An Interesting Case Study - Treating Psychosis and the Delusional Mind
Can psychosis be cured?
Alternative treatment methods can improve the symptoms of psychosis and delusional beliefs
There is widespread agreement that psychosis occurs in people with a vulnerable predisposition of biopsychosocial origin (Garety, et al, 2001); that there are emotional changes, and disruptions in cognitive processes of perception or judgement at onset. Its most prominent symptoms are called positive symptoms this includes delusional belief (Garety et al. 2000). Rogers, (1959) describes psychosis as a state of disintegration involving the breakdown of the neurotic defences of denial and distortion. My paper considers the role of the person centred approach applied when working with my client with complex needs in reducing his symptoms of psychosis in schizophrenia especially delusional belief. Having made sense of his delusions through person centred counselling he will be grounded, self aware in correctly understanding his distortions and will experience improved functioning. He will be more integrated with the society in which he lives. The person centred approach has played a significant role in encompassing therapeutic communication skills that have resulted in the reduction of cognitive distortions for my client, relating to and stemming from his psychotic experiences. I will demonstrate how the person centred approach facilitates positive change for the client and how this became a learning experience for me also. Some of the approaches core ideologies such as unconditional positive regard, empathetic understanding and listening skills are explored to demonstrate that these forms of communication can bring about a positive change for my client and for me
Over the past fourteen years my client - has communicated verbally to me that he has experienced auditory and visual hallucinations regularly since the age of five years old. He has included the content of the hallucinations through his dialogue to me. This has uncovered my subsequential understanding of the basis of his delusional beliefs and I had a wider knowledge of their origin, enabling me to enter in to his frame of reference. He was diagnosed with paranoid schizophrenia at the age of twenty seven years old, he is now fifty three years old and his diagnosis he dispute’s. As a result of the psychosis he encountered over the years, he has developed unhealthy cognitive processes and delusions that leads to him being sectioned under the Mental Health Act as a revolving door patient. He does not perceive the psychotic experiences as neurologically connected to the symptoms of his diagnosis. Instead he has the fixed deluded belief – based only on the content of his experiences and the duration of them - that he is a psychic medium, he believes that he communicates psychically with the actors on the television and with other people in everyday life. He deeply believes that his auditory hallucinations or ‘voices’ and visual hallucinations are of a psychic, spiritual magical nature. I have respectfully expressed to him my reservations of his claim to this and why, however, “It is still possible to demonstrate acceptance in a manner apparently conflicting with the client's frame of reference and for it still to effect positive change” (Wilkins, 2000 pp26). I found myself in a privileged position to be in communication with him about his beliefs. During this time I communicated with my client using the person centred approach core principles (mentioned below) to try and gain positive outcomes for him by giving him the opportunity to become more self actualized through person centred counselling; coming to realistic explanations about his delusions and by helping him explore alternative reasons for his experiences of psychosis. Gradually this process has enabled my client to think more clearly about his cognitions and reduced the number a frequency of his admissions in to hospital due to his psychosis which became distressing for him overwhelmed him completely taking over his ability to cope and lead a functional life in the community independently.
Person centred approach and the therapeutic relationship for effective communication
Person centred counselling is a type of psychotherapy. It is classified as a helping relationship through which positive change can take place through its communication techniques. Singh, 2007 argues that the relationship between my client and I is important as it assisted in facilitating the personal growth of my client. Such a growth was aimed at improving functioning for my client and to change his fixed delusional beliefs. From the humanistic school of thought, the nineteen forties saw the start of Rogers’ revolutionary contribution to the field of therapeutic communication. For Sigmund Freud, (1963) - one of Rogers’s critiques, the purpose of the therapeutic relationship was to control and sublimate the volcanic and destructive aspects of human nature. For Watson, (1924) the aim was to take control and to correct the maladaptive learning of patients. However, Rogers’s theories helped to democratise the role of therapeutic communication by challenging the authoritarianism that was pervasive at the time in the helping professions (Farson, 1974). For Rogers, (1942) the person centred approach provided rich insights into the sociocultural and personally experienced workings of a complex mental health intervention for psychosis (Larsen, 2007). In all psychotherapeutic experiences with psychosis there is a degree of conformation of the appropriateness of the person centred approach (Lidz, 1980). When I applied the person centred approach principles, my client was exposed to an opportunity to perceive healthier ways of making sense of his delusions by aiming for self actualisation. Breaking down delusional beliefs and replacing them with healthier ways of coping was paramount for the client to remain in touch with reality. I began to do this by following the six core conditions for person centred counselling to take place. Firstly, Prouty, (1994) argued that for effective communication to take place between my client and I, there had to be psychological contact between us, this was achieved by my client wishing to talk with me about the subject of psychosis and the experiences had encountered to which I was willing. Second, the client was in a state of incongruence, from this I perceived him as being vulnerable and anxious and in need of psychological intervention. Third, in my role I was congruent and integrated with the relationship. Fourth, I was mindful of listening techniques to uncover deeper meanings; fifth, unconditional positive regard was applied in the process. Finally empathetic understanding which facilitates change through reflection was explored. Additionally, I understood and was accepting of my client’s internal psychotic frame of reference. I listened, became transparent (see Tolan, 2003), I mirrored by verbally reflecting back his experiences with unconditional positive regard and empathy to help him try to facilitating change (Rogers, 1957). The importance of authenticity in our relationship was crucial for communication this idea is supported by Thorne and Lambers, 1998. In order for him to communicate openly about his experiences my client had to perceive levels of warmth, acceptance and genuineness from myself, these criteria for successful communication are reviewed by Patterson, (1984). For him these were the primary factors in the relationship; his (and other sufferers of schizophrenia) main focus was to willingly demonstrate openness in communication and to gain positive outcomes from the principles of the person centred communication (Hewitt and Coffey, 2005). Rodgers, (1975) states these conditions need to be met for change to occur. I was mindful that the absence of acceptance in the relationship would have had a negative impact on my client, the positive outcomes and, successful communication. This has been stressed in empirical research (Whitehorn and Betz, 1975).
