt like. And that's what it totall y felt like. Because really he [child] determined what we would do as a family and everything. He would determine a lot of things. But now we know to be sensitive to his order, and get out, like maybe if there's a crowd we know how to put [child] in the middle to make a little barrier if he feels !!!!!84 uncomfo rtable o r if he feels like he is starting to get overwhelmed we can tell by his facial expression or his body language that he needs to move to a diffe rent area or something else. You know, we are able to pick up on little signs before it gets bigger just like that. So that helps us A LOT, we are better at handling him. We can go out and ri de the bus now to go to places. Another mom talks about feel ing accomplished as she now has the words to help her family and friends understand her child more and with new parenting strategies, she can now complete errands in the community. My famil y is hard to talk to about her [child] because they say she needs more discipline and I donÕt think itÕs about the level of discipline she receives, I think itÕs something within her and I can say that now to them [friends and family] because disciplining her more is not going to help or build her [child] confidence [building the childÕs confidence is a treatment goal]. SheÕs making a lot of improvement, like I said, I can go to the grocery store now and thatÕs like an amazing feat, because it was horrible. I was the embarrassed Mom who left her grocery cart full of th ings because I had a child going bonkers in the store [laughs]. So, now I can finish my shopping and it doesnÕt take me 2 or 3 tries to go do it. Yeah [mom smiles at baby in her arms], it feels good. In conclusion, parents and clinicians reported the c linician -parent relationship to be a key aspect in receiving support, treatment interventions and clinical supportive services; and in feeling more confident and empowered to tailor parenting strategies to meet child/family needs to advocate on behalf of t heir child to frien ds and family and reported improved natural supports and fewer feelings of social isolation . !85 Overall Summary Clinicians used initial and continual assessments to tailor treatment modalities and interventions; however, the wi llingness and readiness of the child, parent and family was assessed prior to implementing proposed interventions. If a child or parent was not willing to engage or ready to participate, interventions were adapted to meet the familyÕs immediate needs or co ncerns. Once a client or parent was willing and ready, clinicians remained flexible when employing treatment modalities and interventions to meet the shifting needs of the family. When examining specific RPT and non -RPT treatment models, clinicians ide ntified the use of Filial Play Therapy and Theraplay along with several non -directive and directive play therapy techniques. In terms of IMH, clinicians identified the use of attachment theory and psychotherapy to help parents explore parenting reactions/ responses and unresolved inner conflicts related to their childhood experiences. Analysis of the Service Provider Checklist indicates clinicians utilized RPT models 49% and IMH models 34 % of the time during home visits within a two -month time frame . Cumu latively, there is a higher perce ntage of play therapy, which may suggest clinicians are integrating specific play therapy techniques, as needed within IMH or other treatment models . Chi-square analyses indicates the relationship between Child -Parent Psy chotherapy (CPP) and the combination of Non -Directive Play Therapy (NDPT) and Directive Play Therapy (DPT) was significant indicating clinicians are more likely to use CPP with NDPT and DPT (than using CPP without NDPT and DPT techniques ). Additionally, r esults indicate significant relationships between CPP and TF -CBT; Art Therapy and DPT; and Bibliotherapy and DPT postulating clinicians were more likely to us e both models within treatment sessions verses the utilizat ion of a single treatment model. !!!!!86 When exploring parental involvement, 19/20 (95%) of the parents reported active involvement within a consistent treatment process. The process as reported by clinicians and parents included a Òcheck -inÓ period to explore previous events or concerns, and prepa re for the parent -child -clinician play session. This was followed by a play session in which parents actively participated or observed. Following the play session, clinicians allotted time for parents to reflect on the process of the play session and their own reactions, which may (or may not) be related to their own childhood experiences as a paren t. Parents also reported a post -session activity where clinicians assigned parents an activity focused on coping skills to complete with their child in -between h ome visits. In addition, parents reported involvement in clinical supportive services and more than half of the parents r eceived Anticipatory Guidance (65%) and Developmental I nformation (55%) and almost half (44%) received advocacy related to school, health, m ental health or court systems whereas less than 12% received concrete needs assistance. Chi-squares tests of independence indicated a significant relationship between CPP and Anticipatory