PRE-THERAPY:

A treatment method for people with mental

retardation who are also psychotic.

Garry Prouty, Ph.D.

In A. Dosen & K. Day (Eds.), Treating mental illness and behavior disorders in
children and adults with mental retardation (pp. 153-166). Washington, D.C.:
American Psychiatric Press. (2001).

Pre-therapy is a theoretical and clinical evolution in client-centered therapy that is

specially designed for severely regressed retarded-psychotic and schizophrenic
patients (Peters, 1992, 1996; Prouty, 1976, 1990, 1995, 1996; Prouty and
Cronwall, 1990; Prouty and Kubiak, 1988a, 1988b: Van Werde, 1989, 1990a,
1990b). Application has also been made been to the regressed aspects of multiple
personality (Roy, 1991). In this chapter, I will examine primarily the treatment of
mentally retarded patients who are also psychotic or “schizophrenic”.

HISTORICAL BACKGROUNDS.

Considerable criticism has been made of client-centered therapy concerning its

range of applicability. Generally, its use has been restricted to high-level, functional
patients (i.e., the “worried well”). These criticisms are not without merit. Rogers
(1942) argued that client-centered therapy was not applicable to those who were
mentally retarded because these patients lacked the autonomy and introspective
skills necessary for psychotherapy. Ruederich and Menolascino (1984) have argued
that Rogers’s view had a limiting effect on psychotherapy research with this
population. It is only recently that several European therapists have produced
articles applying classical client-centered therapy to patients with mental
retardation (Badelt, 1990; Peters, 1981, 1986; Portner, 1990).

Client-centered work with the schizophrenic population has also been quite limited.
Little work has been done since Wisconsin Project (Rogers et al, 1967). Although
these researchers did discern some positive results, they discovered that patients
did not accurately perceive the essential “Rogerian attitudes”; and, secondly, they
did not observe increased “experiencing” (i.e., the central “outcome” measure).
This research marked the end of Roger’s formal collaboration with American
psychiatry and drew to a close any major work with schizophrenic population.
Again, as with retardation research, there are European exceptions, such as Teusch
of Germany (Teusch, 1990; Teusch et al.1983). Although there are these notable
exceptions in the practice of client-centered therapy with retarded and
schizophrenic population, they do not provide a theoretical adaptation or evolution.

CLIENT-CENTERED THERAPY.

Client-centered theory has evolved through three stages: person-centered

relationship, person-centered experiencing, and person-centered contact.
Person-Centered Relationship.

Rogers (1957) hypothesized that “necessary and sufficient conditions” for

therapeutic change were a relationship characterized by 1) unconditional positive
regard, 2) empathy, and 3) genuineness. Unconditional positive regard refers to
deep acceptance and care on the part of the therapist; empathy generally means
and accurate understanding of the patient’s “lived experience” (i.e.,
phenomenology); and genuineness refers to the therapist’s authenticity. These
therapist attitudes were described as the central facilitative elements in personality
change.

Person-Centered Experiencing.

Hart (1970) describes the evolution of person-centered theory into and

“experiential phase”. Gendlin (1964) theorized that client “experiencing” was the
critical factor in therapy. Experiencing was defined as 1) concrete, 2) bodily felt,
and 3) a process. Concrete refers to the patient direct awareness of his or her
immediate experience. Bodily felt means that experiencing is always organismic.
The body “feels” experience. The term process refers to the fact that if we
concretely attend to our bodily felt sense of an experience A, it will undergo a “felt
shift” to experience B, etc. Experiencing is a concrete, bodily felt process. Therapy
is the process of experiencing.

Generally, we can describe Rogers as having described the therapist and Gendlin as
having described the patient. This is the rationale for modern label “person-
centered/experiential therapy”.

Person-Centered Contact.

Rogers (1959) describes “psychological contact” as the first “necessary and

sufficient” condition of psychotherapy. Watson (1984) states that if the other
conditions are operationalized, and then shown to be present, there is no need to
operationalize if “psychological contact” was not present, the other condition were
meaningless. He did not provide any theoretical definitions. Also, he did not provide
any techniques for developing contact in case of its absence or impairment.

Within this context, pre-therapy is a further evolution in client-centered therapy. It

is a theory of psychological contact (Prouty, 1994). Psychological contact is the
“pre” condition of therapeutic relationship/experiencing.

PRE-THERAPY: A THEORY OF PERSON-CENTERED CONTACT.

