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Pre-Therapy:  A Newer Development in the Psychotherapy of Schizophrenia

by Garry Prouty, D.Sc.

This paper was initially published in the Journal of the Academy of Psychoanalysis and Dynamic Psychiatry, (2003) 31, 1, 59-73

Abstract

Pre-Therapy is an evolution from client-centered theory and practice. The focus of Pre-Therapy is on regressed patients such as the psychotic retarded or chronic schizophrenics. It is also applicable to demented populations. The central construct is psychological contact, described as the necessary condition of psychotherapy and outlined on three levels: 1) the contact reflections–the “work” the therapist does, 2) the contact functions–the psychological process of the patient, 3) the contact behaviors– operationalized behavior for measurement. The Pre-Expressive Self, an intuitive and heuristic concept, interprets the progress from pre-expressive to expressive states of communication that are necessary for psychotherapy.

Introduction

According to Rogers’s “client-centered” approach to psychotherapy, certain “core attitudes” of the therapist facilitate the growth tendencies of the client: unconditional positive regard, empathy, and congruence. Rogers defined unconditional positive regard as “a warm acceptance of each aspect of the client’s experience” (Rogers,1957, p.98), empathy as “sensing the client’s private world as if it were your own” (p. 99), and congruence as “within the relationship, the therapist is freely and deeply himself, with his actual experience being presented by his awareness of himself” (p. 97).  Although not formally stated by Rogers, the “Non-Directive Attitude” (Raskin, 1947) is a powerful element in Rogerian therapy defined as a “surrendered” following by the therapist of the client’s own intent, directionality, and process.  The most comprehensive, current, and accurate presentation of Rogers’s view of theory and therapy is through the writings of Bozarth (1998).  The most thorough history of client-centered empirical research appears in Bozarth, Zimring, and Tausch (2002).

Although client-centered therapy has an informal reputation of being relevant mostly to high-level, functional patients, it actually has been one of the more productive modalities used by humanistic researchers in the psychotherapy of schizophrenia [Pugh (1949), Rogers et al. (1967), Hinterkopf and Brunswick (1981), Teusch, et al. (1981), Teusch (1990), Truax (1970), Vanderveen (1967)].  Greenberg, Elliot and Lietaer (1994) perhaps best summarized this research by stating that schizophrenic populations show lower effect scores when compared with other client-centered therapy populations. Prouty (2002) has made available a complete review of these studies and other humanistic research.  Also, summaries of psychoanalytic studies exist (Karon, 2001; Karon and Widener, 1999). This combination of humanistic and psychoanalytic approaches points toward a very valid view concerning the psychotherapy of schizophrenia.

PRE-THERAPY

Pre-Therapy primarily, but not exclusively, constitutes an evolution in the theory and practice of client-centered psychotherapy (Prouty,1994). The approach is developed on four levels: philosophical, theoretical, practice, and measurement.

Phenomenological Foundations

Pre-Therapy, rooted in the phenomenological traditions within psychology and psychiatry (Husserl,1997; Jaspers, 1972), can be described as a “pointing toward the concrete” (Buber,1964, p. 547).  Pre-Therapy approaches phenomenology in a very concrete sense.  This concreteness can be expressed through the metaphor “The As Itself” and is conceptualized in the following manner.

The As Itself is naturalistic.  Its phenomenology appears “naturally” in consciousness (Farber, 1959, 1967; Riepe, 1973; Ki-Kim, 1989) without the traditional Husserlian suspension of naturalistic or realistic attitudes (Jennings, 1992).  The concrete phenomenon is manifested naturally “As Itself.”  The As Itself is self-indicative.  The concrete phenomenon is “Absolutely Self-Indicative.”  The phenomenon is “what it is, absolutely, for it reveals itself as it is.  The phenomenon can be described, as such, for it is absolutely indicative of itself” (Sartre, 1956, p. 4).  Again, the phenomenon can be described “As Itself.”
The As Itself is desymbolized.  The concrete phenomenon is described as “desymbolized.” Scheler (1953, 136-201) wrote, “Something can be self given only if it is no longer given merely through any sort of symbol; in other words, only if it is not meant as the mere fulfillment of a sign that is previously defined in some way or other. In this sense, phenomenological philosophy is a continuous de-symbolization of the world.” In other words, the phenomenon appears non-symbolically (perceptually) “As Itself.”

