Person-centered therapy with impoverished, maltreated, and neglected children and adolescents in Brazil.

This article reports on a program that provides person-centered therapy for impoverished, maltreated, and neglected children and adolescents in Brazil. The program, which is staffed by volunteer therapists, started in 2002. Since then, nearly 100 hundred children and adolescents have received therapy in three institutions, one residential and two nonresidential The general outcomes are described, leading to the conclusion that person-centered therapy is an effective strategy for the promotion of children's and adolescents' resilience, even in the context of multiple adverse conditions such as socioeconomic disadvantage, neglect, maltreatment, and abandonment. We conclude that the multicultural feature of person-centered therapy explains its effectiveness in this distinct population of Brazilian lower-class and non-White children and adolescents.

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Brazil is a country of 176 million. It is a highly stratified society resulting from colonialism and slavery. The relatively high GPD per capita (U.S. $2,593 in 2002) masks deep inequality because Brazil has a highly skewed income distribution, which is among the world s worst. Poverty is most pervasive in the lowest levels in the rural parts of the Northeast, but there are also pockets of urban poverty in the largest cities in the developed regions in the Southeast and South. The number of people who live below the national poverty line was estimated in 2001 to be about 17% of the country s total population. Twenty-two percent of the population survives on less than U.S. $2 a day. Due to the high unemployment levels and widespread informal economic activity, the lowest strata continue to be excluded from full participation in markets and full access to government services (Hudson, 1997; Human Development Reports, 2004). Moreover, as a result of the acceptance of interracial unions, Brazilians form one of the most heterogeneous populations in the world, constituting a trihybrid population with European, African, and Amerindian (i.e., South American Indian) roots. Based on self-declared ethnicity, in 1991, Brazilians were 55.3% White, 39.3% mixed-race (pardos), 4.9% Black, and 0.6% Asian (Parra, Amando, Lambertucci, Roca, Antunes, & Pena, 2003).

Regarding youth and their education, in Brazil, 28.3% of the population is below age 15. If compared with developed countries, Brazil has a relatively young population. There are 32 million children and adolescents who live in families with incomes of less than U.S. $40 a month. The widespread poverty creates a breeding-ground for social ills like malnutrition, abuse, maltreatment, and violence against children (Soca, 2004). Primary school is free and compulsory for children between the ages of 7 and 14, but high drop-out rates and grade repetition are endemic problems. In 1990, school enrollment reached about 90% of school-age children, although there was wide variation, with lower coverage among rural and low-income populations. However, only about one third of students enrolled in primary school finish eight years of mandatory schooling. Students in Brazilian public school receive an average of four hours of class time per day (Hudson, 1997; Human Development Reports, 2004).

Public access to medical care increased after Brazil's constitution of 1988 granted all Brazilian citizens the right to procure free medical assistance. The management and organization of health services was decentralized from the federal to the state and, especially, municipal level. Although the public domain oversees basic and preventive health care, the private nonprofit and for-profit health care sector delivers the bulk of medical services, including government reimbursement and subsidized inpatient care. Therapeutic treatment in hospitals tends to dominate funding at the expense of health promotion and disease prevention programs (Hudson, 1997).

Brazil's mental health care system has been traditionally based on large psychiatric hospitals and asylums. Since the 1970s, debates about the situation of the psychiatric hospitals and the mentally ill have given rise to the creation of alternative social resources for mental health care such as halfway houses, shelters, leisure centers, community centers, day hospitals, night hospitals, psychiatric units in general hospitals, and psychiatric emergency units. Also, multi-professional staffs, including psychologists, nutritionists, nurses, and social workers, have been formed to attend to patients in these alternative settings (Vietta, Saeki, Santa Roas, & Ferriera, 2000). It is important to note that in Brazil the profession of mental health counselor does not exist, as will be discussed more fully below).