Guidance and Developmental Information when focused on eith er the child or family . Similarly, Chi -squares indicated a significant relationship between Parent Psychotherapy (PP) and Anticipatory Guidance focused on the child and family and PP and Developmental Information only when it is focused on the family . Ove rall, higher chi -square and p hi values indicate a stronger relationship when CPP or PP and AG and DI are centered on the needs of the family. During interviews, the inclusion of clinical supportive services was also reported by clinicians and parents to be an important aspect of building a clinical relationship and gaining access to needed resources for families. !87 Finally, a trusting clinician -parent relationship was reported throughout clinician and parent interviews. Parents described the clinician -parent relationship as supportive, consistently available and attentive to parental thoughts/feelings and needs. Within the context of the clinical relationship, parents reported gaining a deeper understanding of child behaviors/symptoms, parenting response s and reactions based on their childhood experiences. With this knowledge and support, parents felt more confident in making parent -related decisions; tailoring parenting strategies to meet child needs at home and in the community; and advocating on behal f of the child with friends and family and reported improved natural supports and fewer feelings of social isolation . !!!!!88 CHAPTER 5: Discussion, Limitations and Implications Introduction Although IMH and RPT have efficacious treatment models rooted in randomized and non-randomized studies, current evidence does not include specific knowledge about the process and/or related outcomes in regard to the integration of RPT into IMH for preschoolers and their families living in poverty. Therefore , the purpose of this study was to gain an in -depth understanding from the experiences of those involved in an integrative treatment process. Research questions center ed on the experiences of parents with at -risk preschoolers and clinicians providing dire ct treatment services with an emphasis on the similar but different aspects of RPT and IMH treatment approaches. A total of four research questions were developed: 1. How do clinicians decide to integrate play therapy within an IMH treatment approach with at -risk 3 to 5 year olds and their families? 2. What RPT models and Non -RPT Models are clinicians utilizing within an IMH treatment approach for at -risk 3 to 5 year old children? 3. How are parents involved in the treatment process when play the rapy is integrated into an IMH treatment approach with at -risk 3 to 5 year old children? 4. How does the clinician -parent relationship impact the integrative treatment process? An integrated phenomenological approach (Creswell, 2013) was implemented to gain an in-depth understanding of the process from the experiences of parents and clinicians involved in an integrative treatment process. This approach integrates a psychological perspective (Moustakas, 1994), and a human science orientation (van Mane n, 1990) that focuses on interpretations between the meanings of the lived experiences (van Manen, 1990). A mixed - !89 method de sign was implemented to order in gain an understanding from multiple perspectives, triangulate results (Klassen et al., 2012) and i dentify contradictory and confirmatory evidence (Green, 2007), all of which can lead to a fuller understanding of an integrative treatme nt process. Qualitative methods included clinician and parent interviews and applied to research questions 1 through 4; and quantitative methods included a Service Provider Checklist that explored patterns of treatment interventions and clinical supportive services and provided answers t o research questions 2 and 3. Qualitative results further illustrated and explained qu antitative results. T his chapter will begin with an in -depth discussion of findings followed by clinical, research and policy implications followed by a conclusion . Discussion The decision to use an integrative model centered on the need to tailor tre atment services and supportive services to address child and parent risk factors related to maladaptive emotions/behaviors and to enhance protective factors associated with the parent -child relationship. Tailored treatment services were accomplished by th e use of initial and continual assessments; utilizing theories (attachment and psychoanalytic) to determine the relevance and types of data needed during assessments (i.e. child maladaptive behaviors, caregiver permanency and parent -child attachment patt erns), assessing the willingness and readiness of the child/parent , and obtaining parental feedback prior to implementing interventions. These attributes represent evidenced -based practices within a collaborative treatment approach (Jordan & Franklin, 2011; Spring & Hitchcock, 2009; Thyer & Pignotti, 2011). Furthermore, clinicians implemented IMH evidenced based mode ls, CPP (Lieberman et al., 2006 ; Ippen et al., 2011) and COS (Hoffmann et al., 2006); and RPT evidenced based models, Filial Play Therapy (Aliv andi -Vafa & Ismail, 2010; Topham et al., 2011) and Theraplay (Wetting et al., 2011). In addition, the use of non -directive !!!!!90 play with children during the assessment period (which was used to assess child willingness) along with a focus on the pare nt-child dyad were predictors of treatment effectiveness in relationship -based progr ams focused with high -risk families living in poverty (Mortensen & Mastergeorge, 2014) . Despite the identification of evidenced -based practices, clinicians reported uncertainty about whether their approach Òfit into Ó an evidenced -based model or what was considered evidenced -based practice. This could be related to the hesitancy clinicians demonstrated in identifying theories and specific components of treatment models, hence, the y were not comfortable commit ting to an established evidence -based practice or treatment model. It may also be plausible that the language of evidence -based model s/practices are not part of day -to-day clinical conversations and with limited training, this could lead to misconceptions between what constitutes an evidenced -based practice or mo del (Spring & Hitchcock, 2009). During interviews, clinician s report ed a range of RPT models (Filial Play Therapy and Theraplay) and techniques (Non -Directive, Direc tive and Non -directive and Directive) along with IMH theories (Attachment and Psychodynamic) and models (CPP and PP). Analysis of the Service Provider Checklist indicate d that clinicians utilized RPT models more often (49%) than IMH models (3 4%) and other treatment models. Other treatment models included utilizing Bibliotherapy (24%), CPP (20%) and TF -CBT 20% of the time. Cumulatively, there is a higher percentage of play therapy, however, the frequencies of individual treatment models highlight the possi bility clinicians are integrating specific play therapy techniques in Non -RPT models such as CPP, TF-CBT or Bibliotherapy . For example, clinicians remarked on using directive play techniques within the context of CPP to introduce play that fosters positiv e attachment behaviors between the parent and child (i.e. cotton ball toss, burrito roll up) or to enhance a !91 childÕs ability to self -regulate within treatment sessions. Other treatment mo dels were identified including Parental Psychotherapy (12%) and Safet y Planning (14%) due to severe aggressive behaviors and/or self -harm ideations or plans. Collectively, the range of interventions reported highlight the diverse needs within high -risk preschoolers and paren ts living in poverty (Lieberman & Van Horn, 2008) and the diverse skills of program clinicians. During interviews, clinicians identified the range of interventions to target maladaptive behaviors, child and parent self-regul ation, parental sensitivity and/or positive attachment behaviors, which is consi stent with the conceptual literature supporting the integration of RPT into IMH (Paradis, 2002; Tuters & Doulis, 2000). Additional analyses of the Service Provider Checklist indicate d significant relationship s between CPP and the combination of Non -Direct ive Play Therapy (NDPT) and Directive Play Therapy (DPT) ; CPP and TF -CBT; Art Therapy and DPT; and Bibliotherapy and DPT. These findings suggest clinicians are more likely to use the combination of the specified treatment models verses the utilization of one single model. It is plausible clinicians are using two models to increase the scope of interventions ( Paradis, 2002 ;Tuters Doulis, 2000 ). However , it may also be possible that clinicians are tailoring specific Non -IMH treatment models (TF -CBT) to emph asis parent -child or family attachment reparation or Non -RPT treatment models (Art Therapy and Bibliotherapy) to include play techniques centered on the specific needs of the parent -child dyad or family. This is consistent with literature that suggest int egration is needed to meet the needs of the family (Gil, 2006; Lieberman & Van Horn, 2005; 2008) and seems probable in this study, as treatment modalities during home visits focused on the parent -child dyad 52% and encompassed families 20% of the time. !!!!!92 When exploring parental involvement, 19/20 (90%) parents reported active involvement within a consistent treatment process , which was understood by parents. Only one 1/20 (5%) parent reported no involvement with the play or reflection aspects of the treatme nt process. Each parent was able to identify the different aspects ( i.e. check -in, play session, reflection and post -session act ivity) in the treatment process; and reported value in being involved and working collaboratively with the clinician. The diff erent aspects in the treatment process could serve as a guidebook for clinicians integrating RPT into IMH treatment services as it represented a blend of IMH and RPT treatment principles. For example, the check -in period allowed gave parents the space to voice their concerns and clinicians to provide support and empathy while providing clinical supportive services to meet the needs of the child, parent or family. The latter aligns with IMH treatment principles (Weatherston & Tableman, 2002) whereas the di scussion of the subsequent play session and role -plays that occurred follows RPT treatment principles ( Gil, 2006; Jernberg & Booth; Landreth, 2002 ). In terms of the play session, parents reported that it was held between the child -parent -clinician or