The concrete phenomenon is perceptually naturalistic, self-indicating, and de-symbolized. This philosophical description provides a phenomenological understanding of the meaning of “concrete” as utilized in psychological-psychiatric research on cognition in schizophrenic persons (Arieti, 1955; Freidman, 1961; Gurswitch, 1966; Goldstein,1939; Goldstein and Scheerer, 1941; Mazumdar and Mazumdar, 1983).  It also provides a focus for the concrete nature of Pre-Therapy responses.  Client cognition and therapist response are coordinated through the quality or property of “concreteness.”

The Theory of Psychological Contact

Rogers (1957, p. 96) defined psychological contact in the following way: “All that is intended by this first condition is to specify that the two people are to some degree in contact, that each makes some perceived difference in the experiential field of the other.”  Unfortunately, Rogers’s definition is incomplete. It does not provide for therapeutic or research operations. It also gratuitously assumes psychological contact between client and therapist, which is often not the case in “contact impaired,” organic, and psychotic patients.  Pre-Therapy is an attempt to resolve these theoretical
and clinical problems.

Contact Reflections

Contact reflections are ultra-concrete reflections of the client’s immediate experiencing and expressive behavior.  There are five contact reflections: 1) Situational (SR), 2) Facial (FR), 3) Word-for-word (WWR), 4) Body (BR), and 5) Reiterative (RR). They establish contact between therapist and client at the client’s level of expression.  They are extraordinarily concrete so as to “fit” the schizophrenic cognitive style (Arieti, 1955; Freidman,1961; Gurswitch, 1966;Goldstein,1939; Goldstein and Scheerer, 1941; Mazumdar and Mazumdar, 1983).

Situational Reflections (SR).   Being imbedded in living concrete situations, environments, or milieus constitutes our literal “being in the world.” Accordingly, situational reflections facilitate reality contact for the client. An example would be “Johnny is pushing the ball.”  Another example could be  “Mary is playing with the cat.” The function of these reflections is to restore or develop reality contact.

Facial Reflections (FR).  The human face,  described as the “expressive organ,” contains not yet formed, pre-expressive affect. Facial reflections facilitate the experiencing or expression of affect. They develop the client’s affective contact. An example would be “You look sad” or, more concretely, “There are tears in your eyes.” Still another example could be “You look angry” or, more literally, “Your jaw is tight.”

Word-for-word Reflections (WWR).  Many schizophrenic, retarded, and geriatric clients present verbal symptoms of incoherence.  For example, many schizophrenic clients present echolalia, neologisms, word salads, etc. interspersed with social language.  Such a flow of communication could be as follows: “(unintelligible), ring, (unintelligible), hat, (unintelligible), house.”  Even though this makes no conventional sense, the Pre-Therapy approach would reflect the social language just as it occurs--word for word. These reflections give the experience of being received as a human communicator--a healing factor in itself.  These reflections facilitate communicative contact from the client/patient.

Body Reflections (BR).  Many schizophrenic patients express bizarre body symptoms such as echopraxia, catatonia, etc. Meddard Boss (1994) presented the concept of “bodying forth.” This means that bodily symptomatology is a form of “being in the world” and, as such, expresses the person’s existence.  Body reflections, empathic responses to  such “bodying forth,” result in a shift toward more verbal communication, illustrated in work reported by Prouty and Kubiak (1988a) concerning the exploration of catatonia.  There are two types of body reflections: verbal (“Your arm is in the air”) and literal body reflections by the therapist.

Reiterative Reflections (RR).  Not specific techniques, these embody the principle of “re-contact.” If any specific reflection produces a response, the therapist should repeat it. There are two types of empathic reiterative reflections. This exemplifies short term-reiteration: A patient remained silent, just touching her forehead, which the therapist kept body reflecting with her own organism.  The patient eventually said “Grandma.”  Word-for-word reflections eventually moved the client into some real feelings about her grandmother’s death.  An example of long-term reiteration occurred when a client kept pointing at her stomach.  The therapist reiterated in a long-term mode by saying, “Last week you said baby and pointed to your belly.” Gradually, the process unfolded in a true story about a real pregnancy and the trauma of an abortion.

Contact reflections, when combined and applied over a period of time, will show an increase in the client’s contact with the world, self, or others.  In the more technical terms of this theory, clients display more reality, affective, and communicative behavior.  What has occurred?  Again, rather technically, the contact reflections have facilitated the contact functions, which result in the emergence of contact behaviors.  To use a metaphor to understand Pre-Therapy, it provides a “web of contact.”  Contact reflections enhance the reality, affective, and communicative functions, so they are functional for psychotherapy. The following case vignette illustrates this process.