The public health institutions decentralized after the 1988 Constitution and were named Basic Health Units (Unidades Basicas de Saude). These units focus on primary health care and prevention and employ few psychologists. According to Dimenstein (1998), throughout Brazil, the mainstream psychotherapeutic approach is psychodynamic therapy, which is taught in all universities and used by most psychologists both in private and public practice. Although there is no systematic research available on the psychologists' work in the public health field, Dimenstein (1988), Silva (1988), and Boarini (1995) point out that patients' drop-outs and poor treatment outcomes are common problems faced by psychodynamic psychologists working in the Basic Health Units. Therefore, in our work with at-risk children and youth we have decided to apply a different therapeutic orientation, and then we chose the person-centered approach.

PERSON-CENTERED THERAPY

The foundational concept in person-centered therapy is the actualizing tendency, which is an inherent directional tendency for the human organism to grow, to develop, and to realize its full potential (Rogers, 1977, 1986). In person-centered therapy, the therapist promotes the actualizing tendency by creating an interpersonal climate through the attitudes of congruence, unconditional positive regard and empathic understanding (Bozarth & Brodley, 1991; Rogers, 1959). Even person-centered therapy with children according to Moon (2001), is a relationship in which the children experience acceptance from a mental health practitioner and consequently, become more self-accepting and better able to further move toward self-fulfillment. Moon further stated that this nurturing relationship between the child and the counselor "will stimulate the inner resources of the child and her innate capacity to find the best way to survive and enjoy her life" (p. 45) and whether the child is narrating personal life experience or just being there in play, the relationship is therapeutic and psychological change will occur. Therefore, the mental health professional does not need any historical, familial, or presenting problem information about a child in order to accomplish effective therapy. Also, it is not a therapist's role to urge children to express their feelings or the meaning underlying their behavior because "to press the child to do anything, is to not fully accept him or her in the present" (p. 47).

Carl Rogers was one of the pioneers in the scientific investigation of psychotherapy process and outcome. He and his colleagues identified client-centered therapy as resulting in clients' increased self-understanding, more positive feelings, greater self-exploration, improved self-concepts, and improved maturity (Rogers, 1959; Rogers & Dymond, 1954). There was, however, little research performed on client-centered therapy after Rogers formulated the hypothesis of the necessary and sufficient conditions of therapeutic personality change. According to Bozarth, Zimring, and Tausch (2002), the research shifted instead to studies of therapists' attitudinal conditions of warmth, empathy and genuineness regardless of theoretical orientations. Results of these studies overwhelmingly support the importance of these conditions to successful psychotherapy outcome (Bozarth, 1998; Bozarth et al., 2002; Patterson, 1984; Tausch & Tausch, 1990). Yet, because we could locate no outcome research on the effectiveness of person-centered therapy with populations other than the western, White, upper-middle class sector, we believe research has not addressed person-centered therapy with other populations. Therefore, our program in Brazil has a great deal to offer U.S. mental health counselors because of filling a lack in the literature.

THE DELPHOS INSTITUTE

The Delphos Institute is a person-centered private institution located in Porto Alegre, which is the capital of the Southernmost state of Brazil and one of the biggest cities of the country, with a population of 1.5 million. This institute offers both internships for undergraduate academic students of psychology and a training program for already licensed psychologists. Brazil's legislation permits only psychologists and psychiatrists to work as psychotherapists or mental health clinicians. After completion of a five-year academic program in psychology, university students obtain a bachelor's degree, which allows them to work as psychotherapists. During the last year of their academic program, students usually have internship training in clinical psychology. After obtaining a bachelor's degree, most psychologists who decide to practice mental health counseling enroll in private training courses in order to further develop specific skills of the psychotherapeutic approach they will apply in their practice.

At the Delphos Institute, students enter internship training with little if any knowledge about the person-centered approach to counseling. In the first two months of training and before providing counseling, the students study the person-centered approach by reading Rogers' most important publications. This study is continued throughout the internship training. In addition, the students have weekly group supervision with two or three additional students. They audio-record and transcribe almost all counseling sessions, with the client's consent, and bring the transcripts to the supervision meetings. Trainees read their transcripts to the group and receive feedback about how they respond and relate to the client. Thus, the supervision meetings provide trainees with the opportunity to improve their skills in delivering the person-centered therapeutic approach.

