Published October 6, 2024 | Version v1 | https://doi.org/10.12794/metadc2356241

Cultural Humility, Cultural Comfort, and the Therapeutic Relationship in Play Therapy

Creators

Description

The current study is the first to explore the role of cultural humility, cultural comfort, and the therapeutic relationship in play therapy. Participants consisted of 69 parent-therapist dyads recruited from university clinics, private practices, and a non-profit counseling center in the southwestern United States. Parents completed a demographic questionnaire, Cultural Humility Scale, Therapist Cultural Comfort Scale, and Barrett-Lennard Relationship Inventory – Other to Self 40 (BLRI OS – 40). Play therapists completed a demographic questionnaire and BLRI MO – 40. A multiple regression analysis indicated that after controlling for the race/ethnicity of both play therapist and parent, parents' perceptions of play therapists' cultural humility and cultural comfort predicted parents' perception of their therapeutic relationship with their child's play therapist. Additionally, exploratory analyses suggested that when therapists report the occurrence of cultural conversation in parent consultations there may be an increase in parent-reported therapeutic relationship scores. However, when also controlling for the child's race/ethnicity, cultural humility and cultural comfort did not have a statistically significant impact on the play therapist's perception of the therapeutic relationship with their child client. These findings underscore the significance of play therapists' cultural humility and cultural comfort on the development of a strong therapeutic relationship with parents of children in play therapy. Limitations and implications for practice and future research are discussed.

Additional details

Identifiers

URL
https://digital.library.unt.edu/ark:/67531/metadc2356241/

Dates

Issued
2024-10-06T20:46:28Z

References

  1. 22 Tex. Admin. Code §681.140 (2023). https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=30&ch=681&rl=140
  2. American Counseling Association. (2014) 2014 ACA code of ethics. https://www.counseling.org/docs/default-source/default-document-library/2014code-of-ethics-finaladdress.pdf
  3. Ancis, J. R., Szymanski, D. M., & Ladany, N. (2008). Development and psychometric evaluation of the Counseling Women Competencies Scale. The Counseling Psychologist, 36(5), 719-744. https://doi.org/10.1177/0011000008316325
  4. The Assistant Secretary for Planning and Evaluation (ASPE, n.d.). Poverty Guidelines. U.S. Department of Health and Human Services. https://aspe.hhs.gov/topics/povertyeconomic-mobility/poverty-guidelines
  5. Atkinson, D. R., & Israel, T. (2003). The future of multicultural counseling competence. In D. B. Pope-Davis, H. L. K. Coleman, W. M. Liu, & R. L. Toporek (Eds.), Handbook of multicultural competencies in counseling and psychology (pp. 591-606). Sage. Axline, V. (1947). Play therapy. Ballentine. https://doi.org/10.4135/9781452231693.n37
  6. Barnicot, K., Wampold, B., & Priebe, S. (2014). The effect of core clinician interpersonal behaviours on depression. Journal of Affective Disorders, 167, 112-117. http://dx.doi.org/10.1016/j.jad.2014.05.064 https://doi.org/10.1016/j.jad.2014.05.064
  7. Barrett-Lennard, G. T. (1998). Carl Rogers' helping system: Journey and substance. SAGE Publications Ltd, https://doi.org/10.4135/9781446217894
  8. Barrett-Lennard, G. T. (2015). The relationship inventory: A complete resource and guide. Wiley. https://doi.org/10.1002/9781118789070
  9. Bartholomew, T. T., Pérez-Rojas, A. E., Lockard, A. J., Joy, E. E., Robbins, K. A., Kang, E., & Maldonado-Aguiñiga, S. (2021). Therapists' cultural comfort and clients' distress: An initial exploration. Psychotherapy (Chicago, Ill.), 58(2), 275-281. https://doi.org/10.1037/pst0000331
  10. Blanco, P. J., & Ray, D. C. (2011). Play therapy in elementary schools: A best practice for improving academic achievement. Journal of Counseling & Development, 89(2), 235-243. https://doi.org/10.1002/j.1556-6678.2011.tb00083.x
  11. Blanco, P. J., Holliman, R. P., Ceballos, P. L., & Farnam, J. L. (2019a). Exploring the impact of Child-Centered Play Therapy on academic achievement of at-risk kindergarten students. International Journal of Play Therapy, 28(3), 133-143. https://doi.org/10.1037/pla0000086
  12. Blanco, P.J., Holliman, R. P. & Carroll, N.C. (2019b) The effect of child-centered play therapy on intrinsic motivation and academic achievement of at-risk elementary school students, Journal of Child and Adolescent Counseling,(5)3, 205-220, https://doi.org/10.1080/23727810.2019.1671758
  13. Bratton, S. C., Ceballos, P. L., Sheely-Moore, A. I., Meany-Walen, K., Pronchenko, Y., & Jones, L. D. (2013). Head start early mental health intervention: Effects of Child-Centered Play Therapy on disruptive behaviors. International Journal of Play Therapy, 22(1), 28-42. https://doi.org/10.1037/a0030318
  14. Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children:A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36(4), 376-390. https://doi.org/10.1037/0735-7028.36.4.376
  15. Brown, A. (2022, June, 7). About 5% of young adults in the U.S. say their gender is different from their sex assigned at birth. Pew Research Center. https://www.pewresearch.org/short-reads/2022/06/07/about-5-of-young-adults-in-the-u-ssay-their-gender-is-different-from-their-sex-assigned-at-birth
  16. Budiman, A. (2020). Key findings about U.S. immigrants. Pew Research Center. https://www.pewresearch.org/short-reads/2020/08/20/key-findings-about-u-s-immigrants
  17. Burgin, E. E., & Ray, D. C. (2022). Child-centered play therapy and childhood depression: An effectiveness study in schools. Journal of Child and Family Studies, 31(1), 293-307. https://doi.org/10.1007/s10826-021-02198-6
  18. Burnes, T. R., Singh, A., Harper, A., Pikering, D. L., Moundas, S., Scofield, T., Maxon, W., Harper, B. Roan, A.. & Hosea, J. (2009). ALGBTIC Competencies for counseling with transgender clients. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC).