CLINICAL VIGNETTE

The client was one of 13 children.  His parents were farmers of Polish nationality. His mother had been hospitalized several times for schizophrenic problems.  Family observation revealed at least one sibling who, although not hospitalized, displayed psychotic symptoms.  The family brought the client to the United States for evaluation. A preliminary observation confirmed that the client was potentially responsive to Pre-Therapy.

Psychiatric documents described the client in these ways: “mute,” “autistic,” “catatonic,” “making no eye contact,” “exhibiting trance-like behavior,” “stuporous,” “confused,” “not establishing rapport,” “delusional,”  “paranoid,” and finally, “experiencing severe thought blocking.” He had been diagnosed with various pathologies: as manic-depressive; hysterical reaction; hebephrenic schizophrenic; paranoid schizophrenic; catatonic schizophrenic; profound schizophrenic; and schizophrenic, affective type.  He had received six electro-shock treatments, as well as numerous chemical interventions including Stelazine, Diazepam, Imipramine, Chlorpromazine, Anafranil, Phenothiazine, Haldol, and Trifluoperazine.

The client returned to his home for several months while plans for residential care and legal details were arranged.  My associate therapist arrived and found that the client, kept at home for several months, had deteriorated into psychosis.  The parents had not re-hospitalized him.  He was in a severe catatonic state, having withdrawn to the lower portion of the three-story home.  He did not eat meals with the family, instead creeping out at night to use the family refrigerator.  He had lost considerable weight, and his feet were blue from being cramped and stiffened due to his lack of movement and circulation.
The contact work.  This vignette describes segments of an unusual 12-hour process that illustrates the application of contact reflections, the successful resolution of the catatonic state, and the development of communicative contact (without medication).

The patient was sitting on a long couch, very rigid, with arms outstretched and even with his shoulders. His eyes stared straight ahead, his face was mask-like, and his hands and feet were blue-gray.  The therapist sat on the opposite side of the couch, giving no eye contact to the patient.  Reflections were given five to ten minutes apart.

Segment I             (approximately 2:00 P.M.)
Therapist: SR       I can hear the children playing.
Therapist: SR       It is very cool down here.
Therapist: SR       I can hear people talking in the kitchen.
Therapist: SR       I’m sitting with you in the lower level of your house.
Therapist: SR       I can hear the dog barking.
Therapist: BR       Your body is very rigid.
Therapist: BR       You are sitting very still.
Therapist: BR       You are looking straight ahead.
Therapist: BR       You are sitting on the couch in a very upright position.
Therapist: BR       Your body isn’t moving. Your arms are in the air.
Client:                    [No response, no movement.]
She brought a chair and sat in it directly in front of the patient and mirrored his body exactly as she saw it.

Segment II            (approximately 3:30 P.M.)
Therapist: BR       Your body is very rigid. You are sitting on the couch and not moving. (approximately 15-20 minutes    later)
Therapist:              I can no longer hold my arms outstretched. My arms are tired.
Client:                    [No response, no movement.]
Therapist: BR       Your body is very stiff.
Therapist: BR       Your arms are outstretched.
Therapist: BR       Your body isn’t moving.
Client:                    [Put his hands on his head, as if to hold his head, and spoke in a barely audible whisper.]  My head hurts me when my father speaks.

Therapist: WWR                  My head hurts me when my father speaks.
Therapist: BR                       [Therapist put her hands as if to hold her head.]
Therapist: RR/WW              My head hurts when my father speaks.
Client:                                    [Continued to hold head for two to three hours.]

Segment III                           (approximately 8:00 P.M.)
Therapist: SR                       It’s evening. We are in the lower level of your home.
Therapist: BR                       Your body is very rigid.
Therapist: BR                       Your hands are holding your head.
Therapist: RR/WW              My head hurts when my father speaks.
Client:                                    [Immediately dropped his hands to his knees and looked directly into the therapist’s eyes.]

Therapist: BR                       You’ve taken your hands from your head and placed them on your knees.  You are looking right into my eyes.
Client:                                    [Sat motionless for hours.]
Therapist: RR/BR                                You dropped your hands from your head to your knees.
Therapist: SR                       You are looking straight into my eyes.
Client:                                    [Immediately, he speaks in a barely audible whisper.] Priests are devils.
Therapist: WWR                  Priests are devils.
Therapist: BR                       Your hands are on your knees.
Therapist: SR                       You are looking right into my eyes.
Therapist: BR                       Your body is very rigid.
Client:                                    [He speaks in a barely audible whisper.] My brothers can’t forgive me.
Therapist: WWR                  My brothers can’t forgive me.
Client:                                    Sat motionless for approximately an hour.]