As a theory of “psychological contact”, pre-therapy is described in terms o

therapeutic method (contact reflections), patient process (contact functions), and
measurable behavior (contact behaviors).

Contact Reflections.

Contact reflections are a “pointing at the concrete” (Buber, 1964). They are
predicated on a conception of the phenomenon that is conceived “as itself”. The
phenomenon is conceived as “naturalistic” (i.e., exactly as it appears in
consciousness) (Faber, 1959). It is also described as “absolutely self-indicative”
(Sartre, 1956). This means that the phenomenon has no meaning beyond it’s
appearance. It is “nonsymbolic” (Scheler, 1953). This construction of the
phenomenon its particularly relevant because brain-damaged and schizophrenic
patients evince “concrete attitudes” (Arieti, 1955; Gurswitch, 1966). Contact
reflections are extraordinarily concrete and literal so as to respond to the “lived
experience” of concretely oriented, retarded, and schizophrenic patients.

Situational Reflections.

Situational reflections are oriented toward the patient’s immediate situation,

environment, or milieu. Their function is to facilitate the reality contact of the
patient. An example would be, “You are playing with the red ball”.

Facial Reflections.

Many regressed patients (due to psychological isolation, institutionalization, and

overmedication) have poor affective contact. Facial reflections have as their
purpose the facilitation of “pre-expressive” emotion. An example could be, “You
look sad”.

Word-for-Word Reflections.

Many retarded and schizophrenic patients suffer from communication disorders. The
retarded psychotic and schizophrenic patients often manifest echolalia, “word
salad”, and neologisms. These are often mixed wit periods of being
incomprehensible. The rationale underlying word-for-word reflection is the
restoration/development of communicative contact. An example would be from
patient: “incoherent word”, “tree”, “incoherent word”, “boy”. The therapist would
reflect word for word: “tree”, “boy”.

Body Reflections.

Many schizophrenic or retarded schizophrenic persons evidence bodily symptoms

such as echopraxia and catatonia. Such patients often have difficulty integrating
their body as a part of the self. Body reflections are verbal (Sometimes nonverbal)
reflections of the patient’s “bodying” or expressive behavior. A verbal example
would be a statement such as, “Your arm is in the air”. A nonverbal example would
be for the therapist to reflect by raising his or her own arm in the air.

Reiterative Reflections.

Reiteration is not a specific technique: it’s a principle. If any of the other four
contact reflections are successful in producing a patient response, repeat the
response. Reiterative contact is facilitative of the experiencing process. Contact
facilitates experiencing and relationship. Contact is “pre-experiential” and “pre-
relationship”.

Contact Functions.

Pre-therapy, broadly conceived, is the facilitation of contact functions. Contact

reflections facilitate the contact functions. Perls (1969) defines contact as an “ego
function” but fails to provide a fleshed-out description of the functions. Pre-Therapy
defines them as reality, affective, and communicative contact.

Contact functions are based on the philosophical assumption of Heidegger that a

human is a being who is “open” to being (Boss, 1963). Such an ontological
description, however, lacks concrete specificity and application. Open to what
concretely? A possible answer can be derived from Merleau-Ponty (1962), who
describes the human phenomenal field in terms of “world”, “self”, and “other”.
Consciousness is open to “world”, “self”, and “other” and is open the human
existence.

Again, Merleau-Ponty’s description lacks concrete specificity. How does one

describe “world”, “self”, and “other”? How does one describe these giant “existential
structures of consciousness” (Prouty, 1994)? The existential structures of
consciousness are the natural and absolute categories of experience through which
particular concrete existents manifest themselves. Psychological contact is our
awareness of these. In terms of consciousness, how are we concretely aware of
“world”, “self”, and “other”?

The “world” is manifested in existential phenomenological forms of concrete: 1)

people, 2) places, 3) things, and 4) events. Awareness of people, places, things and
events is the definition of reality contact.

The self is manifested through existential phenomenological forms that differentiate

as 1) moods, 2) feelings, and 3) emotions. Awareness of moods, feelings, and
emotions is the definition of affective contact.

The other is powerfully related to us through human communication. We symbolize

the “world” and “self” to the “other”. This is communicative contact. Communicative
contact is the symbolization of our reality and affective contact to others.

Reality, affective, and communicative contact are our awareness of existence. Pre-
therapy is the resolution of existential autism (Prouty, 1994). It is the restoration or
development of contact with the “world”, “self”, or “other” (i.e., “existential
contact”) (Prouty, 1994).