  19. Cabral, R. R., & Smith, T. B. (2011). Racial/ethnic matching of clients and therapists in mental health services: A meta-analytic review of preferences, perceptions, and outcomes. Journal of Counseling Psychology, 58(4), 537-554. https://doi.org/10.1037/a0025266
  20. Ceballos, P. L., Post, P., & Rodríguez, M. (2021). Practicing child-centered play therapy from a multicultural and social justice framework. In E. Gil & A. A. Drewes (Eds.), Cultural issues in play therapy (pp. 13-31). The Guilford Press.
  21. Center for Disease Control and Prevention. (n.d.) Glossary. https://www.census.gov/glossary/?term=Nonfamily+household
  22. Centers for Disease Control and Prevention. (2023, May 15). Disability impacts all of us. https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html
  23. Chapin, M., McCarthy, H., Shaw, L., Bradham-Cousar, M., Chapman, R., Nosek, M., Peterson, S. Yilmaz, Z., & Ysasi, N. (2018). Disability-related counseling competencies. American Rehabilitation Counseling Association.
  24. Chase, L., & Post, P. (2022). Factors impacting play therapists' social justice advocacy attitudes. International Journal of Play Therapy, 31(4), 248-258. https://doi.org/10.1037/pla0000184
  25. Chung, R. K., Ray, D. C., Aguilar, E. V., & Turner, K. K. (2023). The multicultural play therapy room: Intentional decision making in selecting play therapy toys and materials. International Journal of Play Therapy, 32(4), 197-207. https://doi.org/10.1037/pla0000203
  26. Clark, M., Moe, J., Chan, C. D., Best, M. D., & Mallow, L. M. (2022). Social justice outcomes and professional counseling: An 11-year content analysis. Journal of Counseling & Development, 100(3), 284-295. https://doi.org/10.1002/jcad.12427
  27. Cochran, N. H., Nordling, W. J., & Cochran, J. L. (2023). Child-centered play therapy: A practical guide to developing therapeutic relationships with children. Routledge. https://doi.org/10.4324/9781003260431
  28. Cohen J. (1988). Statistical power analysis for the behavioral sciences. Routledge Academic
  29. Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2003). Applied multiple regression/correlation analysis for the behavioral sciences (3rd ed.). Lawrence Erlbaum Associates Publishers.
  30. Collins, P. H., & Bilge, S. (2020). Intersectionality (2nd ed). Polity Press.
  31. Constantine, M. G., & Ladany, N. (2000). Self-report multicultural counseling competence scales: Their relation to social desirability attitudes and multicultural case conceptualization ability. Journal of Counseling Psychology, 47, 155-164. https://doi.org/10.1037/0022-0167.47.2.155 https://doi.org/10.1037//0022-0167.47.2.155
  32. Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1989(1), 139-167.
