The Efficacy of Counselling Children and Young people Experiencing Socioeconomic Disadvantage using Person-Centred, Solution Focused and Child Centred Play Therapy

Carl Rogers (1951) highlighted three main principles to fostering person-centred therapy: congruence, unconditional positive regard, and empathic understanding. Virginia Axline (1989) further adapted this model to a child-focused approach titled “non-directive play therapy”. Children and young people appreciate these aspects within the therapeutic space, but the application requires creativity (Zhu et al., 2021). Learning to relate through feelings, communicating through play and movement, visual methods such as play therapy, journalling, and collages. These are methods which underpin the utilisation of concepts and activities which match the client’s age and developmental level (Geldard, Geldard & Foo, 2018). Connection, awareness, and engagement are still critical factors in facilitating a successful counselling session (Zhu et al., 2021) though deeper consideration towards qualities of openness, acceptance, closeness, and understanding will enhance readiness and willingness to engage children and young people in therapy (Crocket et al., 2015; Griffiths, 2013; Knight, Gibson, & Cartwright, 2018). Solution-focused therapy is an alternative therapeutic intervention for children and young people where the client works with the counsellor to develop well-formed goals within the client’s frame of refence which can later be evaluated for progress (De Jong & Berg, 2013). Person-centred and solution-focused counselling both emphasise the client as the expert and the client is encouraged to develop and understand the personal lens, or frame of reference, with which they see the world through. Children and young people are especially influenced by their external circumstances and this impacts the child’s behaviour, attendance, and progress in therapy. More specifically, this client group particularly suffer from the consequences of socioeconomic disparities. Not only do people living in highly deprived areas have less access to mental health treatment (Saxon et al., 2007; Reis, 2013), the prevalence of common mental health problems such as anxiety and depression are reported to be two to three times higher in socially disadvantaged populations (Fryers, Melzer, & Jenkins, 2003; Wilkinson & Pickett, 2007; Dashiff et al., 2009; Silva, Loureiro, & Cardoso, 2016). Research has found even when access is provided to people experiencing greater socioeconomic deprivation, there is a poorer response to treatment and a lesser chance of improvement (Delgadillo, Asaria, Ali, & Gilbody, 2016; Green et al., 2015). Using the aforementioned therapeutic interventions, children and young people from low-income families and socioeconomic deprivation are provided an opportunity to withdraw from everyday hardships and engage in self-improvement activities.

Connection is the central theme for successful engagement with children and young people in counselling (Knight, Gibson, & Cartwright, 2018). Dynamic imbalances whether perceived or actual will reflect the client’s relationship with other adults and may hinder the collaborative process. This requires honesty, genuineness, empathy, and humility of oneself and cultural values and limitations (Zhu et al., 2021). Knight et al. (2018) identified five main themes that express young people’s view of a positive counselling relationship: feeling connected to their counsellor, feeling listened to, feeling believed in, feeling that the counsellor is available when needed, and feeling that the counsellor will support them and ‘stand up’ for them. Note that these five themes reflect Rogers (1951) initial principles for person-centred counselling.  Being listened to is a priority for all people in counselling, especially young people (Bright, 2018). The desire to engage in dynamic self-reflection can only occur when there is a feeling of safety and space from other person, that they are attentively listening rather than employing the typical adult ‘educative role’ (Harper, Dickson, & Bramwell, 2014). Drawing from Rogers (1951), by implementing the foundational components of a therapeutic relationship: genuineness, acceptance, and unconditional positive regard, therapists invite children of all ages, developmental levels, and cultures to engage fluidly in the here-and-now reality as it is experienced. For example, play therapy is a child-focused person-centred therapy which allows children to explore personal issues through the modality of play (Jayne, Ray, 2015). The resources are used to enhance growth and change whilst addressing conscious and unconscious influences on the present (Clark, 2018). Using play, art and narratives, children are able to express their inner feelings through their own agenda and in their own language. The underlying therapeutic approach is that the individual has an innate capacity for growth and self-direction, that the child has agency in their own healing. Roger’s (1951) unconditional positive regard goes beyond superficial ‘liking’ to a deeper acceptance and acknowledgement of the person’s whole being exactly as they are. In order to safely to explore their emotional and psychological environment, children and young people must feel the counsellor’s self-awareness and congruence of character (Bright, 2018). Working in the client’s frames of reference and allowing them to identify their own resistances and concerns increases the therapeutic alliance.