Segment IV                           (approximately 1:45 A.M.)
Therapist: SR                       It is very quiet.
Therapist: SR                       You are in the lower level of the house.
Therapist: SR                       It is evening.
Therapist: BR                       Your body is very rigid.
Client:                                    [Immediately, in slow motion, put his hand over his heart and talks.] My heart is wooden.

Therapist: BR/WW               [In slow motion, put her hand over her heart and talks.] My heart is wooden.
Client:                                    [Feet start to move.]
Therapist: BR                       Your feet are starting to move.
Client:[                                   More eye movement.]

The therapist took the patient’s hand and lifted him to stand.  They began to walk.  The patient walked with the therapist around the farm and in a normal conversational mode spoke about the different animals. He brought the therapist to newborn puppies and lifted one to hold.  The client had good eye contact.  The client continued to maintain communicative contact over the next four days and was able to transfer planes and negotiate with customs officers on the way to the United States.  He was able to sign himself into the residential treatment facility, where he underwent classical person-centered/experiential psychotherapy.

This vignette illustrates the function of Pre-Therapy, which is to restore the client’s psychological contact, thereby enabling treatment. Very clearly, this client’s reality and communicative contact improved sufficiently for him to enter psychotherapy.

CONTACT FUNCTIONS


The Existential Structures of Consciousness.

Merleau-Ponty often says that his entire phenomenology is meant to be a reduction to the lived and pre-objective realm where primordial contact is disclosed” (Mallin,1979, p. 53).  This means that conceptualizations of the contact functions derive from phenomenological, naturalistic, and realistic descriptions of consciousness. Merleau-Ponty (1962) further described the phenomenal field as the “world, self and the other.”  These are described by him as “concrete a priori” (Mallin, 1979, p 58).  “The world, self and other are the natural and categorical ‘revelatory absolutes’ of immediate consciousness through which particular concrete existents manifest themselves” (Prouty, 1994,  p. 33).  As Prouty, Van Werde, and Portner (1998, p. 28-32) described, “I live with and consciously experience the ‘world’ in all its immanent power”; “I live with and experience the ‘self’ with all of its psychological value”; “I live with and consciously experience the ‘other’ with all their significance.”  These polarities of involvement for our daily conscious life constitute the “revelatory absolutes” of our existence. This describes the existential structures of consciousness.

AWARENESS AND CONTACT .
Psychologically, the existential-phenomenological terms world, self, and other appear vague and lack specific or self-evident definition. Awareness, although not a construct utilized in client-centered therapy, receives considerable attention from gestalt theorists Perls, Hefferline, and Goodman (1969), Also, Perls defined contact as an “ego function” (Perls 1969 p. 139). Blending these descriptions of awareness and contact, Pre-Therapy expands Perls’s definition of contact as an ego function into contact as “ego function (s)” and describes them as awareness functions. Reality contact (world) constitutes the awareness of people, places, things, and events; affective contact, awareness of moods, feelings, and emotions; and communicative contact, the symbolization of world and self to others. Contact reflections facilitate reality, affective, and communicative contact--the practical and  theoretical work of  Pre-Therapy

THE CONTACT FUNCTIONS: A VIGNETTE.
It is, of course, necessary to illustrate the manifestation of reality, affective, and communicative contact.  The following vignette illustrates the restoration of these functions with a very chronic schizophrenic woman. "Dorothy," an old woman and one of the more regressed women on X ward, was mumbling something [as she usually did].  This time, I could hear certain words in her confusion.  I reflected only the words I could clearly understand.  After about ten minutes, I could hear a complete sentence.
 
Client:                                 Come with me.
Therapist:  WWR                 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.  Since I could not communicate with her, I watched her body movements and closely reflected these.]
Client:                                    [The patient put her hand on the wall.]  Cold.
Therapist: WW-BR              [I put my hand on the wall and repeated the word.]  Cold.

[She had been holding my hand all along; but when I reflected her, she would tighten her grip.  Dorothy would begin to mumble word fragments.  I was careful to reflect only the words I could understand.  What she was saying began to make sense.]