The Delphos Institute has developed a program that provides person-centered therapy for impoverished, maltreated and neglected children and adolescents. Counselors volunteering to work in this program are psychology students undertaking their one-year internship in clinical psychology. This program started in 2002 with only two therapists. In the following years, more therapists have joined the program. During the one-year internship, each counselor trainee is assigned at least 4 clients; some have worked with 12 clients. The therapists and the supervisors are not paid for this work. Since 2002, 16 therapists, 14 female and 2 male, have participated in the program. Their ages ranged from 23 to 54 years old. The five supervisors are all women between the ages of 26 and 52.

THE LAUNCH OF THE PERSON-CENTERED PROGRAM FOR IMPOVERISHED, MALTREATED AND NEGLECTED CHILDREN AND ADOLESCENTS

This program providing person-centered therapy for impoverished, maltreated and neglected children and adolescents was first launched at a long-term residential shelter providing care to children and adolescents from ages 6 to 18 years old who were legally committed to the shelter due to abandonment, neglect, abuse, or death of their parents or guardians. These children and adolescents are also victims of poverty and social exclusion. Many of them were living on the streets before going to the shelter.

The shelter is a nonprofit private institution that can house up to 70 children and adolescents. Most of its financial resources come from a Norwegian nongovernmental organization. The shelter is located in a small village in a rural area in the Southernmost state of Brazil, Rio Grande do Sul. The children and adolescents who are committed to the shelter come from small and medium-sized cities in this area. The children and adolescents attend a school in the village, where they have the opportunity to foster social relationships with the community. On weekends and vacations, when it is possible, they visit their families.

Before the program was launched, the developers believed that group therapy would be more effective than individual therapy, because the former would reach a larger number of clients. Soon, however, it was realized that these children and adolescents needed individualized attention and a private space-time of their own, because they live in a group situation 24 hours a day. Therefore, we decided that an individual therapeutic setting would be of great help. At the very least, it would provide an experience of privateness.

The shelter provided two rooms for the therapy sessions, which the counselors converted into play-therapy settings. The therapists come once a week, from Porto Alegre which is two hours away by car, to the shelter to provide 50 minutes of therapy for each of their clients. The children and adolescents are referred to therapy by one of the directors of the shelter because of relationship problems, such as defiant behavior, aggressiveness, and social isolation, with educators (i.e., para-professional staff members) and peers.

The First Outcome

The non-directivity of person-centered therapy produced a strong impact at the very beginning of the program. The children and adolescents were accustomed to being interrogated by a multitude of professionals, including psychologists, social workers, psychiatrists, educators, and directors of the institution. They were so accustomed to answering questions that the non-directive climate of the therapeutic relationship surprised them. For instance, Paul, a fictitious name for a 14-year-old boy, said to the therapist in his first session, "Are you not going to ask me questions?" Similarly, Jane, a 13-year-old girl, said in her first session,

    I don't know what to say ... I have nothing to talk about ... there
    were so many psychologists with whom I talked, so I have already
    talked a lot with them, but then I was quiet and they asked me
    questions ... They asked a lot of things that they wanted to know.
    Now it's just me who has to talk ... So. what am I supposed to do'?
    I have nothing to talk about.

Despite this puzzled initial response to the therapist's non-directive attitude, Jane talked a great deal during the whole session, freeing painful and deep feelings, sharing them with the therapist, without the therapist asking a single question. The therapist's only utterances were empathic understanding responses (Temaner, 1977).

The puzzled initial reaction to the non-directive person-centered interaction suggests that these children and adolescents were not used to being allowed to experience autonomy and self-determination. They were not accustomed to experiencing their personal power within a relationship. Nonetheless, they soon came to realize that the relationship with the therapists of this program was unique, quite distinct from anything they had experienced before. For instance, when Carlos saw his therapist in front of the dining hall while waiting for the door to be opened for lunch, he asked her this:

   Tia ["tia," aunt, is the affectionate way children in Brazil address
   adult women], this "psychology" is different, isn't it? We do not
   have to keep answering questions because the tia does not ask
   questions of us. We talk whenever we want. If we do not want to
   talk. we can just play. It's we who choose what to do.

When the therapist agreed with him, Carlos turned to another boy next to him and said, "You see? I told you!"