  33. D' Andrea, M., Daniels, J., & Heck, R. (1991). Evaluating the impact of multicultural counseling training. Journal of Counseling and Development, 70(1), 143-150. https://doi.org/10.1002/j.1556-6676.1991.tb01576.x
  34. Data USA. (n.d.) Mental health counselors. , or%20More%20Races% 20(8.69%25). https://datausa.io/profile/soc/mental-health-counselors#:~:text=In%202022%2C%2064.2%25%20of%20the
  35. David, E.J.R., & Derthick, A. O. (2017). The psychology of oppression. Springer Publishing Company, LLC. https://doi.org/10.1891/9780826178176
  36. Davis, D. E., DeBlaere, C., Brubaker, K., Owen, J., Jordan, T. A. II, Hook, J. N., & Van Tongeren, D. R. (2016). Microaggressions and perceptions of cultural humility in counseling. Journal of Counseling & Development, 94(4), 483-493. https://doi.org/10.1002/jcad.12107
  37. Davis, D. E., Deblaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., Van Tongeren, D. R., Worthington, E. L., & Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100. https://doi.org/10.1037/pst0000160
  38. Davis, D. E., Worthington, E. L, Jr., Hook, J. N., Emmons, R. A., Hill, P. C., Bollinger, R. A., & Van Tongeren, D. R. (2013). Humility and the development and repair of social bonds: Two longitudinal studies. Self and Identity, 12(1), 58-77. https://doi.org/10.1080/15298868.2011.636509
  39. DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook, J. N., & Owen, J. (2022, December 8). Multiple microaggressions and therapy outcomes: The indirect effects of cultural humility and working alliance with Black, Indigenous, women of color clients. Professional Psychology: Research and Practice. Advance online publication. https://dx.doi.org/10.1037/pro0000497 https://doi.org/10.1037/pro0000497
  40. Dietrich, S., & Hernandez, E. (2022, December 6.). What languages do we speak in the United States? United States Census Bureau. https://www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html
  41. Doyle N. (2020). Neurodiversity at work: a biopsychosocial model and the impact on working adults. British Medical Bulletin, 135(1), 108-125. https://doi.org/10.1093/bmb/ldaa021
  42. Eagan, J.L. (2024, April 26). Multiculturalism. Britannica. Retrieved June 6, 2024, from https://www.britannica.com/topic/multiculturalism
  43. Farber, B. A., Suzuki, J. Y., & Lynch, D. A. (2018). Positive regard and psychotherapy outcome: A meta-analytic review. Psychotherapy, 55(4), 411-423. https://doi.org/10.1037/pst0000171
  44. Fretz, B. R. (1966). Postural movements in a counseling dyad. Journal of Counseling Psychology, 13, 335-343. http://dx.doi.org/10.1037/h00 23716 https://doi.org/10.1037/h0023716
  45. Frey, W. H. (2020, July 1). The nation is diversifying even faster than predicted, according to new census data. Brookings. https://www.brookings.edu/articles/new-census-data-showsthe-nation-is-diversifying-even-faster-than-predicted
  46. Frey, W. H. (2021, June 23). All recent US population growth comes from people of color, new census estimates show. Brookings. , gains%20in%20people %20of%20color https://www.brookings.edu/articles/all-recent-uspopulation-growth-comes-from-people-of-color-new-census-estimates-show/#:~:text=These%20new%20estimates%20show%20annual
  47. Friere, P. (1993). Pedagogy of the oppressed (Rev. ed., M. B. Ramos, Trans.). Continuum.
  48. Gallup. (2024, March 29). How religious are Americans?. https://news.gallup.com/poll/358364/religious-americans.aspx
  49. Garza, Y., & Bratton, S. C. (2005). School-Based Child-Centered Play Therapy with Hispanic Children: Outcomes and Cultural Consideration. International Journal of Play Therapy, 14(1), 51-80. https://doi.org/10.1037/h0088896
  50. Gil, E., & Drewes, A. (2006). Cultural issues in play therapy (1st ed.). Guilford Press.
  51. Gil, E., & Drewes, A. (2021). Cultural issues in play therapy (2nd ed.). Guilford Press.
  52. Gil, E., & Pfeifer, L. (2016). Issues of culture and diversity in play therapy. In K. J. O'Connor, C. E. Schaefer, & L. D. Braverman (Eds.), Handbook of play therapy (pp. 599-611). John Wiley & Sons, Inc. https://doi.org/10.1002/9781119140467.ch32
  53. Gurman, A. S. (1977). The patient's perception of the therapeutic relationship. In A. S. Gurman, & A. M. Razin (Eds.), Effective psychotherapy: A handbook of research (pp. 503-543). Pergamon.
  54. Guzman, G. & Kollar, M. (2023). Income in the United States: 2022. (Report Number P60-279). United States Census Bureau. https://www.census.gov/library/publications/2023/demo/p60-279.html
  55. Hanna, F.J., Talley, W.B. & Guindon, M.H. (2000). The power of perception: Toward a model of cultural oppression and liberation. Journal of Counseling and Development, 78(4), 430-441. https://doi.org/10.1002/j.1556-6676.2000.tb01926.x
  56. Hansen, J. C., Moore, G. D., & Carkhuff, R. R. (1968). The differential relationships of objective and client perceptions of counseling. Journal of Clinical Psychology, 24, 244 -246. https://doi.org/10.1002/1097-4679(196804)24:2<244::AID-JCLP2270240238>3.0.CO; 25 https://doi.org/10.1002/1097-4679(196804)24:2<244::aid-jclp2270240238>3.0.co;2-5
  57. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., Harper, B. Graham, S., Singh, A., Kocet, M., Travics, L., & Lambert, S. (2009). ALGBTIC Competencies for Counseling LGBQIQA. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC).
