PCCS BOOKS Ltd., 2 Cropper Row, Alton Road, Ross-on-Wye, Herefordshire, HR9 5LA, UK
www.pccs-books.co.uk
edited by Pete Sanders
With contributions from Catherine Clarke, Penny Dodds, Marlis Portner, Lisbeth Sommerbeck and Dion Van Werde
reviewed by Beatrice Popescu
EJOP founding editor
“Much more than a primer … this is a superb practical introduction to Pre-Therapy and contact work that will be of value to all mental health professionals working with contact-impaired individuals”
Mick Cooper Professor of Counselling, University of Strathclyde
Pre-Therapy as individual psychotherapy was born in the United Sates and contact work for institutional settings was developed in Europe. This book reflects the development of contact work with growing range of clients.
Professor Garry Prouty’s Pre Therapy is an approach which focuses on clients who are difficult to engage. It is applicable for clients who experience regression, psychosis, learning disabilities, special needs, dementia and Alzheimer’s disease.
Making connections with clients successfully in order to engage in meaningful conversations has thwarted clinicians for decades. This has resulted in clients being psychologically isolated and trapped within their own being. However, Prouty’s natural flair of reaching through in making contact with clients has been a major break through. Following years of working with clients suffering from regressive behaviour and psychotic experiencing, Prouty eventually formulated his expertise in 1994.
Pre Therapy is a Person-Centered and deeply respectful approach, bringing alive the meaning of Carl Rogers ‘Psychological Contact’: this is the essential contact which is necessary for all people to engage in reciprocal relationships. Over all apsychotic people are unaware of their individual functioning within psychological contact. Pre Therapy’ Contact Reflections are the Skills which encourage psychotic clients who are out of touch with their own sense of self, in relation with other people and their surroundings to regain their essential contact; clients are increasingly able to engage in the daily activities of life and at the same time the tenacity of psychotic experiences begins to recede.
In Chapter 2 of the book, Pete Sanders introduces Pre-Therapy history and concepts, he writes a critical essay on the current nature of research methodology for counseling and psychotherapy. Most used applications of Pre-Therapy methods are in Sander’s opinion used to help restore, strengthen or sustain contact of people in a state of severe psychotic withdrawal, catatonia and regression; people suffering for dissociative states, people with learning disabilities which impairs communication or contact, people with temporary contact impairment due to an organic condition or people suffering from a brain injury or damage.
Sanders determines some responsibilities of the practitioner of Pre-Therapy techniques: assumes full responsibility for contacting clients, validates the client’s experience (e/g psychotic), values the importance of the client expressions, recognizes hallucinations and delusions are meaningful, contributes to the client’s healing process.
Chapter 3 allows Sanders to introduce the reader an other concept of Pre-Therapy, discovered by Dion Van Werde: the grey zone. She introduced the grey zone to indicate the region where people oscillate sometimes almost imperceptibly between pre-expressive and expressive functioning. In the grey zone, a person’s contact functions are variable, moving in and out of contact in few seconds. Depending on the person, the out-of-contact state can vary from mild dissociation to a fleeting florid hallucination or delusion. In the grey zone the therapist must be in full alert, shifting from primarily listening to looking.
Catherine Clark’s experience is fully pictured in the Chapter 4. Catherine, a state registered nurse and a state certified midwife, who has written articles and given presentations at conferences on carer issues in mental health, invites us in the fascinating and rewarding experience of using pre-therapy work while caring for his son.
Lisbeth Sommerbeck is a psychologist accredited as a specialist in psychotherapy and supervision by the Danish Psychological Association. Her special interest, reflected in Chapter 5 of the book, are the application of the person-centered approach with staff and inmates in the backyards of psychiatry. She offers us two examples of individual, psychotherapeutic contact work in the grey-zone: one is with Lilian, a client diagnosed with paranoid schizophrenia who was motivated to attend psychotherapy of her own accord. The other is with Sved, a client for whom the idea of psychotherapy was beyond of the grasp at the time, the therapist being the one who initiated the contact.
In Chapter 6, Dion Van Werde looks back over 20 years of practice and tries to formulate the essentials of what constitutes a person-centered Pre-Therapy ward milieu. In this approach, the client isn’t reduced to either psychological process and behavior. Therapists try to work with both aspects of the same reality.
In Chapter 7 “Pre-Therapy, contact work and dementia care”, Penny Dods gives us examples of approaches in dementia care. At early stages, cognitive behavioral approaches focusing on understanding, reframing and coping with the onset of dementia are helpful, while at more severe stages and at later stage, validation therapy, resolution therapy, sensory approaches are used.
The application of Pre-Therapy to dementia is relatively new, Van Werde and Morton (1996) first introduced it within an overview of person-centered approaches in dementia care, seeing that it has the potential to offer “emotional palliative care”. (Morton, 1996). Penny Dods stresses the importance of the difference between contact work and Pre-Therapy. For people working in a counseling or psychotherapy role, the contact role may lead to further therapeutic work which aims at a more sustained engagement with the emotional world of the person with dementia.
In Chapter 8 “Pre-Therapy and contact work for people with learning and other mental disabilities, Marlis Portner reviews counseling approaches, enabling us to understand the integration process of pre-therapeutic elements into person-centered care: (1) offering life-conditions that strengthen contact functions instead of impairing them even more and (2) using contact reflections when the situation is appropriate. Marlis exemplifies critical situations when a person who is hurting herself might stop doing so if carers use body reflections – whether verbally or by doing the same. Self-mutilation for contact-impaired persons often represents a desperate attempt to establish some kind of contact.
The last two chapters of the book (10 and 11), written by Pete Sanders, reveal research in Pre-Therapy and contact work and highlight future directions for development of pre-therapy and contact work in psychiatry, gerontopsychiatry and suggests introducing this type of approach in mental health nurse training curriculum.
Authors have come to some interesting conclusions from research studies they conducted: Pre-Therapy increase psychological contact, but this is also the client-centered theoretical approach, from where Prouty started his thinking. Secondly, any changes in behavior as a result of contact reflections are due to a learning and developmental process which result in more appropriate relationship behavior, and least but not last, we might speculate that contact reflections may distinctly affect linguistic ability.
As for the future of pre-therapy and contact work, it is investigated the practice of pre-therapy in a range of settings, well established now in several institutions in European countries. Saint Camillus psychiatric hospital in Gent, Belgium is the best example of the contact milieu in action for people suffering of psychosis. There are encouraging signs of successful use of pre-therapy and contact work in Europe: St. Amandus psychiatric hospital, Beemem, Belgium, integrates Pre-Therapy in individual therapy by psychologists and group sessions for chronic psychotic and/or patients with mental disabilities. At the Sans Souci hospital in Brussels the staff on two wards received training in Pre-Therapy and as a consequence of the influence of the training, staff were also invited to give suggestions on how to integrate the concept of contact into the architecture of a new pavilion. More encouraging news are from Scotland, where Pre-Therapy is part of the curriculum of the Mental Health Branch programme of nurse training at the University of Paislay.
Czech organization “Quality in Practice” received European Union funding to provide Pre-Therapy training, including the work of Marlis Portner (2002-2007) for representatives from a diverse range of institutions on care for a variety of mentally challenged people.