Not surprisingly, after the program was operating for a few weeks, many children and adolescents came on their own initiative to the therapists asking for counseling. This fact showed that the space-time of therapy and the therapeutic relationship were of great value to them. The following client utterances illustrate their appreciation: "I'm so happy that now I have someone who listens to me"; "It's so good that I can talk about these things with someone. That relieves me;" and "I would like you to assist my friends, too. It's so good here!"

Six months after the beginning of the program, the first outcomes were shown to be quite positive. The children and adolescents who had received counseling made noticeable improvements in their relationships with the shelter's staff, their peers and their families.

The case below illustrates the nature of these first outcomes.

Judy

Judy is a 13-year-old girl. Her mother died when Judy was 12, and then she had to live with her grandmother. The relationship with her grandmother was conflicted, and Judy got involved with drugs and robbery. Eventually, she ran away from home. She was living on the streets when she was committed to the shelter. She was referred to therapy because she was having relationship problems with her colleagues and was perceived as "too quiet" by the educators. In the first session, she said to her therapist:

   I'm alone now. Sometimes I start to cry, and I cry a lot, and I
   don't want to talk with anybody. I don't want to talk. Talking
   doesn't help. The more I think, the more I talk, the more I want to
   cry ... It feels so bad.

By the fourth session, she showed a significant improvement in her mood:

   [Now] I feel better talking than crying ... Before, any little thing
   that I thought would make me cry. Now it's different. Now everything
   has changed. Now I feel much better. I feel good when I'm alone.
   Sometimes, when I was thinking and I was alone, I cried. Now, I
   don't cry. Now, when I'm sad, I know that I have someone to talk to,
   and that feels so good!

After the eighth session, Judy went to her grandmother's house for summer vacation. She stayed at home the entire time and did not try to run away, as she used to do. After the vacation she told her therapist that she had helped her grandmother with the housekeeping and had taken care of her little sister. Moreover, she said that when an old friend invited her to run away to go to a party she refused the invitation:

   The vacations were pretty good! ... I had the experience of having
   my family and I felt much better ... I have my home. Before, I
   wouldn't think about family ... [when I was] on the streets I used
   to do a lot of wrong things.... Now I'm going to live my life. I've
   decided that I do want to go back home, I want to be accepted, I
   don't want to do wrong things any more.... Now I think about my own
   life, and I give more value to what I have ... I have grown up.

The positive outcomes achieved at this shelter motivated the Delphos' staff to extend this program to two other institutions in Porto Alegre. These institutions provide community day programs for impoverished and at-risk children and adolescents from the outskirts of the city during the day time when they are not at school.

FEATURES OF THE THERAPEUTIC PROCESSES IN THE INSTITUTIONS

Since the beginning of the Delphos program, in August 2002, 98 children and adolescents, aged 5 to 18, have participated in this program. In the shelter, there were 47 children and adolescents, 17 female and 30 male; there were 34, 14 female and 20 male in the Catholic institution setting; and 17, 6 female and 11 male, in the public institution setting.

According to the principles of client autonomy and self-determination in person-centered therapy, it is the client who decides when to terminate counseling. In the shelter, 3 children (6.38%) decided to discontinue counseling before the fourth session. The other children terminated counseling because their therapists had finished their one-year internship or because the children left to be reunited with their families. To date, the number of therapy sessions per client has ranged from 2 to 39, with an average of 14 sessions. In the two nonresidential institutions, the children and adolescents may miss more sessions than the children in the residential setting because of a scheduling conflict. In these two institutions, 9 children (17.64%) decided to discontinue therapy before the fourth session. To date, the number of sessions per client has ranged from 1 to 27 sessions, with an average of 10 sessions. The reasons for the clients' dropouts in this program in are still not well understood. One hypothesis is that the therapists, who were inexperienced and still beginners in their training, were not able to implement the person-centered therapeutic attitudes adequately. Another hypothesis is that the children and adolescents did not appreciate the unstructured feature of the person-centered interaction and might have experienced it as psychologically threatening or boring.