  58. Hartmann, A., Joos, A., Orlinsky, D. E., & Zeek, A. (2015). Accuracy of therapist perceptions of patients' alliance: Exploring the divergence. Psychotherapy Research, 25(4), 408-419. http://dx.doi.org/10.1080/10503307.2014.927601 https://doi.org/10.1080/10503307.2014.927601
  59. Hawkins, J. M., Bean, R. A., Smith, T. B., & Sandberg, J. G. (2022). Representation of race and ethnicity in counseling and counseling psychology journals. The Counseling Psychologist, 50(1), 123-144. https://doi.org/10.1177/00110000211041766
  60. Hays, D. G. (2008). Assessing multicultural competence in counselor trainees: A review of instrumentation and future directions. Journal of Counseling & Development, 86(1), 95-101. https://doi.org/10.1002/j.1556-6678.2008.tb00630.x
  61. Herman, J.L., Flores, A.R., & O'Neill, K.K. (2022, June). How many adults and youth identity as transgender in the United States. The Williams Institute. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states
  62. Holcomb-McCoy, C. C., & Myers, J. E. (1999). Multicultural competence and counselor training: A national survey. Journal of Counseling & Development, 77(3), 294-302. https://doi.org/10.1002/j.1556-6676.1999.tb02452.x
  63. Holliman, R., Blanco, P., & Kowalis, C. (2022). Play therapy and academic achievement: A secondary analysis. International Journal of Play Therapy, 31(2), 82- 96. https://doi.org/10.1037/pla0000160
  64. Hook, J. N., Boan, D., Davis, D. E., Aten, J. D., Ruiz, J. M., & Maryon, T. (2016a). Cultural humility and hospital safety culture. Journal of Clinical Psychology in Medical Settings, 23, 402- 409. http://dx.doi.org/10.1007/s10880-016-9471-x https://doi.org/10.1007/s10880-016-9471-x
  65. Hook, J. N., Farrell, J. E., Davis, D. E., DeBlaere, C., Van Tongeren, D. R., & Utsey, S. O. (2016b). Cultural humility and racial microaggressions in counseling. Journal of Counseling Psychology, 63(3), 269-277. https://doi.org/10.1037/cou0000114
  66. Hook, J. N., Davis, D. E., Owen, J., Worthington, E. L., & Utsey, S. O. (2013). Cultural humility: measuring openness to culturally diverse clients. Journal of counseling psychology, 60(3), 353-366. https://doi.org/10.1037/a0032595
  67. Jones, J.M. (2024). LGBTQ+ identification in the U.S. now at 7.6%. Gallup. https://news.gallup.com/poll/611864/lgbtq-identification.aspx
  68. Kazdin, A. E., & Whitley, M. K. (2006). Pretreatment Social Relations, Therapeutic Alliance, and Improvements in Parenting Practices in Parent Management Training. Journal of Consulting and Clinical Psychology, 74(2), 346-355. https://doi.org/10.1037/0022- 006X.74.2.346 https://doi.org/10.1037/0022-006x.74.2.346
  69. Kenney, K. R., Kenney, M. E., Alvarado, S. B., Baden, A. L., Brew, L., Chen-Hayes, S., Crippen, C. L., Harris, H. L., Henrikson, R. C., Malott, K. M., Paladino, D. A., Pope, M.L., Salazar, C. F., Singh, A. A. (2015). Competencies for counseling the multiracial population. American Counseling Association.
  70. Kim, B. S. K., Cartwright, B. Y., Asay, P. A., & D'Andrea, M. J. (2003). A Revision of the Multicultural Awareness, Knowledge, and Skills Survey-Counselor Edition. Measurement and Evaluation in Counseling and Development, 36(3), 161-180. https://doi.org/10.1080/07481756.2003.11909740
  71. Kolden, G. G., Klein, M. H., Wang, C.-C., & Austin, S. B. (2011). Congruence/genuineness. Psychotherapy, 48(1), 65-71. https://doi.org/10.1037/a0022064
  72. Kolden, G. G., Wang, C.-C., Austin, S. B., Chang, Y., & Klein, M. H. (2018). Congruence/genuineness: A meta-analysis. Psychotherapy, 55(4), 424- 433. https://doi.org/10.1037/pst0000162
  73. LaFromboise, T. D., Coleman, H. L. K., & Hernandez, A. (1991). Development and factor structure of the Cross-Cultural Counseling Inventory- Revised. Professional Psychology: Research and Practice, 22, 380-388. https://doi.org/10.1037/0735-7028.22.5.380 https://doi.org/10.1037//0735-7028.22.5.380
  74. Landreth, G. (1991). Play therapy: The art of the relationship (1st ed.). Routledge.
  75. Landreth, G. (2023). Play therapy: The art of the relationship (4th ed.). Routledge. https://doi.org/10.4324/9781003255796
  76. Lanjekar, P. D., Joshi, S. H., Lanjekar, P. D., & Wagh, V. (2022). The Effect of Parenting and the Parent-Child Relationship on a Child's Cognitive Development: A Literature Review. Cureus, 14(10), e30574. https://doi.org/10.7759/cureus.30574
  77. Leblanc, M., & Ritchie, M. (2001). A meta-analysis of play therapy outcomes. Counselling Psychology Quarterly, 14(2), 149-163. https://doi.org/10.1080/09515070110059142
  78. Lee, K. R., & Ray, D. C. (2020). Child-centered play therapy parent services: A Qmethodological investigation. International Journal of Play Therapy, 29(3), 131- 143. https://doi.org/10.1037/pla0000120
  79. Lewis, J.A., Arnold, M.S., House, R., & Toporek, R. L. (2003). ACA Advocacy Competencies. American Counseling Association.