the clinician and child with parental observation. Parents did report understanding the utility of play and how it related to client or parent treatment goals , which highlights parental investment within treatment services . However, it was noted clinicians or parents did not report the assessment or use of symbolic or metaphoric play within play sessions. Clinicians may have implied this when they reported the use of RPT treatment models; nonetheless, the capacity to use symbolic or metaphoric play is an im portant aspect of RPT and was identified as a primary rationale for integration (Benham & Slotnick, 2006). Therefore, further examination of this treatment aspect is needed. !93 The reflective time clinicians allotted for parents to explore and process the play and its potential meaning(s) also represented a blend of RPT and IMH treatment principles. However, utilizing psychoanalytic theory, clinicians examined parental reactions/responses to the play and how they relate d to their own childhood experiences. The latter is a cornerstone in IMH treatment approaches and allows parents the opportunity to examine unresolved conflicts and reorganize internal working models, which in turn can facilitate growth and modify in the parent -child relati onship (Fonagy & Ta rget, 2003). In other words, it gives parents the therapeutic space to resolve conflicts, which can impact their understanding of the parental role and change how they interact and respond to their child. This inclusion confirms the use of psychoanalytic theory and treatment principles within the integrative treatment process and fulfills a current need within RPT to focus on parental mental health in relation to parenting (Benedic t & Mongoven, 1996; Gil, 2006). The final aspect of the consistent treatm ent process was a post -session activity, which extended and reinforced parental involvement in -between home visits. C lini cians assigned parents an activity to complete with their child throughout the week that focused on using positive coping skills (i.e. blowing bubbles for deep breathing , reading a feeling book) . The idea of post -session activities is embedded with one RPT model, Theraplay (Jernberg & Booth, 2010) and one IMH model, CPP (Lieberman & Van Horn, 2005). However, the goal or focus of the activity for CPP and Theraplay is different and relates to the child/parent practicing positive attachment behaviors focused on attunement, engagement and/or providing structure in the relationship to enhance the reorganization of internal working models of attachment (Jernberg & Booth, 20 10; Lieberman & Van Horn, 2005) verses learning/practicing a coping skill. It is plausible clinicians assign similar activities, however, further examination is needed to determine !!!!!94 if post -sessions activities include a focu s on attachment reparation and effectiveness within the treatment process. In this study, parents reported high levels of stress due to child behaviors; therefore it is not surprising the most frequent clinical supportive service was Anticipatory Guid ance (65%) and Developmental Information (55%), which focused on either the child or family. Interestingly, the significant relationships between CPP and Anticipatory Guidance and Developmental Information indicated higher chi -squares and phi values when A nticipatory Guidance and Developmental Information were focused on the family verses the child. These findings may be due to interrelation of the parent -child dyad to other members of the family, which may create a need for Anticipatory Guidance/Developmen tal Information to address family verses child concerns (Patterson, 2001; Walsh, 2006). Similarly, a significant relationship was indicated between PP and Anticipatory Guidance focused on the client or family and PP and Developmental Information focused o n the family. This is also interesting and speaks to the need of Anticipatory Guidance/Developmental Information within a parent -focused treatment intervention. Although Developmental Information and assistance with specific parenting strategies is a par t of RPT treatment models, chi -square relationships were non -significant, which may indicate limited knowledge about the use of Parenting Guidance and Developmental Information within RPT treatment models (Gil, 2001; Landreth, 2002). These findings repres ent a need for parents of preschoolers to obtain Anticipatory Guidance and Developmental Information o n child o r parent -based treatment models, in order to help reduce the stressors related to child and family behaviors, and/or special needs associated wit h DMS -IV disorders. Additionally, clinical supportive services assisted parents in getting conc rete n eeds met 12% of the time whereas a dvocacy within school systems occurred 20% of the time, which may !95 rep resent a specific need for this population. Duri ng interviews, c linicians re ported consultation with teachers on behavior/symptom management and attendance at IEP meetings. Parents valued clinician attendance at IEP meetings and reported it helped them learn the language of the school system s and gain a deeper understanding of school processes. Per parent report, school advocacy did secure additional services within the school system, w hich included extra