Defining directive and non-directive psychotherapy.
Directive psychotherapy can be defined as the
“therapists activity with respect to the degree of immersion and level of interpretation. Immersion relates to the degree to which the therapists enters and directs…” (Yasenik & Gardner, 2012).
Directive psychotherapy is a process whereby the therapist decides in conjunction with the client (or parents) what the client needs therapeutically and involves encouraging, motivating, problem-solving, reassurance and emotional release. Carl Rogers (1942) described non-directive psychotherapy as being
characterised by a preponderance of client activity, the client does most of the talking about his problems. The counsellor’s primary techniques are those that help the client more clearly to recognise and understand his feelings, attitudes and reaction patterns, and which encourage the client to talk about them (Rogers, Kirschenbaum & Land Henderson, 1990, p. 84).
At the heart of non-directive therapy, regardless of different theoretical models, lies the therapist’s adherence to the core conditions of a person-centred approach (Rogers, 1967), i.e.: Empathy, congruence and unconditional positive regard. Interventions rooted in the person-centred model are shown to increase secure attachment with the therapist (Anderson & Gedo, 2013) thus decreasing internalised anxieties and promoting positive change. A valid concern regarding non-directive therapy for young children is that they may not yet posses the cognitive skills and emotional capacity to integrate and repair traumatic events on their own (Rasmussen & Cunningham, 1995).
Child Centred Play Therapy (CCPT)
Developed from Virginia Axline’s (1989) experiences working with children, the child centred play therapist maintains respect for the child’s ability to solve his problems and will not attempt to direct the child’s actions or conversation , (Axline, 1989, pp. 69-70). In CCPT, the non-directive relationship
“is one of the foundational elements of the neurosequential model, in that it allows the child to engage in somatosensory activities without having to use language…” (Kottman et al., 2017, p. 41).
Research supports the use of this model with children and adolescents presenting with internalising problems (Garza and Bratton, 2009) and externalising or disruptive behaviours (Schottelkorb and Ray, 2009).
Modalities of directive psychotherapy
In directive psychotherapy for children or adolescents, the therapist plays a much bigger role in therapeutic process, such as engaging in play with the child, suggesting games, activities or discussion topics and is typically more structured than non-directive therapy.
Theraplay (Jernberg, 1979), is a therapy modality where the emphasis is on the initial parent-child relationship which set the scene for the child’s subsequent relationships.
“Theraplay therapists carefully guide and structure the child’s experience so that the child feels safe and well regulated” (Booth, P.B., & Winstead, M., 2015, p. 143)
It is heavily influenced by Bowlby’s Attachment Theory, Kohut’s self-psychology theory and Winnicott’s theories on object relations. It is focused and structured and aims to heal attachment issues. Neurobiologically, Theraplay is sympathetic to the neurosequential research (Munns, 2011) as it understands the effect of early developmental stress or trauma and has been shown to be effective in reducing oppositional behaviours (Wettig, Franke, & Fjordbak, 2006), repairing attachment (Ammens, 2000), and improved self-esteem (Siu, 2009).
Mixed Modalities of psychotherapy
Many more forms of psychotherapy for children and adolescents include elements of both direction and non-direction, in this section, we will take a cursory look at a selection of those.
Cognitive Behavioural Therapy (CBT)
CBT (Beck, 1960) aims to assist a client with addressing distortions in their cognition (automatic thoughts/irrational beliefs), it is a well researched and often time-limited form of therapy and is therefore seen as effective from an affect and cost point of view. CBT can be particularly useful with adolescents “who are unable to recognise their own self-destructive beliefs, thoughts and feelings” (Reid & Westergaard, 2011, p. 98) incorporating a mix of directive and non-directive interventions; it also offers key psycho educational information for the client.
“Cognitive behavioural strategies have been successful, to varying degrees, when working with young people who are anxious, depressed, aggressive, oppositional and unmotivated, and with young people who have difficulty with interpersonal and social skills” (Geldard, K., Geldard, D., & Foo, R. Y., 2016).
Solution Focused Therapy (SFT)
Solution-focused therapy, developed by de Schazer and Kim Berg, is a strengths-based therapy which includes elements of directive (e.g.: goal setting, miracle question), and non-directive (e.g.: rapport building, listening) interactions and aims to help a client with a particular problem rather than exploring the deeper underlying causes or pathologies. Studies show substantial evidence that SFT is an effective treatment for a wide variety of behavioural and psychological outcomes in adolescents (e.g., Franklin, 2009; Cepukiene & Pakrosnis, 2011; Cook, 1998; Corcoran, 2006). It can include a brief; time limited focus and is becoming a cost-effective treatment favoured by schools, state-run organisations and crisis intervention.
Sandtray therapy provides a “safe and protected space” (Kalff, 1980, pp. 16-17) and is a flexible, integrative, projective and expressive therapy which can be directive or non-directive. Sandtray therapy provides a distance for the client to work on their presenting issues as well as a neurosequential model (Perry, 2006) and a facilitative relationship in which the therapist attempts to understand how the child views her world through the act of play. Direction in sandtray therapy often takes the form of agreeing on a theme for the scene and a discussion about the created scene. Badenoch (2008) wrote:
“in terms of brain integration, talking about the tray … can help foster connection between the hemispheres by adding words to the rich experience that has unfolded non-verbally” (as cited in Malchiodi & Crenshaw, 2016, p. 185).
Play Therapy Dimensions model (PTDM)
The PTDM (Yasenik & Gardner, 1996) is an integrative model well suited to children. It is based on Prescriptive Play Therapy (Schaefer, 2001) and recognises that at times the therapist’s immersion in the child’s play needs to be fluid to meet the unconscious and conscious needs of the child. Immersion equates to the level of direction and interaction from the therapist.
Currently, research lends support to the use of play therapy across a range of presenting problems. For example, LeBlanc and Ritchie (1999) conducted a meta- analysis of play therapy research, indicating that play therapy was an effective intervention regardless of the presenting problem of the child. (Yasenik, L., & Gardner, K., 2012, p. 20).
This model allows for multimodal approaches to be integrated to meet the needs of a specific child and provides much latitude and freedom within the therapeutic process.
Both directive and non-directive forms can be efficacious, almost all modalities build upon the person-centred core conditions, and the personal philosophy of the therapist is important as the therapist must feel comfortable in the way they work. Whether directive or nondirective, “counselling is not persuading, prevailing upon, overcoming the client’s resistances, wearing the client down or ‘bringing’ the client to their senses” (Sutton & Stewart, 2002, p. 2). Direction in therapy should be facilitative and encouraging, not an attempt to fix a child or adolescent and is employed to help a child or adolescent address a specific problem. Non-directive therapy is geared towards helping the child understand their inner world and express internalised anxieties.