  80. Li, Y., Whiston, S., Wong, Y. J., & Gilman, L. (2024). Clients' race/ethnicity as a moderator of the relationship between the therapeutic alliance and treatment outcome. International Journal for the Advancement of Counselling. Advance online publication. https://doi.org/10.1007/s10447-024-09546-3
  81. Lin, Y., & Bratton, S. C. (2015). A meta-analytic review of child-centered play therapy approaches. Journal of Counseling and Development, 93(1), 45-58. https://doi.org/ https://doi.org/10.1002/j.1556-6676.2015.00180.x
  82. Lolan, A. R. (2011). Play therapists' practice patterns and perceptions of the factors that influence caregiver engagement in play therapy (Unpublished doctoral dissertation). University of New Orleans, New Orleans.
  83. Moon, S. H., & Sandage, S. J. (2019). Cultural humility for people of color: Critique of current theory and practice. Journal of Psychology and Theology, 47(2), 76- 86. https://doi.org/10.1177/0091647119842407
  84. Mosher, D. K., Hook, J. N., Captari, L. E., Davis, D. E., DeBlaere, C., & Owen, J. (2017). Cultural humility: A therapeutic framework for engaging diverse clients. Practice Innovations, 2(4), 221-233. https://doi.org/10.1037/pri0000055
  85. Moustakas, C. (1959). Psychotherapy with children: The living relationship. Harper & Row.
  86. Nienhuis, J. B., Owen, J., Valentine, J. C., Winkeljohn Black, S., Halford, T. C., Parazak, S. E., Budge, S., & Hilsenroth, M. (2018). Therapeutic alliance, empathy, and genuineness in individual adult psychotherapy: A meta-analytic review. Psychotherapy research: journal of the Society for Psychotherapy Research, 28(4), 593-605. https://doi.org/10.1080/10503307.2016.1204023
  87. Norcross, J. (2011). Psychotherapy relationships that work: Evidence- based responsiveness (2nd ed.). Oxford University Press. http://dx.doi.org/10.1093/acprof:oso/9780199737208.001.0001 https://doi.org/10.1093/acprof:oso/9780199737208.001.0001
  88. Norcross, J. C., & Lambert, M. J. (Eds.). (2019). Psychotherapy relationships that work: Evidence-based therapist contributions (3rd ed.). Oxford University Press. https://doi.org/10.1093/med-psych/9780190843953.001.0001
  89. Ogawa, Y., Cheng, Y., & Ray, D.C. (2022). Cultural opportunities and comfort in play therapy. In D. C. Ray, Y. Ogawa & Y. Cheng (Eds.), Multicultural play therapy: Making the most of cultural opportunities with children (pp. 29-43). Routledge.
  90. Ormhaug, S. M., Shirk, S. R., & Wentzel-Larsen, T. (2015). Therapist and client perspectives on the alliance in the treatment of traumatized adolescents. European Journal of Psychotraumatology, 6(27705), 1-10. http://dx.doi.org/10.3402/ejpt.v6.27705 https://doi.org/10.3402/ejpt.v6.27705
  91. Owen, J. J. (2013). Early career perspectives on psychotherapy research and practice: Psychotherapist effects, multicultural orientation, and couple interventions. Psychotherapy, 50(4), 496-502. https://doi.org/10.1037/a0034617
  92. Owen, J. J., Tao, K., Leach, M. M., & Rodolfa, E. (2011). Clients' perceptions of their psychotherapists' multicultural orientation. Psychotherapy (Chicago, Ill.), 48(3), 274282. https://doi.org/10.1037/a0022065
  93. Owen, J., Drinane, J., Tao, K. W., Adelson, J. L., Hook, J. N., Davis, D., & Fookune, N. (2017). Racial/ethnic disparities in client unilateral termination: The role of therapists' cultural comfort. Psychotherapy Research, 27(1), 102-111. https://doi.org/10.1080/10503307.2015.1078517
  94. Owen, J., Drinane, J. M., Tao, K. W., DasGupta, D. R., Zhang, Y. S. D., & Adelson, J. (2018). An experimental test of microaggression detection in psychotherapy: Therapist multicultural orientation. Professional Psychology: Research and Practice, 49(1), 9- 21. https://doi.org/10.1037/pro0000152
  95. Owen, J., Jordan, T. A. II, Turner, D., Davis, D. E., Hook, J. N., & Leach, M. M. (2014). Therapists' multicultural orientation: Client perceptions of cultural humility, spiritual/ religious commitment, and therapy outcomes. Journal of Psychology and Theology, 42(1), 91-98. https://doi.org/10.1177/009164711404200110
  96. Owen, J., Tao, K. W., Drinane, J. M., Hook, J., Davis, D. E., & Kune, N. F. (2016). Client perceptions of therapists' multicultural orientation: Cultural (missed) opportunities and cultural humility. Professional Psychology, Research and Practice, 47(1), 3037. https://doi.org/10.1037/pro0000046
  97. Pallant, J. (2016). SPSS Survival Manual (5th ed.). McGraw-Hill Education.
  98. Parker, M. M., Hunnicutt Hollenbaugh, K. M., & Kelly, C. T. (2021). Exploring the impact of child-centered play therapy for children exhibiting behavioral problems- A metaanalysis. International Journal of Play Therapy, 30(4), 259-271. https://doi.org/ https://doi.org/10.1037/pla0000128