support in completing math and reading assignments, as well as speech and la nguage services. These finding s ascertain the presence of a risk factor for children living in poverty (lower school success due to the presence of behaviors/sym ptoms in school) and a need within this population for clinicians to advocate with parents to help them gain knowledg e regarding the language, services and processes of school systems in order to reduce the impact of this specific risk factor (Emerson, 2004; Issacs, 2012). Lastly, clinicians advocated and/or supported mental health services a total of 17 % of the time , which indicates a need to help parents further understand and/or navigate psychiatric or health services and provide transportation . The latter is consistent with literature indicating limited or unreliable transportation a s a risk factor associated with living in poverty and can influence accessing or obtaining medical services (Broussard & Joseph, 2009). Within the context of treatment interventions and clinical supportive services, parents identified a supportive clinician relationship, which influe nced the treatment process and child and parent risk factors associated with living in poverty. Parents stated they valued the relationship and reported clinicians to be consistent, attuned to parental needs, genuine and supportive. Clinicians continuall y acknowledged the importance of the clinician -parent relationship throughout interviews and viewed it as a conduit to provide parental support, assess the willingness and readiness for treatment interventions, examine parental childhood !!!!!96 experiences and pa renting responses. Clinicians remarked on the use of clinical supportive services; in particular concrete needs assistance and adv ocacy to build rapport and Anticipatory Guidance and Developmental I nformation once a trusting relationship was established. To maintain a positive therapeutic relationship, clinicians reported the need to be flexible when employing treatment int erventions and modalities. P arents reported this to be a key aspec t in meeting immediate and ongoing family needs, which may relate to a parentÕ s ability (if needs were addressed or met) to engage in treatment interventions or clinical supportive services. This study confirmed the presence of parental risk factors associate d with living in poverty including lower parental satisfaction and competence and strained interpersonal relationships (Neece, 2013; Olson & Banyard, 1993; Pisula, 2007; Rodrigue et al., 19 90; Sanders & Morgan, 1997). However, w ithin the context of the supportive clinician -parent relationship and tailored treatment services , parents reported feeling more confident about parenting decisions and knowing how to adapt parenting strategies to meet the nee ds of the child and/or family. Parents also reported feeling empowered to advocate for their child with friends and family, which led to a greater familial understanding about the childÕs behaviors and/or needs, improved natural supports and few er feelings of social isolation . These findings highlight the role of a supportive clinician -parent relationship to serve as a c onduit to help parents fee l more confident and empowered to advocate for their child . In summary , understanding the experiences of parents and clinicians involved in integrative treatment model allowed an in -depth understanding of how treatment inter ventions and modalities and clinical supportive services are ta ilored to meet needs, enhances parental involvement and reduce s the influence of r isk factors for preschoolers and families living in poverty within the context of a supportive clinician -parent relationship. !97 Limitations This study involved a small non-probability sample of parents and clinicians involved in a CMH treatment program in the Midwest. Although the demographic characteristics represent a diverse population of parents for the Midwes t, the sample was in clusive of only one father and one grandfather. The population for clinicians was homogeneous in race and gender. Questions for clinicians and parents were developed for the purpose of a program evaluation impacting their validity. It is possible there may have been selection bias as participation was voluntarily and parents satisfied with treatment services were more likely to participate in interviews than parents who were not satisfied. The majority of clinicians participated in interviews and all clinicians completed Service Provider Checklists. Data collected in interviews were based on self -report and may have been influenced by the positive clinician -parent relationship reported by parents. The Service Provider Checklists w ere also based on self -report and due to the nature of program evaluations, clinician data may have also been biased and positively skewed. The researcher had a previous working relationship with the program supervisor and one clinician in the program due to similar professional interests ( i.e. early childhood and CMH treatment services), thus b racketing was completed to set aside previous experiences as much as possible (Creswell, 2013). Although a phe nomenological approach elicits multiple forms of dat a and a streamlined data collection process (Creswell, 2013), generalizability