Though both person-centred therapy and solution-focused therapy focus strongly on the client as the expert, person-centred therapy engages the client with problem-solving and self-exploration whereas solution-focused therapy centralises around goal setting and solutions. Solution-focused therapy utilises the client’s strengths to solve problems. It presumes the client has the resources to grow and change, however for whatever reason, they are not in touch with this (Institute for Solution-Focused Therapy, 2022). Speaking to the client with goal-oriented questions, their problems or ‘exceptions’ are illuminated, and strengths are employed to resolve issues as they arise. Focusing on areas of the client’s life where problems are not occurring or where they are less severe the client can identify areas where personal actions are successful and can adapt them to other problematic areas of their life (De Jong & Berg, 2013). Both therapeutic interventions are adaptable for a variety of diverse groups.

Cultural humility and the ability to be informal and establish a genuine connection with this client demographic will enhance the therapeutic relationship through a deeper understanding and awareness the subtle multiplicity of culture (Zhu et al., 2021). Research shows children in low-income families and adolescents living in poverty report higher incidents of behavioural problems and are three times more likely to have mental health problems compared to peers from more affluent families (Reiss, 2013; McLaughlin et al., 2011). The more persistent exposure to poverty and low socioeconomic conditions, the more vulnerable a child is to mental health problems. Research indicates that even when variable such as baseline severity of symptoms, functional impairment, disability, and comorbid illnesses are controlled, on average, poorer psychological treatment outcomes are still associated with aspects of lower socio-economic status (SES). A person-centred model emphasises a therapeutic relationship which fosters self-esteem, authenticity, and actualisation in the client (AIPC, 2010). Person-centred therapy fosters a healthy interpersonal bond where there is provision of a safe space for the child or young person to express their emotions and behaviours without fear of reaction or repercussions (Geldard, Geldard, & Foo, 2018). Being able to accept one’s own history, childhood, adolescence, and adulthood including child-rearing and parenting issues provide more breadth to one’s therapeutic abilities and enhance cultural competence for counselling people in this demographic. The relationship between the client and the counsellor is central to a young person’s engagement. Goal-driven models would be helpful for some clients as it gives points of reference for goal setting whilst supporting analysis and comprehension of the current issue. Though it helps to generate new idea, for some clients experiencing severe trauma, counsellors must be cautious not to retraumatise due to visiting past traumas using this approach (Institute for Solution-Focused Therapy, 2022).

Person-centred therapy is a gentle mode of intervention which gives strength to the client on their journey of growth and change. It provides a safe space for self-initiated learning to build problem-solving skills and coping strategies for psychological and emotional conflicts (Geldard, 2016). Successful application of this is an attentive flow of narrative awareness where emotions and meanings can be expressed without fear of judgement or demise. However, Bright (2018) notes truly employing unconditional positive regard can be a challenge for some counsellors where there is a need for congruence of character that includes attitudinal conditionality. Furthermore, expressing empathy requires continual suspension of one’s own perceptual reality to live within the client’s frame of reference to compassionately understand the experience in the here-and-now.

Play therapy is universal and comes with a treatment manual, so it can be adapted to different developmental levels, for different age groups, and children from different cultures, genders, and abilities (Jayne & Ray, 2015). So long as the child has worked through the stage of feeling safe enough to commence therapy, play therapy can begin. Considering children are the controller in this type of therapy, therapists must be cautious not to rush children into topics they are not yet ready to address. Some authors critique that play therapy can initiate change outside conscious awareness of the association between their life experiences and the symbolism initiated in their play expression (Clark, 2018). However, this non-directive approach may also be considered a strength whereby client’s tap into their intuitive knowledge and bypass their critiquing mind. A child’s world is functional, when they are able to express themselves in manner that requires little vocabulary, they are likely to provide more information than words alone.