  99. Pedersen, P. B. (1998). Multiculturism as a fourth force. Brunner/Mazel.
  100. Pedersen, P.B. & Pope, M. (2016). Toward effectiveness through empathy. In P.B. Pedersen, W.J. Lonner, J.G. Draguns, J.E. Trimble, & M.R. Scharrón-del Río, Counseling Across Cultures (7th ed., 13-30). Sage. https://doi.org/10.4135/9781483398921.n2
  101. Pérez-Rojas, A. E., Bartholomew, T. T., Lockard, A. J., & González, J. M. (2019). Development and initial validation of the therapist cultural comfort scale. Journal of Counseling Psychology, 66(5), 534-549. https://doi.org/10.1037/cou0000344
  102. Peter G. Peterson Foundation. (2023, November 9). Income and wealth in the United States: An overview of recent data. https://www.pgpf.org/blog/2023/11/income-and-wealth-in-theunited-states-an-overview-of-recent-data
  103. Ponterotto, J. G., Burkard, A., Rieger, B. P., Grieger, I., D'Onfrio, A., Dubuisson, Heenehan, B., Parisi, M., Rath, J. F., & Sax, G. (1995). Development and initial validation of the Quick Discrimination Index (QDI). Educational and Psychological Measurement, 55, 1016-1031. https://doi.org/10.1177/00131644950550060 https://doi.org/10.1177/0013164495055006011
  104. Ponterotto, J. G., Gretchen, D., Utsey, S. O., Rieger, B. P., & Austin, R. (2002). A revision of the Multicultural Counseling Awareness Scale. Journal of Multicultural Counseling and Development, 30(3), 153-180. https://doi.org/10.1002/j.2161-1912.2002.tb00489.x
  105. Ponterotto, J. G., Potere, J. C., & Johansen, S. A. (2002). The Quick Discrimination Index: Normative data and user guidelines for counseling researchers. Journal of Multicultural Counseling and Development, 30, 192-207. https://doi.org/10.1002/j.21611912.2002.tb00491.x https://doi.org/10.1002/j.2161-1912.2002.tb00491.x
  106. Ponterotto, J. G., Rieger, B. T., Barrett, A., Harris, G., Sparks, R., Sanchez, Caridad, C.M., & Magids, D. (1996). Development and initial validation of the Multicultural Counseling Awareness Scale. In G.R. Sodowsky & J.C. Impara (Eds). Multicultural assessment in counseling and clinical psychology (pp. 247-282). Buros Institute of Mental Measurements.
  107. Ponterotto, J.G., Sanchez, C.M.,&Magids, D.M. (1991, August). Initial development and validation of the Multicultural Counseling Awareness Scale (MCAS). Paper presented at the annual meeting of the American Psychological Association, San Francisco.
  108. Pope-Davis, D. B., & Dings, J. G. (1994). An empirical comparison of two self-report multicultural counseling competency inventories. Measurement and Evaluation in Counseling and Development, 27, 93-102.
  109. Popkin, S. J., & Morriss, S. (2023). Proposed census changes would drastically undercount disabled Americans. Urban Institute. https://www.urban.org/urban-wire/proposed-censuschanges-would-drastically-undercount-disabled-americans
  110. Post, P., & Tillman, K. S. (2016). Cultural issues in play therapy. In D. A. Crenshaw & A. L. Stewart (Eds.), Play therapy: A comprehensive guide to theory and practice (pp. 496- 510). The Guilford Press.
  111. Purswell, K., & Bratton, S. (2018). Children's experiences in the therapeutic relationship: Development and validation of a self-report measure. The Journal of Humanistic Counseling, 57(2), 82-102. https://doi.org/10.1002/johc.12069
  112. Ratts, M. J. (2009). Social justice counseling: Toward the development of a "fifth force" among counseling paradigms. Journal of Humanistic Counseling, Education and Development, 48(2), 160-172. https://doi.org/10.1002/j.2161-1939.2009.tb00076.x
  113. Ratts, M. J., Singh, A. A., Butler, S. K., Nassar-McMillan, S., & McCullough, J. R. (2016, January 17). Multicultural and social justice counseling competencies: Practical applications in counseling. Counseling Today. https://ct.counseling.org/2016/01/multicultural-and-social-justice-counselingcompetencies-practical-applications-in-counseling/ https://doi.org/10.1002/jmcd.12035
  114. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and Social Justice Counseling Competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28- 48. https://doi.org/10.1002/jmcd.12035
  115. Ray, D. C. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child practice. Routledge. https://doi.org/10.4324/9780203837269
  116. Ray, D. C., & Landreth, G. (2019). Child-centered play therapy. Play Therapy Magazine, 14, 1819.
  117. Ray, D. C., Armstrong, S. A., Balkin, R. S., & Jayne, K. M. (2015). Child-centered play therapy in the schools: Review and meta-analyses. Psychology in the Schools, 52(2), 107123. https://doi.org/10.1002/pits.21798
  118. Ray, D. C., Burgin, E., Gutierrez, D., Ceballos, P., & Lindo, N. (2022a). Child-centered play therapy and adverse childhood experiences: A randomized controlled trial. Journal of Counseling & Development, 100(2), 134-145. https:// doi:10.1002/jcad.12412 https://doi.org/10.1002/jcad.12412
  119. Ray, D. C., Chung, R. K., Turner, K. K., & Aguilar, E. V. (2022b). The multicultural playroom: A delphi study. In D. C. Ray, Y. Ogawa & Y. Cheng (Eds.), Multicultural play therapy: Making the most of cultural opportunities with children (pp. 29-43). Routledge.