of the interviews is lim ited to the sample population. However, detailed descriptions of clinician and parent remarks were included, which improves the transferability of the d ata to a similar population (Creswell, 2013). To increa se the trustworthiness, data were triangulated using multiple sources (clinicians and parents), multiple methods (interviews and Service Provider Checklist) and multiple !!!!!98 investigators (the researcher and two undergraduate student researchers); debriefings took place between the researcher and undergraduate student research and qualitative experts several times throughout the study; a codebook was developed and significant statements were independently rev iewed (inter -rater code was 83 %); and negative case analysis was completed. The Service Provider Checklis t was developed for this study, therefore the validity and reliability are unknown which impacts generalizability of findings. To improve valid ity, clinician and parent interview data informed the items on the Service Provider Checklist, and clinician feedback was obtained prior to finalizing the checklist. In addition, a codebook was developed to ensure clinicians understood the meaning of each item. Despite study limitations, this study does offer an in -depth understanding of an integrative treatment process and the identification of multiple interventions and clinical supportive services utilized with at -risk preschoolers and families living i n poverty. Implications and Recommendations Clinical Implications For clinicians, results provide a better understanding of the decision to tailor treatment services and identifies what specific RPT and N on-RPT models are being integrated within an IMH treatment approach for at -risk preschoolers and families living in poverty . Results outline a consistent treatment process and specific methods to enhance parental involvement (i.e. treatment inventions and modalities, parental feedback, clinical supporti ve services and post -session activities), which can help clinicians make evidenced -informed practice decisions (Spring & Hitchcock, 2009; Thyer & Pignotti, 2011). !99 Additional ly, results highlight the integral aspects of the clinician -parent relationship and its relation to improving paren tal confidence and empowerment, which led to fewer feelings of social isolation per parental reports. Although the occurrence of risk factors were not measured, results accentuate a need for clinicians to include clinica l supportive services within treatment services, especially school advocacy to improve academic success for at -risk preschoolers who display behaviors/symptoms at school (Emerson, 2004; Issacs, 2012). In addition, significant relationships between C hild Parent Psychotherapy (CPP) and Parental Psychotherapy (PP) and Anticipatory Guidance and Developmental Information were stronger when focused on the family (verses an individual child), which postulates a family focus may be needed when clinicians are worki ng with at -risk preschoolers and families. During interviews, clinicians were reserved with the identification of theories and specific treatment models (verses clinical techniques), which may be interrelated to the uncertainty clinicians reported about whether their treatment approach fits into an established evidenced -based m odel or is considered evidenced -based practice. For clinicians, this may indicate a need for additional trainings and/or trainings focused on clinical techniques to be inclusive o f theory and coordinating treatment models. Regulations within early childhood clinical associations or university continuing education programs may need to require presenters to include this information within clinical trainings especially when focused on an integrative treatment approach. Additional t rainings on evidence -based practices and models are recommended to assist clinicians in understanding its applications to day -to-day client interactions and treatment services. !!!!!100 Research Implications This study provides knowledge about the process in which clinicians tailor treatment services, and specific RPT and Non -RPT treatment interventions employed within an IMH treatment approach . However, further treatment model development is needed as it relat es to the application of theories, the identification or assessment of symbolic or metaphoric play (as this is an important aspect in RPT models), and the four different aspects of the treatment process, in particular the use of a post -session activity. F urther examination of the significant relationships between IMH (CPP) and RPT (NDPT & DPT) treatment models, along with other treatment approaches (TF -CBT, Art Therapy and Bibliotherapy) are needed to identify the specific tenet s of each approach clinician s utilize when integrating two treatment models. This will provide a more clear and transparent process, which is needed to enhance reliability of future studies focused on the integrative treatment process for this population (Cassidy et al., 2011). Future studies also need to examine outcomes related to the IMH/RPT integrative treatment process, in particular the clinician -parent relationship. This relationship was interwoven throughout the assessment and treatment process as