Clinical Vignette.

The following rare clinical vignette is an example of using contact reflections to

facilitate the contact functions. It illustrates the restoration of reality, affective, and
communicative contact with a chronic schizophrenic woman.

Dorothy is an old woman of the more regressed women on X ward. She was
mumbling something (as she usually did). This time I could hear certain words in
here confusion. I reflected only the words I could clearly understand. After about 10
minutes, I could hear a complete sentence.

Patient: Come with me.

Therapist (word-for-word reflection): Come with me.

The patient led me to the corner of the day room. We stood there
silently for what seemed to be a very long time. Because I couldn’t
communicate with her, I watched her body movements and closely
reflected these.

Patient [puts her hand on the wall]: Cold.

Therapist (word-for-word reflection/body reflection) [I put my
hand on the wall and repeat the word]: Cold.

She had been holding my hand all along, but when I reflected, she
would tighten her grip. Dorothy would begin to mumble word fragments.
I was careful to reflect only the words I could understand. was she was
saying began to make sense.
 Patient: I don’t know what this is anymore. [Touching the wall (reality
contact)]: The walls and chairs don’t mean anything anymore
(existential autism).

Therapist (word-for-word reflection/body reflection) [touching

the wall]: You don’t know what this is anymore. The chairs and walls
don’t mean anything to you anymore

The patient began to cry (affective contact).

After a while the patient began to talk again. This time she spoke clearly
(communicative contact).

Patient: I don’t like it here. I’m so tired… so tired.

Therapist (word-for-word reflection) [As I gently touch her arm,
this time it is I who tightened my grip on her hand. I reflect]: You’re
tired, so tired.

The patient smiled and told me to sit in a chair directly in front of her
and began to braid my hair.

This vignette illustrates the resolution of the problem inherent in Rogers’s

formulation of psychological contact. It provides a definition of contact and
techniques to assist the “contact impaired” patient. It also illustrates the
assertion that contact is “pre” relationship.

Reality, affective, and communicative contact are the theoretical goals of pre-
therapy. In existential-phenomenological terms, pre-therapy is the restoration
or development of existential contact between consciousness and the world,
self or other (i.e., the resolution of existential autism).

Contact Behaviors.

Contact reflections facilitate the contact functions resulting in the emergence of

contact behaviors. Contact behaviors represent the operationalization necessary for
measurement and scale development. Reality contact is operationalized as the
verbalization of people, places, things, and events. Affective contact is
operationalized as 1) the verbalization of “feeling words” (e.g., “sad”) and 2) the
expression of affect through bodily and facial signs. Communicative contact is
operationalized through words and/or sentences.

Early pilot studies provide some evidence to support construct validity and
reliability. Prouty (1994) presents data from a single case study of a mentally
retarded schizophrenic patient, indicating a correlation coefficient of 0,9966
between independent raters, with a P value of 0,0001. The t value was a 0,9864,
with a P value of 0,3528.

A second case study of mentally retarded schizophrenic patient yielded a correlation

coefficient of 0,9847 between independent raters, and P value of 0,0001. The t
value was 2,3728, with a P value of 0,0526. No difference was indicated at 1% or
5% level of significance.

A reliability study in chronic schizophrenic was undertaken by De Vre (1992). She

and her colleagues developed rating scores for three independent raters and three
patients. They then correlated these with non-rater trained nurses. They obtained
kappa scores of 0.7, 0.76, and 0.87.

An evolved form of measurement for pre-therapy has been devised (Dinacci, 1994).
It more directly focuses on patient expression as an outcome.

PRE-THERAPY APPLICATIONS.

Pre-therapy is generally applied to mentally retarded patients who are overtly

psychotic or manifest psychotic features. They are often referred because they lack
of reality, affective, or communicative contact necessary for psychotherapy.
Because of regression, acting-out, and bizarre behavior, treatment is usually within
the context of more structured settings. In selected cases or circumstances,
treatment may be conducted on an outpatient basis. Length and frequency of
sessions vary with attention span, behavioral control, and willingness to participate.

In sharp contrast to classic patient-centered, pre-therapy pays careful attention to

spatial and temporal factors. Many schizophrenic-type patients are very sensitive to
psychological contact. Contact reflections that are too rapid make provoke a feeling
of intrusion. Contact reflections that are too slow may be experienced as lack of
empathy. Spatial experience is also important. Nearness may be experienced as
threatening. Generally, the therapist needs to carefully sense out and test the
patient’s spatial and temporal boundaries.