  120. Ray, D. C., Schottelkorb, A., & Tsai, M.-H. (2007). Play therapy with children exhibiting symptoms of attention deficit hyperactivity disorder. International Journal of Play Therapy, 16(2), 95-111. https://doi.org/10.1037/1555-6824.16.2.95
  121. Ray, D. C., Stulmaker, H. L., Lee, K. R., & Silverman, W. K. (2013). Child-Centered Play Therapy and impairment: Exploring relationships and constructs. International Journal of Play Therapy, 22(1), 13-27. https://doi.org/10.1037/a0030403
  122. Ray, D.C., Ogawa, Y., Cheng, Y. (2022c) Multicultural play therapy: Making the most of cultural opportunities with children. Routledge.
  123. Ritter, A., Bowden, S., Murray, T., Ross, P., Greeley, J., & Pead, J. (2002). The influence of the therapeutic relationship in treatment for alcohol dependency. Drug and Alcohol Review, 21, 261-268. http://dx.doi.org/10.1080/0959523021000002723 https://doi.org/10.1080/0959523021000002723
  124. Ritzi, R. M., Ray, D. C., & Schumann, B. R. (2017). Intensive short-term child-centered play therapy and externalizing behaviors in children. International Journal of Play Therapy, 26(1), 33-46. https://doi.org/10.1037/pla0000035
  125. Rogers, C. (1951). Client-Centered Therapy: Its Current Practice, Implications and Theory. Constable.
  126. Rogers, C. R. (1957). The necessary and sufficient conditions for therapeutic personality change. Psychotherapy (Chicago, Ill.), 44(3), 240-248. https://doi.org/10.1037/h0045357 https://doi.org/10.1037/0033-3204.44.3.240
  127. Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships: As developed in the client-centered framework. In S. Koch (Ed.), Psychology: A study of a science. Formulations of the Person and the Social Context (Vol. 3, pp. 184-256). McGraw Hill.
  128. Rogers, C.R. (1961). On becoming a person. Houghton Mifflin.
  129. Rothman, D. B. (2007). The role of the therapeutic alliance in psycho- therapy with sexual offenders (Unpublished doctoral dissertation). University of Manitoba, Manitoba, Canada.
  130. Schottelkorb, A. A., Swan, K. L., & Ogawa, Y. (2020). Intensive child-centered play therapy for children on the autism spectrum: A pilot study. Journal of Counseling & Development, 98(1), 63-73. https://doi.org/10.1002/jcad.12300
  131. Shrider, E. A., & Creamer, J. (2023, September, 12). Poverty in the United States: 2022. (Report Number P60-280). United States Census Bureau. , Official%20Poverty%20Measure, 37.9%20million%20people%20in%20poverty. https://www.census.gov/library/publications/2023/demo/p60-280.html#:~:text=Highlights-
  132. Slone, N. C., & Owen, J. (2015). Therapist alliance activity, therapist comfort, and systemic alliance on individual psychotherapy outcome. Journal of Psychotherapy Integration, 25(4), 275-288. https://doi.org/10.1037/a0039562
  133. Smith, T. B., & Trimble, J. E. (2016). Foundations of multicultural psychology: Research to inform effective practice. American Psychological Association. https://doi.org/10.1037/14733-000
  134. Sodowsky, G. R., Taffe, R. C., Gutkin, T. B., & Wise, S. L. (1994). Development of the Multicultural Counseling Inventory: A self-report measure of multicultural competencies. Journal of Counseling Psychology, 41(2), 137-148. https://doi.org/10.1037/0022-0167.41.2.137 https://doi.org/10.1037//0022-0167.41.2.137
  135. Soto, A., Smith, T. B., Griner, D., Rodríguez, M. D., & Bernal, G. (2019). Cultural adaptations and multicultural competence. In J. C. Norcross & B. E. Wampold (Eds.), Psychotherapy relationships that work: Evidence-based therapist responsiveness (3rd ed., pp. 86-132). Oxford University Press. https://doi.org/10.1093/med-psych/9780190843960.003.0004
  136. Stulmaker, H. L., & Ray, D. C. (2015). Child-centered play therapy with young children who are anxious: A controlled trial. Children and Youth Services Review, 57, 127-133. https://doi.org/10.1016/j.childyouth.2015.08.005
  137. Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: Theory and practice (7th ed). John Wiley & Songs, Incorporated.