Solution-focused therapy has success with setting goals and future evaluation strategies. Factors such as lower family average income and living in deprived neighbourhoods show a higher prevalence of general mental health problems in areas of socioeconomic deprivation (Finegan, Firth, Wojnarowski, & Delgadillo, 2018). Therefore, for children and young people in these circumstances, this type of therapy which seeks to resolve issues, may only highlight the multiplicity of areas within a young person’s life which cannot be changed or improved within a perceivable time period. Social causation theory (Dohrenwend et al., 1992) suggests that continuous exposure to socioeconomic hardship and stress are the cause of mental health problems. Though these theories are dated, numerous studies support the findings that there is a strong association between low SES and increased mental health problems (Fryers, Melzer, & Jenkins, 2003; Wilkinson & Pickett, 2007; Davis et al., 2010; McLaughlin et al., 2011; Dashiff et al., 2009; Schreier & Chen, 2013; Melchior et al., 2012; Silva, Loureiro, & Cardoso, 2016). People from families with a higher average income were found to show greater improvements post treatment (Kelly et al., 2015; Pirkis et al., 2011; Falconnier, 2009). Even though these therapies seek to alleviate the hardships with the minds of children and young people, the evidence suggests that until the external factors of social deprivation are altered, the likelihood of growth is difficult at best. Notwithstanding the above, there are still models of therapeutic intervention to assist at least in some part towards enhancing the quality of life for children and young people within a socially deprived system. Acknowledging young people from socially disadvantaged backgrounds have a higher propensity for mental health problems, specifically anxiety and depression (Loureiro, & Cardoso, 2016), an integrative counselling model which focuses on supporting clients with these two presentations would provide a foundational step in being an ethical and culturally responsive counsellor. Providing space for the client to feel comfortable in the counselling room before needing to engage with the counsellor, would invite security and trust within the developing relationship. Through the provision of multiple lines of communication, counsellors create freedom through choice. Different activities give the client a sense of control over the situation, and specifically for young people from low SES, this may be the first time they have felt any level of control over their lives.

Once a relationship has been established, focusing on building a relationship which fosters mutuality and reassures the client that they are important. Support their need to feel safe, validate all feelings that arise and all versions of themselves that arise then encourage the client to create their own strategies for resolutions (Geldard, 2016). Presume the client has the resources to grow and change and work towards building self-awareness of their thought patterns and ways of thinking as well as their physical body (De Jong & Berg, 2013). The relationship between the client and the counsellor is crucial to play therapy (Jayne & Ray, 2015). This relationship invites the child to explore their own therapeutic goals whilst building self-respect and self-acceptance which improves self-esteem and a capacity for self-regulation (Clark, 2018). The overall goal for child-centred therapy is to be a conduct for change and growth within the client.

It is clear that the counsellor plays an important role for young people, and the perceived relationship with the counsellor majorly influence their likelihood to engage appropriately with a service. Acting in a dual role of supporting them with openness and understanding, but also as a mediator between them and other adults with whom they have difficulty expressing themselves to, the non-judgmental, person-centred and emotionally supportive values which counsellors aspire to are what create a space of refuge for young clients. The accepting and confidential relationship developed through providing these qualities are what allow children and young people to develop self-awareness, social sensitivities, and personal boundaries through a healthy and safe dynamic. Integrating methodologies from a variety of resources, Rogerian (1951), Axline (1989), and solution-focused therapies, a counselling model which includes the fundamental qualities of a therapeutic environment with the addition of child-focused play modalities, these clients can learn to self-regulate, explore, and enhance self-confidence, self-esteem and have the resources and capabilities within themselves to build on strengths, to resolve concerns, heal and achieve desired outcomes.

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