The Person Centered Journal

The Person Centered Journal, Volume 5, Issue 1, 1998

Korey McWilliams & Garry Prouty

Chicago Counseling Center

Client centered therapy has traditionally neglected therapeutic work with mentally retarded clients. Rogers (1942) believed such clients lacked the autonomy and introspective skills necessary for psychotherapy. Some scholars believed such a position by Rogers resulted in a profound inhibiting effect on the development of therapy and research for this population (Ruederich and Menolascino, 1984). Consequently, only a handful of European publications have appeared: Badelt of Germany (1990), Peters of The Netherlands (1981, 1986a, 1986b, 1992, 1996), and Poertner of Switzerland (1990, 1996a, 1996b)

PRE THERAPY

As an evolution of Client centered therapy (Prouty, 1994), Pre Therapy proposes a theory of psychological contact specifically designed for application to retarded clients, as well as, other low functioning populations (Prouty, 1976, 1990, 1997, Prouty & Cronwall, 1990, Prouty & Kubiak, 1988, Van Werde, 1990). Rogers (1957) described psychological contact as the first condition for forming a therapeutic relationship. Unfortunately, Rogers did not present a concept of psychological contact, nor did he describe the means to develop it when impaired or absent in clients. As with higher functioning clients, he tended to assume its presence.

Pre Therapy delineates the concept of psychological contact in both theoretical and applied detail. The method or technique of establishing psychological contact is described as Contact Reflection(s). Theoretically, the underlying psychological processes are labeled as Contact Functions and the measurable behavioral outcomes are referred to as Contact Behaviors.

Contact Reflections

Contact Reflections are specifically designed to make psychological contact with the regressed retarded type of client. They are extraordinarily concrete and literal so as to empathically match the client's "concrete attitude" (Gurswitch, 1966). Contact Reflections are different from classical Rogerian reflections. Because of the client's lack of communicative capacity, often the therapist cannot know the client's internal frame of reference. Consequently, the reflections are directed at the client's over expressive behavior. These Contact Reflections take five forms: situational, facial, word for word, body, and reiterative.

Situational Reflections (SR) are oriented towards a client's situation, environment, or milieu, Their theoretical intent is to assist concrete reality contact. An example is "Jane is playing with the toy."

Facial Reflections (FR) are directed towards the client's pre expressive affect. Their theoretical purpose is to develop affective contact. This type of response is exemplified as "You look angry."

Word for Word Reflections (WWR) are focused on client's speech, often times incoherent. The client may express (an incoherence), (incoherence), sky, street. The therapist may reflect "sky," "street." This is designed to assist communicative contact.

Body Reflections (BR) are pointed toward the client's body posturing. An example is "Your arms are straight in front of you." The purpose is to assist awareness functions, such as bodily, spatial and perceptual experiencing.

A Reiterative Reflection (RR) is a principle that states, if any of the preceding therapist responses elicit a client response repeat it. This allows the reinforcement of previous contactful experience.

These reflections, through following the clients' verbal and non verbal efforts, provide the client with a network of psychological contact at the client's level of expression and communication. Theoretically, these contact reflections will function to increase the client's contact with the World, Self, and Others (Merleau Ponty, 1962).

The Contact Functions refer to the client's experiencing of World, Self and Other. They are a direct result of Contact Reflections. Perls' (1969) suggestion of "contact as an ego function' is divided into three psychological functions; Reality, Affective, and Communicative Contact. These are described as awareness functions. Reality contact is the awareness of people, places, things, and events. Affective contact is the awareness of moods, feelings, and emotions. Communicative contact is the symbolization of reality and affective contact. Put in another way, Pre Therapy restores contact with the World, Self and Other.

The following is a clinical example (Prouty, 1994, op. cit.) that describes an encounter between a student therapist and a schizophrenic, functionally retarded, woman in a custodial institution. The abbreviations label the type of Contact Reflection(s) utilized in the therapist's (T) response to the client (C).

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

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

[Touching the wall REALITY CONTACT]. The walls and chairs don't mean anything anymore.

This vignette illustrates the facilitation of the contact functions through the use of Contact Reflections. Reality, Affective, and Communicative Contact are restored and the client moves toward the therapeutic relationship.