reported by parents and clinicians. In fact, clinicians viewed this relationship as a conduit to provide parental support, assess willingness and readiness for treatment interventions, examine parental childhood experiences and parenting responses, and deliver clinical supporti ve services. To further examine the relationship between the strength of the clinical alliance and therapeutic outcomes , measures such as the Working Alliance Inventory (WAI) (Horvath & Green berg, 1989) may elicit insight into the collaborative elements b etween the working alliance of parents and clinicians and its association with therapeutic outcomes. The inclusion of a measure with good internal consistency (Horvath & Symonds, 1991) and demonstrated convergent and discriminate !101 validity with similar mea sures (Horvath & Greenberg, 1989) improves study reliability and validity, and hence its application in the clinical field and in shaping policies to ensure quality treatment services for at -risk 3 to 5 year olds and families living in poverty . Future studies are also needed to examine child and parent outcomes in relation to an integrative IMH /RPT treatment approach . Parents in this study reported high levels of stress prior to treatment services and the presence of risk factors; hence potential measu res could include the Parenting Stress Index (PSI) (Abidin, 1983), which attributes the total amount of stress a parent experiences is due to child characteristics, social support, parental health, role restrictions, parental attachment, and relationships with spouse (Abidin, 1990). Therefore, the PSI provides a baseline or outcome measure for interventions focused on decreasing risk factors associated with parenting stress, family functioning, and/or parenting skills, which could be correlated with WAI re sults. Ideally, future outcome studies wou ld maintain a diverse sample and strive for larger sample sizes that are inclusive of more fathers or father figures. Policy Implications Results from this study will be disseminated to pr ogram clinicians and administrators and agency stakeholders including the senior management t eam and the bo ard of directors . The dissemination will include knowledge regarding the integrative treatment process from multiple perspectives and its impact on parental involvement, the clinician -parent relationship and child and parental risk factors. As part of the discussion, agency p olicies regarding the use of relationship -based integrative treatment models and clinical support ive services will be examined. The need for agency trainings focused on evidenced -based practices and/or evidenced -based relationship models that are inclusive of theories will also be examined. !!!!!102 As Michigan recently expanded the IMH definition to include 4 and 5 year olds, results from this study cou ld help facilitate discussion regarding competencies for clinical endorsements by infant mental health associations, and/or introduce the idea of competencies for at-risk preschoolers within play therapy associations. Endorsements may increase the number of trainings (as a specific number of training hours are required for endorsements) for clinicians throughout the State of Michigan on integrative treatment a pproaches with young children, and create an opportunity to advocate for regulations that include theories and evidenced -based practices in the content of trainings. Recently , the U.S. State Senate passed the Medicare Access and ChildrenÕs Health Insurance Program on April 14, 2015, which includes a two -year extension for the Maternal, Infant and Early Childhood Home Visiting Program for low -income families (NASW, 2015) . It is plausible the results from this study could assist in advocating for legislative policies to ensure continued home -based programs for young children. This extension provid es motivation to furthe r examine home -based treatment models inclusive of integrative approaches specific to at -risk preschoolers and families living in poverty. Conclusion !Findings from this study provide an examination on the process of integrating R PT into IMH treatment services for at -risk preschoolers and families living in poverty . Results highlight the need for initial and continual assessments along with parental feedback and flexibility in treatment delivery to meet the shifting needs of famil ies and tailor treatment specific to the needs of the child, parent and parent -child dyad. A variety of RPT, IMH and other treatment models were reported including parental psychotherapy and safety planning which represent the variety of interventions ne eded to meet the complex needs of high -risk families (Gil, 2006; Lieberman & !103 Van Horn, 2005) . Results indicated higher frequencies of RPT verses IMH, which may demonstrate a need for additional or specialized technique s within Non -RPT treatment models significant chi -square relationships !represent a need for clinicians to tailor Non -IMH treatment models to center on attachment reparation and non -RPT treatment models to include specialized play techniques centered on the specific needs of the parent -child d yad or family. Nearly all parents were actively involved within a consistent treatment process , which represented a blend of RPT and IMH