The non-directive and empathic attitude of the person-centered therapist makes each therapeutic session and each therapeutic process unique. The children and adolescents assisted in this program interact, therefore, with their therapists in a multitude of ways. They play games (with the therapist or alone), talk, or remain silent. The topics that the children discuss within a session also vary from subjective and emotional experiences, to their daily activities (e.g., school, family or friends) and mundane issues like movies and sports. This multitude of ways of interaction occurs because, in person-centered therapy, whatever the client does or says is unconditionally accepted by the counselor. The counselor does not lead the child toward any predetermined direction and does not impose a professional agenda on the client. The child leads the therapeutic process, and the therapist just follows.

The outcome of this person-centered program has been assessed through interviews with educators and directors of the institutions and also through analysis of the clients' utterances and behavior within the counseling hour. These interviews and analyses showed that, in general, the children and adolescents who received therapy achieved: (a) important and relevant improvement in interpersonal relationships, with more positive attitudes towards others (e.g., peers, family, institution's staff); (b) better performance at school; and (c) improved in mood and emotional functioning, encompassing the accomplishment of a greater and more constant well-being. The following case histories illustrate these outcomes.

Tony

Tony is a 9-year-old boy. He was committed to the shelter because he was wandering and begging on the streets. He would not attend school and did not know how to read. Tony lived with his mother who beat him. His father had left the family. When Tony came to the shelter, he behaved aggressively and violently towards educators and peers, beating, kicking, and shouting at them. He did not develop any friendships and made sexual advances towards the boys in the shelter. After six months of therapy, the director of the shelter said that Tony's behavior had improved significantly. He became calm, tranquil, and "self-controlled." He developed friendships and gained respect with peers and educators. Also, the sexual harassment towards peers discontinued. The director believes that the therapy was fundamental in that change.

Juliano

Juliano is a 6-year-old boy who received therapy in one of the non-residential institutions. He was referred to therapy because the educators perceived him as troublesome, agitated, and aggressive, with difficulties relating to peers and teachers. After six months of therapy, the teachers said that he had become calmer and more sociable, engaging in constructive interactions with others. Furthermore, his change triggered positive changes in his family, too. He lived with his mother and four siblings in conditions of extreme privation and poverty. His mother was rather neglectful about herself and her children, as if she had simply given up taking care of her and their lives. The family lived with no hygienic care at all, and the institution's staff said that their home was extremely dirty. Following the positive changes in her son's behavior, Juliano's mother asked his therapist for psychological help for herself. She started therapy, and soon her behavior also changed quite positively. The institution's staff described her as "another woman" after she started therapy and as actively engaged in taking care of herself, the children, and the house. The change in her appearance was quite impressive: from being someone who was dirty, with tattered clothing and disheveled hair, to a "good-looking woman, clean, and well dressed."

Maria

Maria is a 13-year-old girl, who was committed to the shelter because of family negligence. She was referred to therapy because she had episodes of violence and aggressiveness towards peers and educators. Also, her mood was very unsteady, and she had sudden episodes of crying. Some educators said that they could not trust her because her behavior was quite unpredictable. The educators were also concerned about her sexual behavior for they observed that she seduced and "dated" many boys, although dating was forbidden in the shelter. After six months of therapy, the educators perceived a great change in her behavior and mood. She became calm, and the episodes of violence, crying, and aggressiveness discontinued. Before she started therapy, she was taking antidepressants with no improvement at all. As her mood improved after she began therapy, the psychiatrist who was treating her decided to discontinue medication because it had become unnecessary. The educators also observed that Maria had discontinued her somewhat "promiscuous" behavior. She developed a love relationship with one boy of the shelter and has no longer been sexually involved with others boys.

These cases illustrate the pattern of change and outcomes that have been achieved with the implementation of person-centered therapy in these institutions. This pattern of change reflects the achievement of some important aspects of resilience: personal characteristics, context cohesion and lack of conflict, and social and emotional network (Garmezy, 1996). In fact, there has been an improvement in children's and adolescents' personal skills, which were expressed through positive attitudes towards others, better school achievement and emotional functioning (i.e., well-being). They have also presented more cohesion with their environment, which generated less conflict. And finally, those personal characteristics and the context cohesion promoted the establishment of a more powerful social and emotional network with peers and staff.