  138. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20(2), 64-88. https://doi.org/10.1002/j.2161-1912.1992.tb00563.x
  139. Sue, D. W., Bernier, J. E., Durran, A., Feinberg, L., Pedersen, P., Smith, E. J., & VasquezNuttall, E. (1982). Position paper: Cross-cultural counseling competencies. The Counseling Psychologist, 10(2), 45-52. Tabachnick, B. G., & Fidell, L. S. (2013). Using multivariate statistics. Pearson Education. https://doi.org/10.1177/0011000082102008
  140. Tao, K. W., Owen, J., Pace, B. T., & Imel, Z. E. (2015). A meta-analysis of multicultural competencies and psychotherapy process and outcome. Journal of Counseling Psychology, 62(3), 337-350. https://doi.org/10.1037/cou0000086
  141. Taylor, L., & Ray, D. C. (2021). Child-Centered Play Therapy and social-emotional competencies of African American children: A randomized controlled trial. International Journal of Play Therapy, 30(2), 74-85. https://doi.org/10.1037/pla0000152
  142. Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125. https://doi.org/10.1353/hpu.2010.0233
  143. Tilliman, D. (2016). The effects of unconditional positive regard on psychotherapy outcome (Doctoral dissertation). The Chicago School of Professional Psychology, Chicago, IL.ProQuest LLC 10108864
  144. Toporek, R. L. & Daniels, J. (2018). American Counseling Association advocacy competencies: Updated. American Counseling Association. https://www.counseling.org/docs/defaultsource/competencies/aca-advocacy-competencies-updated-may-2020.pdf
  145. Trevino, A. Y., Tao, K. W., & Van Epps, J. J. (2021). Windows of cultural opportunity: A thematic analysis of how cultural conversations occur in psychotherapy. Psychotherapy, 58(2), 263-274. https://doi.org/10.1037/pst0000360
  146. Truax, C. B. (1966). Therapist empathy, warmth, and genuineness and patient personality change in group psychotherapy: A comparison between interaction unit measures, time sample measures, patient perception measures. Journal of Clinical Psychology, 22, 225-229. https://doi.org/10.1002/1097-4679(196604)22:2<225::aid-jclp2270220236>3.0.co;2-o
  147. Tryon, G. S., Blackwell, S. C., & Hammel, E. F. (2007). A meta-analytic examination of clienttherapist perspectives of the working alliance. Psychotherapy Research, 17(6), 629-642. https://doi-org.libproxy.library.unt.edu/10.1080/10503300701320611 https://doi.org/10.1080/10503300701320611
  148. United States Census Bureau. (2022a). ACS demographic and housing estimates. (Table ID DP05) [Data set]. 2018-2022. American Community Survey 5-year Estimates.
  149. United States Census Bureau. (2022b). Disability Characteristics. (Table ID S1810) [Data set.]. 2022 American Community Survey 1-year Estimates.
  150. United States Census Bureau. (2022c). Place of birth for the foreign-born population in the United States. (Table ID B05006) [Data set]. 2018-2022. American Community Survey 5-year Estimates.
  151. United States Census Bureau. (2022d). Selected characteristics of the native and foreign-born populations. (Table ID S0501) [Data set]. 2017-2021. American Community Survey 5year Estimates.
  152. United States Census Bureau. (2022e). Selected social characteristics in the United States. (Table ID DP02) [Data set]. 2022 American Community Survey 1-year Estimates.
  153. United States Census Bureau. (2023a, May, 25). Census bureau releases new 2020 Census data on age, sex, race, Hispanic origin, households and housing. [Press Release]. United States Census Bureau. (2023b, May 25). Exploring age groups in the 2020 Census. https://www.census.gov/library/visualizations/interactive/exploring-age-groups-in-the2020-census.html https://www.census.gov/newsroom/press-releases/2023/2020-census-demographicprofile-and-dhc.html
  154. Watkins, C. E., Jr, Hook, J. N., Owen, J., DeBlaere, C., Davis, D. E., & Van Tongeren, D. R. (2019). Multicultural Orientation in Psychotherapy Supervision: Cultural Humility, Cultural Comfort, and Cultural Opportunities. American journal of psychotherapy, 72(2), 38-46. https://doi.org/10.1176/appi.psychotherapy.20180040
  155. Watson, J.C., & Geller, S. M. (2005). The relation among the relationship conditions, working alliance, and outcome in both process-experiential and cognitive-behavioral psychotherapy. Psychotherapy Research, 15(1-2), 25-33. https://doi.org/10.1080/10503300512331327010
  156. Weinrach, S. G., & Thomas, K. R. (2002). A critical analysis of the Multicultural Counseling Competencies: Implications for the practice of mental health counseling. Journal of Mental Health Counseling, 24(1), 20-35.
  157. Wilson, B., & Ray, D. (2018). Child-centered play therapy: Aggression, empathy, and selfregulation. Journal of Counseling & Development, 96(4): 399-409. https://doi.org/10.1002/jcad.12222
  158. Worthington, R. L., Soth-McNett, A. M., & Moreno, M. V. (2007). Multicultural counseling competencies research: A 20-year content analysis. Journal of Counseling Psychology, 54(4), 351-361. https://doi.org/10.1037/0022-0167.54.4.351
  159. Young, N.A.E. (2021, March 5). Childhood disability in the United States: 2019. United States Census Bureau. https://www.census.gov/library/publications/2021/acs/acsbr-006.html