treatment principles. P arent s understood and valued their involvement within the process . Additionally, p arents wer e involved in Clinical Supportive Services, which validates the presence of risk factors associated with living in poverty and represent s a need for at-risk families with preschoolers to receive advocacy focused on school, mental healt h/health, court syste ms and concrete needs assistance. Additionally, the use of Anticipatory Guidance and Developmental I nformation demonstrated a greater effect when focused on family needs verses an individual child . !Parents reported a positive and supportive clinician -parent relationsh ip, which was interwoven throughout the assessment and treatment process. Clinicians viewed this relationship as a conduit to provide parental support and treatment services. Within the context of the clinical relationship, parents reported feeling empowered to advocate on behalf of their child to friends and family, which improved familial understanding and fewer feelings of social isolation. This finding highlights the role of the clinician -parent relationship to clinical supportive servic es and its potential influence on reducing parental stress and risk factors associated with living in poverty. Finally, clinicians reported uncertainty about theories and if their treatment approach was considered evidenced -based practice or fit into an a lready established treatment model. This !!!!!104 could be related to the hesitancy in identifying theories and specific components of treatment models, or the possible limited use of evidence -based model/practice language in day -to-day clinical conversations (Spri ng & Hitchcock, 2009). Implications of this study include further development of the integrative treatment model, and fu ture studies focused on outcomes related to the integration process and child/parent outcomes in relation to the integrative treatment process. Additional clinical trainings related to early childhood theories, treatment models and evidenced -based practices are needed . !105 APPENDICES !!!!!106 Appendix A: List of Search Words, Data Bases and Specific Journals Search Words Poverty and very young children Risk factors and preschoolers Risk factors and parents Parent risk factors Protective factors for parents Prevalence of mental health disorders and young children Prevalence of mental health disorders an d preschoolers Resiliency theory Resiliency theory and poverty Attachment theory Attachment treatment models for preschoolers Attachment meta -analyses Integrated treatment models, young children Mental health treatment models, young children Infant M ental Health (IMH) IMH Treatment Models Evidence based IMH Treatment Models IMH meta -analyses Child Parent Psychotherapy Circle of Security Watch, Wait, and Wonder Parent Child Interaction Therapy IMH Treatment Approach IMH Home visiting model Comprehensive treatment for preschoolers Home visiting and young children Parental involvement in home visits Play and young children Play and parents Play and families Play in IMH Play Therapy in IMH Play and mental health treatment Play Therapy ( PT) PT treatment models Evidence based PT treatment models PT effectiveness PT meta -analyses PT treatment models with preschoolers Preschool mental health Clinical perspectives Developmental perspectives !107 Theraplay Theraplay with preschoolers Integrated Play Therapy Filial Play Therapy Child Parent Relationship Therapy Thematic Play Therapy Case studies in IMH Case studies in PT Integration of mental health treatment Integration of IMH and PT Integration of Non -directive and Directive PT Integration of IMH treatment models Integration and early childhood Data Bases ProQuest Social Sciences ProQuest Pysc Info., Psyc Articles, Tests & Critiques ProQuest Dissertations and Theses ProQuest Health & Medicine: PsycExtra ERIC E-Library , Psychology Specific Journals Infant Mental Health Journal International Journal of Play Therapy Child Development Clinical Social Work Journal Research on Social Work Practice !!!!!108 Appendix B : Conceptual Map Figure 1: Conceptual Map !!!"#$!%&'$()*'+,&!,-!.$/*'+,&*/!0/*1!"#$)*21!+&',!%&-*&'!3$&'*/!4$*/'#!-,)!5' 6.+78!0)$79#,,/$)7!*&:!;*<+/+$7 !!=!!"*+/,)$: !")$*'<$&'!>$)?+9$7! !!%&'$()*'$:! ")$*'<$&'!3,:$/! -,)!5' 6.+78! 0)$79#,,/$)7!@! ;*<+/+$7! !!")$*'<$&'! A,<2,&$&'7 !!A/+&+9*/! B$9+7+,&!',! %&'$()*'$ !.0"!*&:! C,& 6.0"! A/+&+9*/! "$9#&+DE$7 !"#$)*2$E'+9! .$/*'+,&7#+2 !0*)$&'*/! %&?,/?$<$&'! !5'6.+78! 0)$79#,,/$)7! @!;*<+/+$7 !F!!G$&$-+'7! !!FH!!%&9)$*7$7!'#$!79,2$!,-! +&'$)?$&'+,&7! !IH!;,7'$)7!'#$!E7$!,-!71 Weiner & W.E. Craighead (Eds.), CorsiniÕs Encyclopedia of Psychology , 4th Edition (pp.603 -607). New York, NY: Wiley and Sons. Tew, K., Landreth, G., Joiner, K.D., & Solt, M .D. (2002). Filial therapy with parents of chronically ill children. International Journal of Play Therapy, 11 (1), 79-100. doi:10.1037/h0088858 Thyer, B., & Pignotti, M. (2011). Evidence -based p ractice s do exist. Journal of Clinical Social Work, 29 , 328-333. doi: 10.1007/s10615 -011-0358-x Thyer, B. (2001). The handbook of social work me thods. Thousand Oaks, CA: Sage Publications, Inc. Topham, G.L., Wampler, K.S., Titus, G., & Rolling, E. (2011). 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