The Therapeutic Factor in the Person-Centered Interaction

The multitude of distinct ways of interacting that were developed by these children and adolescents in their therapeutic sessions supports the Rogerian hypothesis that it is the therapist's unconditional acceptance of the client's experiential world that ultimately promotes growth and therapeutic change (Rogers, 1959). The pattern of change described above was found in children who only played cards or other games with their therapists during the therapeutic hour, without any talk about their feelings or experiences, and also in children who only talked about movies, sports, and such with their therapists, as well as in children who talked about themselves in the more culturally expected way of doing therapy. These outcomes support the assertion that whatever way the client behaves, if the therapist is unconditionally accepting and present with the client, then the actualizing tendency is promoted.

CONCLUSION

The multiculturalism movement in mental health practice argues that the form of counseling that had been developed in the United States and other Western countries for upper-middle-class White clients is inappropriate for other subcultures, racial groups, gender groups, and economic groups (e.g., the poor) (Goldstein, 1973; Pedersen, 1976). The basic assumption of multiculturalism is that mental health counselors have to use techniques that fit the presumed characteristics of clients. According to Pedersen, "each cultural group requires a different set of skills, unique areas of emphasis, and specific insights for effective counseling to occur" (p. 26).

Cross-cultural scholars also assume that minority clients tend to prefer and respond better to directive than nondirective approaches and that counseling approaches that are structured are more effective with minority clients than unstructured and ambiguous approaches (Sue & Sue, 1990). However, the outcome of Delphos' program with Brazilian impoverished and non-White children and adolescents does not support this assumption, because the non-directive and unstructured person-centered approach was found to be quite effective with this group. Bozarth (1998) also criticized the assertion that because the person-centered approach is grounded in the U.S. culture it may not be useful for non-U.S, clients. Instead Bozarth insisted that the essence of the person-entered theory is organismic, natural and universal. In fact, the person-centered attitudes of empathy and unconditional positive regard make the counseling relationship unique for each client. In that sense, the person-centered approach is, by its own essence, multicultural (Patterson, 1996).

The outcome of this program supports the conclusion that person-centered therapy is an effective factor in the promotion of children's and adolescents's resilience in the context of multiple adverse conditions, such as socioeconomic disadvantage, neglect, maltreatment and abandonment. The resiliency processes found in these children and adolescents who achieved positive adaptation, despite exposure to significant threat or severe adversity, are understood as ultimately due to the underlying functioning of their organismic actualizing tendency. In addition, the effectiveness of this program supports the conclusion that person-centered counseling is a multicultural approach. In fact, it is the multicultural feature of the person-centered interaction that explains the effectiveness of person-centered therapy with this distinct population of Brazilian lower-class and non-White children and adolescents. Also, the effectiveness of this program suggests that a person-centered model of therapeutic interaction should be implemented in service programs for other underserved populations in various cultural settings and minority contexts. U.S. mental health counselors, for instance, may want to develop person-centered programs like this one to provide specialized services at probably a low-cost, for at-risk youth in the United States.

The authors would like to thank Dr. Barbara Temaner Brodley, Jerry Temaner and Dr. Marcela Rafaelli for their helpful comments and revisions.

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AUTHORS' NOTE

Elizabeth Schmitt Freire is a Brazilian psychologist and person-centered therapist with an M.A. in clinical psychology. She is Director of Instituto Delphos and is currently completing a Ph.D. program in developmental psychology at Universidade Federal do Rio Grande do Sul, Brazil. Silvia Helena Koller is a Brazilian psychologist, and professor at Universidade Federal do Rio Grande do Sul. Aline Piason and Renata Beatriz da Silva are psychologists, person-centered therapists and supervisors of instituto Delphos. Eletronic mail concerning this article may be sent to [e-mail]

Elizabeth Schmitt Freire is with the Instituto Delphos & Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil Silvia Helena Koller, Ph.D, .is with Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil Aline Piason and Renata Beatriz da Silva are with Instituto Delphos, Porto Alegre, Brazil E-mail: [e-mail].