Contact Behaviors refer to the observable results of Pre Therapy. Contact behaviors emerge through the facilitation of the contact functions. Reality, Affective and Communicative Contact form the three dimensions of measauement.. The operationalization of affective contact is defined as the bodily/facial or verbal expression of affect. Communicative Contact is described as the linguistic symbolization of reality and affective contact. Early pilot studies (Hinterkopf, Prouty and Brunswick, 1979) found significant differences in reality and communicative contact as a function of treatment. Evidence of construct validity was developed by Prouty (1994, op. cit.). Reliability measures have been obtained by DeVre (1992) and Dinacci (1995).

CASE STUDY

The present study reviews the history of a forty one year old, profoundly retarded woman whose step mother implemented contact reflections in their home.

The main participants were a family of three: Darlene the profoundly retarded woman, her father, and Darlene's step mother (new mom]. All information in this paper was obtained through interviews with the step mother. At the time of the interviewer's contact, the father had passed away and due to severe health problems, the step mother was unable to continue to provide the attention necessary to care for Darlene; consequently, she now lives in a residential home for handicapped persons in her parent's neighborhood.

Eleven years earlier, all three were living together and Darlene had the love of her father and the growing love of her new step mother. However, at that time, as observed by the step mother, caring and love were necessary, but were insufficient. Although physically and emotionally close to her parents, Darlene remained alone, isolated in her own world, that was in many ways, a world unknowable.

Docile and agreeable, Darlene rarely smiled, offered negligible eye contact, showed little reaction to others and rarely initiated interactions. Her verbal language skills were non existent and she was unable to communicate biological needs for thirst, hunger, or using the bathroom. Furthermore, she was semi ambulatory and prone to petite and grand mal seizures, requiring continuous and constant monitoring.

Darlene lived in a psychological shell, her world within ours, yet little contact existed between the two worlds. Sensing this existential isolation, her step mother, having learned Pre Therapy's approach to communicating with non communicative mentally retarded persons, began to initiate

contact reflections. By doing this, her step mother opened the door to a new way of life, not only for herself, but also for Darlene and her father.

The step mother began implementing contact reflections in the morning and evenings when Darlene was home from her sheltered workshop. These included the situational, bodily, facial, word for word, and reiterative reflections described above.

With all clients, and in the case of Darlene, the level of impairment will dictate which type of reflection a therapist will use. For example, the use of situational reflections requires some vocabulary on the part of the client. Because Darlene's language comprehension was minimal, the step mother's use of situational reflections was, therefore, limited.

Bodily reflections are either behavioral, verbal, or simultaneously both. If Darlene raised a hand in the air, her step mother raised her hand and/or said, "you're holding your hand in the air." Although severely language impaired, these verbal reflections were utilized to express "receiving" communication from Darlene. Other examples the step mother used were crossing her fingers, tapping her thigh and tilting her head slightly, all attempts to bodily reflect Darlene's behavior.

Facial reflections respond to an individual's facial expressions of affect, either verbally or behaviorally. Unfortunately, because of isolation, medication, or institutionalization, some mentally retarded clients may be emotionally flat and their facial expressions may offer only a glimmer of feeling. Facial reflections respond to those edges as a way of bringing the client into contact with their underlying affect. Though clearly not indicated by Pre Therapy, her stepmother only reflected "positive" affect such as "looking happy" and "smiling." If Darlene smiled, her step mother would say "Darlene is smiling" and smile back at her. Expressing intense negative behavior was not empathically reinforced because of the home living situation. Disruptive, high pitched, screams would be one of the negative behaviors not to be encouraged.

Word for word reflections are the literal repetition of words and meaning fragments communicated by the client. This reinforces the client's sense of being a communicator who may be able to establish contact. Again, because Darlene was non verbal, her step mother did not reflect words although she actively reflected a variety of humming and throat sounds.

The reiterative reflection is better thought of as not a type of reflection, but as a guiding principle of recapturing that which previously established contact. For example, Darlene spontaneously made a humming sound to which her step mother reflected. Because this established con tact, her step mother later reiterated this sound to attempt re contact. Likewise, whenever the step mother discovered anything else that established contact, she would remember it and utilize it again later

Because Darlene and her step mother's contact was not limited to fifty minute sessions, once per week, the frequency of reflections differed from the usual therapeutic encounter. Her step-mother expressed this as "It was a daily routine. Whenever the situation presented itself, or I could make it possible ... [eventually] it became automatic. I even taught her father." "I will never forget the moment when Darlene realized she was understood and no longer isolated. She could communicate. For the thirty years prior to this her father could only love her and meet her needs Now they could relate. The awe in Darlene's face was profound."

