1. 1 PRE-THERAPY THEORY AND PRACTICE OF PSYCHOLOGICAL CONTACT Catherine Clarke 2007 www.psychological-wellbeing.co.ukwww.psychological-wellbeing.co.uk

2. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 2 PRE THERAPY ROOTS  Person Centred - Psychotherapists, Rogers, Gendlin, (1973) Rogers Person Centred Psychotherapy  Form of therapy - which promotes self-knowledge and awareness  Allowing clients to be their own guide in therapy  Clinicians attitudes – congruence, unconditional positive regard, empathy

3. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 3 PRE THERAPY ROOTS  Gendlin Existential - Phenomenology Phenomenology  Study of phenomena Scientist being objective Scientist being objective Phenomenologists state each experience is coloured by subjective perspectivePhenomenologists state each experience is coloured by subjective perspective And no one is able to separate the two perspectives. And no one is able to separate the two perspectives.Existentialism  Phenomenological study of human existence Respect each person’s current way of being ‘being’ within the world Respect each person’s current way of being ‘being’ within the world Surrounds verbal & non-verbal behaviourSurrounds verbal & non-verbal behaviour Existential contact being the right simply to exist & be recognised as a member of humanity Existential contact being the right simply to exist & be recognised as a member of humanity

4. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 4  Concept introduced by Carl Rogers 1957 - ‘The Necessary and Sufficient Conditions of Therapeutic Personality Change’ For psychotherapy to progress, ‘two persons must be in psychological contact’ For psychotherapy to progress, ‘two persons must be in psychological contact’ What is Psychological Contact  When two people are affected by & respond to the other Response either negative/positive which is appropriate to shared situation Response either negative/positive which is appropriate to shared situation Reciprocal, mutual, equal balanced relationships require this elemental psychological contact.Reciprocal, mutual, equal balanced relationships require this elemental psychological contact. ROGERS / PSYCHOLOGICAL ROGERS / PSYCHOLOGICALCONTACT

5. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 5 MEANINGFUL BEHAVIOUR EXPRESSIVE CONTACT BEHAVIOUR  Healthy / Fully Functioning  Internal Processes – the three Contact Functions:  Reality - Affective - Communication 1. Reality Contact Function is Our Awareness  People Places Things Events All part of our living existence All part of our living existence Associated with timeAssociated with time All are part of our reality sense. All are part of our reality sense. Connected to our sense of being within the world.Connected to our sense of being within the world.

6. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 6 MEANINGFUL BEHAVIOUR 2. Affective Contact Function is Being in Touch  Feelings Moods Emotions  Living part of the world  Inherent part of our existence  Essential - Develop our lives to our full potential 3. Communication Contact Function  Convey thoughts and feelings through language  In a socially acceptable way so that others can understand  Though our internal processes we are in psychological contact with each other

7. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 7 PROBLEMATIC FUNCTIONING Low Functioning  Contact Functions: Reality Affect Communication below Psychological Contact. Clients:Autism Alzheimer’s Disease Severe Learning Difficulties Regress Emotionally Severe Depression DissociationPsychosis

8. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 8 PROBLEMATIC FUNCTIONING PRE EXPRESSIVE BEHAVIOUR or LOW FUNCTIONING  Isolated withdrawn hallucinations delusions, catatonia, frozen terror, emotional regression  Bizarre physical behaviour  Verbal – fragmented / jumbled  Each person presenting their current way of being within the world  Verbal & non-verbal expression is communication of clients Pre Expressive Self  Highly important & requires respect

9. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 9 PROBLEMATIC FUNCTIONING Persons out of touch in varying degrees with: Themselves Other people Other people Their surroundings Their surroundings GREY ZONE FUNCTIONING Combination of Expressive & Pre Expressive Behaviour Combination of Expressive & Pre Expressive Behaviour Psychosis presents with expression of psychotic reality & congruent behaviour Psychosis presents with expression of psychotic reality & congruent behaviour

10. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 10 Levels of Functioning Psychological Contact Healthy functioning Expressive, congruent Problematic functioning Pre-expressive functioning Level of functioning Patient’s level Psychological Contact Client: Healthy functioning Expressive, congruent, functioning Client: Problematic functioning Pre-expressive functioning Grey-zone functioning

11. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 11 PRE THERAPY CONSTRUCTIVE HELP AIMS  Enable clinical staff to make contact with person in psychosis  Regain contact functions of reality, affect and communication  Achieved by five interventions known as contact reflections  So restoring people – back in touch themselves world other people

12. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 12 CONTACT REFLECTIONS  Focus on person’s immediate surroundings + non – verbal and verbal expressions  Concrete repetitive  No guessing / interpreting / jumping to conclusions  ‘What you can hear clearly and see is exactly what you give back.’ SITUATIONAL REFLECTION (SR) Related with Reality Contact Function  Refer to present situation / environment: things, people, place and time  ‘ The room is cold’. ‘The sun is shining’  Encourage contact - shared world of reality  Acute psychotic crisis - most reality orientating

13. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 13 CONTACT REFLECTIONS FACIAL REFLECTION (FR) Related with Affective Contact Function Related with Affective Contact Function  Verbalising person's face  'You look sad' or 'You look scared’  Get in touch with their own feelings BODY REFLECTION (BR) Verbally stating body posture Verbally stating body posture  'Your arm is above your head ’ ‘You are lying on your side’  Enhance verbal reflection, mirror his action with my physical body  Regains their own sense of self within own body experience

14. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 14 CONTACT REFLECTIONS WORD FOR WORD REFLECTION (WWR)  Reflect words and phrases back to client  Develop/ increase the communication contact  Reflect only the words that you can clearly hear REITERATIVE REFLECTION (RR)  Principle - a specific reflection achieves response - reflection repeated  Psychological contact being achieved & repetition encourages further relating

15. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 15 IMPLICATIONS OF PRE THERAPY FOR CLINICIANS  Clients are sensitive Ability to sense those clinicians who are trustworthy and sincere Ability to sense those clinicians who are trustworthy and sincere Provides a safe & secure environment for clients Provides a safe & secure environment for clients Clinicians spoken word together with ‘how’ each clinician is ‘being’ clients affects their interaction Clinicians spoken word together with ‘how’ each clinician is ‘being’ clients affects their interaction  Clinicians need to work in a sensitive manner Pre Therapy reflections are powerful Pre Therapy reflections are powerful Entering private phenomenological world of Client Entering private phenomenological world of Client Consideration of client’s comfort level is important Consideration of client’s comfort level is important Reflections practiced to ensure minimal distress for client Reflections practiced to ensure minimal distress for client Facilitates movement towards shared reality Facilitates movement towards shared reality

16. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 16 FINER NUANCES Timing important  Keep with person’s pace - don’t over whelm  Room to respond  Rapid psychotic expressions - clinicians periodic reflections Space consideration important  Psychotic clients react strongly to physical closeness of others  Intrudes into psychotic space  Clinicians to keep distance – avoid inducing distress

17. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 17 OUTCOME OF CONTACT WORK Contact Reflections  Persons’ sense of isolation decreases & process of relating increases  Shown - person responding to the reflections  Communicating increasingly & appropriately within our shared reality Contact Functions  Reality, affect and communication - strengthened & maintained  Person is able to engage with the routine of daily living  Psychosis recedes - less overwhelmed by the psychosis  When firmly anchored in Expressive Level of Healthy Functioning  Informed choice regarding psychotherapy

18. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 18 PRE SYMBOLIC PSYCHOTHERAPY  Pre-expressive functioning is described as ‘the royal road to the unconscious’ Prouty (1994)  The psychosis is clients’ expression of deep trauma  Delusions/Hallucinations are meaningful to client  Hallucinatory experiencing which is ‘reality based’ – not conscious experiencing  Integrated into conscious experiencing

19. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 19 Person Centred Approach Key to Therapeutic Healing Relationship  Lies within clinician and client relationship  Clinicians who embrace the values of the PCA  Provide optimal conditions promote psychotherapeutic growth It enables clinicians to know ‘what’ to say and ‘how to be’ with clients Pre Therapy does not deny, collude or smother psychotic distress  Has the potential to bring more clinician safety and satisfaction  Pre Therapy is an open door  An opportunity for clinicians to assist clients on their path to full recovery.

20. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 20 POSITIVE OUTCOME  CLINICIANS  Increased awareness of different types of behavioural functioning Develop an awareness of skills to alleviate hallucinations and delusions  Encourage clients to get back in touch within themselves, other people and the shared world  Increased ability to engage with clients  Increased ability to earn the trust of the client.  Greater potential involvement for deeper personal healing relationships  An increase in job satisfaction  PATIENTS  Reduction of psychotic distress Clients become ‘grounded’ and more able to engage in daily life activities Fosters clients’ trust with practitioner  Clients’ have a reality based informed consent regarding psychotherapy input  Clients’ process facilitated to integrate painful experiences  Clients become self-empowered and have the capacity to lead a life that fulfils their potential

21. Catherine Clarke 2007 www.psychological-wellbeing.co.uk 21 SUGGESTED READING Clarke C., (2005), Prouty's Contact Work: a Carers Perspective Mental Health Practice 2005 Vol.9 No.24 p.24-27 Clarke C., Pre Therapy: A Carers Perspective of Prouty’s Contact Work Meriden Newsletter December 2006 Dodds P., Morton I., Prouty G. (2004), Using Pre-Therapy Techniques in Dementia Care. Journal of Dementia Care 2004 Vol.12 No.2 p.25-28 Joseph S., Worsley R. (eds.) (2005) Person-Centred Psychopathology: A Positive Psychology of Mental Health. PSSC BOOKS: Ross on Wye. Prouty G., (1994) ‘Theoretical Evolutions in Person–Centered/Experiential Therapy. Applications to Schizophrenic And Retarded Psychoses’. Praeger Prouty, G., (2001) ‘The Practice of Pre Therapy’. Journal of Contemporary Psychotherapy’, Vol. 31. No1. Prouty G. (2003) 'Pre-Therapy: A Newer Development in the Psychotherapy of Schizophrenia', Journal of the Academy of Psychoanalysis and Dynamic Psychiatry, (2003) 31, 1, 59-73 Prouty G., Van Werde D., Portner M., (2002) ‘Pre Therapy Reaching Contact Impaired Clients’. PCCS This popular book has been translated into Portuguese, Dutch, German and Japanese. Rogers, C. R. (1989) The necessary and sufficient conditions of therapeutic personality change, in: H Kirschenbaum & V. L. Henderson (Eds) The Carl Rogers Reader, p221 (London, Constable) Van Werde, D. & Morton, I. (1999), The Relevance of Prouty’s Pre-Therapy to Dementia Care. In: Morton, I., Person-Centred Approaches to Dementia Care. Bicester, Oxon, Winslow Press, 139-166. Van Werde, D. (2005) Facing psychotic functioning: Person-centred contact work in residential psychiatric care. In S. Joseph and R. Worsley Person-Centred Psychopathology: A Positive Psychology of Mental Health. PSSC BOOKS: Ross on WyePre-Therapy: A Newer Development in the Psychotherapy of Schizophrenia