CIient:                                    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:  WW-BR             [Touching the wall.]  You don't know what this is anymore.  The chairs and walls don't mean anything to you anymore.
Client:                                    [The patient began to cry. (AFFECTIVE CONTACT).]
Client:                                    [After a while she began to talk again.  This time she spoke clearly (COMMUNICATIVE CONTACT).]  I don't like it here.  I'm so tired. . . so tired.
Therapist: WWR                  [As I gently touched her arm, this time it was I who tightened my grip on her hand.  I reflected] You're tired, so tired.
Client:                                    [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 process of restoring reality, affective, and communicative contact.

CONTACT BEHAVIORS

Contact behaviors are the emergent behavioral changes indicative of the effects of Pre-Therapy.  Reality contact (world) is operationalized as the client’s verbalization of people, places, things, and events.  Affective contact (self) is operationalized as the body or facial expression of affect.  Affective contact may also be measured by the use of “feeling words” such as “angry,” “happy,”etc.  Communicative contact (other) is measured by social words or sentences.

Prouty (1994, pp. 45-46) developed evidence for construct validity by recording a three-month inter-rater correlation and a one-day set of correlations.  Table I describes nine pairs of mean scores, from two independent raters. Mean scores per month are compared between raters. These results show no statistical difference between raters.

Table I (3 months)

Table 1

     

Table II describes 24 pairs of scorings from two independent raters through a single session of Pre-Therapy with a schizo-affective, retarded client. Scores were drawn from percentiles 1-20, 40-60, and 80-100. In other words, the beginning, middle, and the end of the session were evaluated.

Table 2

An independent pilot study (DeVre,1992) further confirmed construct validity and developed evidence for reliability. Utilizing the Pre-Therapy Scale, DeVre measured three data samples from two clients described as chronic schizophrenics and a third diagnosed as borderline, all measured under hospitalized conditions.

The first measure of agreement between two raters was kappa 0.39.  After refinement of the English to Flemish translation, the second measure, with the same raters and a second client, was kappa 0.76.  A third measure, with the same raters and a third client, was kappa 0.87.  These measures of agreement were significant at 0.00005.  A measure of reliability was taken by having two independent psychiatric nurses instructed with the Pre-Therapy Scale.  The rating of the first data sample was 0.39.  The nurses’ level of agreement was kappa 0.7 at a 0.0005 level.  These U.S. and Belgian pilot studies provided the beginning of evidence for the valid and reliable measurability of contact behaviors.

Prouty (2002) reported that Danacci (1997) produced a video study of clients receiving Pre-Therapy.  This study involved a single therapist, 2 experimental clients, and 2 control clients diagnosed with mental disability/schizophrenia and hospitalized for 30 years.  The experiment demonstrated strong qualitative and quantitative communicative increases in the near-mute clients.  The Evaluation Criterion for the Pre-Therapy Interview (ECPI) used measures verbal coherence and severe levels of disorganization (Danacci, 2001).  Reporting a beta coefficient of .77, Danacci found a corresponding confidence level of 97.5% that the differences will fall between 16.195 and 28.257 communicative units.  Controlling for first-session differences, Pre-Therapy patients averaged 22.226 units higher communicative scores than the control group at a p>.02.  This statistical interpretation revealed that client communications scores occurred within the range predicted by a much larger sample and were not the result of extraneous variables.  Additional pilot studies (Hinterkopf, Prouty and Brunswick, 1979; Prouty, 1990) provided evidence for positive outcomes.

THE PRE-EXPRESSIVE SELF


The Pre-Expressive Self, a heuristic concept inferred from the case histories and empirical studies of Pre-Therapy, constitutes a central concept for understanding the regressed aspects of the client and the nature of Pre-Therapy.  The first observation is that many chronic schizophrenic clients have periods of sudden lucidity, illustrated by the psychiatric descriptions of Roelens (1994).  Such lucidity gives credence to the belief “that somebody is in there.”  Beneath the chaos, confusion, and incoherence exists a Pre-Expressive Self. 

The second observation is that Pre-Therapy moves the client from a pre-expressive state to an expressive state, revealed over and over again in case histories and quantitative explorations and described as Pre-Expressive Movement.  The third observation concerns Pre-Expressive Language.  Schizophrenic clients often express themselves in obscure metaphors as well as echolalia, word salad, and neologisms, simply understood as psychotic speech.  A semiotic examination, however, reveals a structure. Often the words lack a reality context or a reality referent.  However, when reflected “word for word,” they unfold into a latent reality.

Finally, observing these processes reveals the Pre-Expressive Self as a nucleus of self-integration, the central intuitive empathy of our work.  Pre-Therapy facilitates the emergence of the pre-expressive self-enabling growth toward an expressive self that is capable of psychotherapy.

 
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