RESULTS

Pre Therapy theorizes that with exposure to contact reflections, a client psychological contact will increase. This contact can be defined as a triumvirate classification of contact with World, Self, and Other. According to the step mother's reports, the effects of utilizing contact reflections

demonstrated clinically significant changes in Darlene's emotional growth and behavior. Specifically, Darlene's contact with the World, Self and Other was born.

Her step mother reported that prior to Darlene's exposure to contact reflections, she would sit expressionless and inattentive to the "world." When the family would go for car rides, Darlene preferred to gaze downward and play with her toys, rarely glancing outside and never showing interest in her surroundings. Subsequent to the step mother's efforts to make contact, Darlene began to pay more attention and developed an interest in her environment. Now, on car rides she would sit up, eyes focused and looking around, tracking the passing objects, as well as, noticing passersby. It seemed as if a new curiosity was born within, reaching out to the world for stimulation. Ultimately, Darlene's contact with her environment culminated in her first trip to the movie theater where she sat quietly and attentively.

Darlene's contact with "Self' also appeared significant. For example, prior to the stepmother's efforts, Darlene would pass by their bathroom mirror uninterested, barely stopping to look in its direction. Gradually, as the step mother continued her use of contact reflections, Darlene took notice of her own image and eventually would look in the mirror with enjoyment, smiling and laughing. Not only did Darlene smile and laugh at just the mirror, but in many other situations she began fully expressing her joy and happiness this way.

Even more significant was Darlene's increased contact with the "other." In this case, the “other" was "others." That is, Darlene's upswing in communicative contact with her father and step mother was quite dramatic. The formerly regressed world, where Darlene often withdrew, was now broken open and outward. Concretely, and most significantly, this included her father enjoying his daughter, something he had rarely experienced. Darlene no longer sat by and watched her father and step mother interact, helpless to be a part. Instead she would initiate eye contact and other gestures, eliciting verbal and physical responses from both parents. Furthermore, over time Darlene eventually learned to signal her hunger needs by holding her arm in the air, crossing her fingers and simultaneously humming.

Other positive outcomes of her step mother's contactful relating were Darlene's increased initiative. Beyond just the ability to perform, there was a fresh, new willingness on Darlene's part to attempt new tasks, such as taking off her coat upon demand or learning to climb the steps and board her school bus without assistance.

Not only did it seem rewarding for Darlene to experience the intrinsic satisfaction of autonomy and accomplishment, but the level of psychological stress on the parents was somewhat diminished; in that parental isolation was also reduced. This, in turn, enabled them to be more available for interactive contact with Darlene.

It should be noted that as Darlene was being prepared for placement in the group home. An independent psychologist tested Darlene's I.Q. He noted the shift in Darlene's cognitive performance from that of a recorded 8 month mental age to that of a three year old in limited command comprehension.

SUMMARY

Pre Therapy evolved from Rogers' suggestion of psychological contact as the first condition of a therapeutic relationship. Psychological Contact can be understood as consisting of Contact Reflections, Functions, and Behaviors. Contact Reflections refer to the techniques of making contact. Contact Functions are awareness functions resulting from the Contact Reflections. Contact Behaviors are the emergent, measurable behaviors resulting from increased psychological contact.

This paper expands the use of Pre Therapy to include familial participation in the psychological development of a profoundly retarded woman. Non verbal contact reflections were utilized by her parents as a "life enricbment 'facilitation. Improved contact with the World, Self and Other resulted. Darlene demonstrated increased contact with the world around her through increased attentiveness to reality. The client also demonstrated increased contact with self through enjoyment of her mirror images. She further demonstrated contact with others by becoming more communicative through the use of primitive expressions and gestures. A further positive development was the effect on the parents as a result of the increased communication. They could have emotional satisfaction from the increased human contact with their daughter. In these ways, family "therapy" occurred.

This case study on a single "home bound," profoundly retarded, non verbal woman generally confirms more quantitative pilot studies with more verbal, but retarded, clients. Further value of the study is the presentation of improved ordinary living within the family unit.

Future applications of Pre Therapy should extend the approach to teaching parent/caretakers and significant others to utilize contact reflections as a part of normal interaction. Just as Carl Rogers suggested that the principles of client centered therapy extend to all interpersonal relationships, so it seems that in relationships with retarded persons, Pre Therapy may be thought of not merely as a technique, but as a "Way of Being."

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