Empathy is also applied differently. Empathy is for the patient a literal “pre-
expressive” behavior because frequently the therapist does not know the patient’s
frame of reference, a classic phenomenological response is not possible. On a more
subtle level, empathy is for the patient’s efforts at expression and coherence.

Prouty and Kubiak (1988b) describe the use of contact reflections to resolve a
psychotic crisis with a mentally retarded schizophrenic patient. The case is
important because it illustrates the use of an empathy method without severe
controls or tranquilizing medications.

The patient, a woman, was one of seven on an outing from a halfway

house. She was seated in the near seat of the van. As I looked in the
near-view mirror, I noticed the patient crouched down into seat with one
arm outstretched above here head. The patient’s face was filled with
terror and here voice began to escalate with screams.

I pulled the van off the road and asked the volunteer to take the others
out of the van. I sat next to the patient, sharing the same seat. The
patient’s eyes were closed and here face was wincing with fear.

Patient [in escalated voice]: It’s pulling me in!

Therapist (word-for-word reflection): It’s pulling me in.

The patient continued to slip farther down in the seat, with here left arm
outstretched. Here eyes were still closed.

Therapist (body reflection): Your body is slipping down into the seat.
Your arm is in the air.
 Therapist (situational reflection): We are in the van. You are setting
next to me.

The patient continued to scream.

Therapist (facial reflection): You are screaming, Carol.

Patient: It’s pulling me in!

Therapist (word-for-word reflection): It’s pulling you in.

Therapist (situational reflection): Carol, we are in the van. You are

sitting next to me.

Therapist (facial reflection): Something is frightening you. You are

screaming.

Patient: It’s sucking me in!

Therapist (word-for-word reflection): It’s sucking you in.

Therapist (situational reflection/body reflection): We are in the

van, Carol. You are sitting next to me. Your arm is in the air.

Patient: [She begins to sob very hard. Her arms drop to her lap]. It was
the vacuum cleaner.

Therapist (word-for-word reflection): It was the vacuum cleaner.

Patient: [Gives me direct eye contact]. She did it with vacuum cleaner.
[Now in a normal tone of voice]. I though it was gone. She used to turn
on the vacuum cleaner when I was bad and put the hose right on my
arm. I thought it sucked it in. [Less sobbing]. [It should be noted that
daily this patient would kiss her arm up to her elbow and stroke it
continuously].

Therapist (word-for-word reflection): Your arm is still here. It didn’t

get sucked into the vacuum cleaner.

The patient smiled and was held by the therapist.

Latter that afternoon a therapy session was held, and the patient began
to delve into here feelings regarding the punishment she received as a
child. Is should also be noted that the “kissing and stroking of arm”
behavior ceased.

This clinical vignette illustrates the application of pre-therapy techniques for

managing an acute crisis in a psychotic mentally retarded patient. The patient was
helped to deal with this acute exacerbation and understand how her symptoms
were related to a negative childhood experience. (i.e., here mother threatening her
with a vacuum cleaner). The patient was able to utilize the newly acquired
insightful experiences as a basis for further therapy. In addition, the meaning of
symptomatic behavior (arm kissing) became clarified as a trauma related; that
behavior also ceased.
CONCLUSIONS.

Pre-therapy is a development in person-centered theory and technique applicable

to the psychotic mentally retarded population. Evolving from Rogers’s view that
psychological contact is the first condition of a therapeutic relationship, pre-therapy
develops the functions necessary for psychotherapy. Consequently, it is constructed
as “pre” therapy.

As a theory, pre-therapy describes psychological contact. Contact is described on

three levels: 1) contact reflections, 2) contact functions, and 3) contact behaviors.
Contact reflections refer to very literal and extraordinary concrete reflections.
Contact functions refer to the psychological functions of the patient that involve
contact with the “world”, “self”, or “other”. The restoration and/or development of
these functions are the theoretical goals of pre-therapy. Contact behaviors refer to
the behavioral change of the patient that can be utilized for measurement.
Preliminary pilots studies provide some evidence as to construct validity and
reliability.

The developments in theory and practice help dislodge the criticism that person-
centered therapy is mainly to well-functioning patients and not suitable for the
psychiatrically impaired patient. It also highlights the restoration/development of
reality, affective, and communicative functions necessary for psychotherapy to be
undertaken with psychotic mentally retarded patients.

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