Listening skills in person centred counselling
Wilkinson’s, (1992) point of view supports the fact that when listening in a sensitive way I was so much inside the private world of my client that I could clarify not only the meanings of which the client is aware but even those just below the level of his awareness. This kind of sensitive, active listening technique is exceedingly rare in our lives. I applied this listening technique in order to facilitate change. We think we listen, but very rarely do we listen with real understanding and true empathy. Yet listening of this very special kind is one of the most potent forces for change that is known (Rogers, 1979). For effective communication I had to avoid what Wood, (2012) called pseudo listening, selective and literal listening as this would have disturbed the therapeutic communicative process.
Unconditional positive regard for effective communication
The relationship between my client and I was vitally linked to successful communication. Rogers and Raskin, (1989) argue that this was to be more effective if the positive regard is unconditional. I prized my client in total rather than in a conditional way (taken from the work of Rolfe, 1990). I didn’t accept certain feelings in him and disapprove of others. This way of thinking mirrored Rogers’ (1967) paradigm of acceptance. I felt unconditional positive regard for this person. When non evaluative prizing was present in the encounters between me and my client, Maslowski and Morgan, (1973) argued that constructive communication facilitating change and was more likely to have occurred. Unconditional positive regard has been a fundamental communication system when administering the person centred principles toward my client. Wilkins, (1999) states that holding this attitude deeply values the humanity of my client, it is not deflected in that valuing by any particular belief of my client. The attitude manifested itself in my consistent acceptance of and enduring warmth towards him, (taken from Mearns and Thorne, 2007). A critique of unconditional positive regard and communication is that the effectiveness of it may only lie in its ability to be able to maintain and facilitate a long term working relationships with clients (Farber and Lane, 2001).
Communication and empathetic understanding
Empathy is the most well known of Rogers therapeutic conditions, (Raskin, 1948; Patterson et al, 2000). Empathy is an attitude through which I strived to enter my client’s private perceptual world (supported by Rogers, 1961). The outcome for me was that by using empathy as a communication tool and to encourage communication from my client I had created willingness in him to communicate his beliefs with me. Through communicating an acceptance of his beliefs that I reflected back to him I could work with my client to assist him in perceiving a clearer and more realistic understanding of his delusions and their origins. During this process and in doing this, he became more self aware. Drawing on empathic understanding in practice exposed me to my client’s world where positive changes can begin to take place. Using the principles of person centred counselling and by communicating the key characteristics of empathetic understanding allowed me to engage in an understanding of my client’s subjective reality as he experienced it, at any given moment, in his book The Interpreted World, Spinelli (2005) supports this point. For me, practicing empathy in our communications has been crucial in achieving successful communication and in maintaining openness from my client and in facilitating change. Achieving this required orientation to enter the frame of reference (Gillan, 2007). As my client was empathetically heard, it became possible for him and me to listen more accurately to the flow of inner experiencing (this point is taken from the work Vandershot, 1990). From empathetic understanding there was a greater freedom to grow (Rogers, 1965) and to be the whole person that he inwardly was. Employing the empathetic tool is crucial for the continuation of open communication between us that lead on to healthier ways of coping with his symptoms, bringing his deluded ideas more in tune with reality. Moreover I was able to work with my client and accompany him on his journey by allowing him to safely replace each delusional belief created over time.
My paper begins with the definition of psychosis offering a critique of Rogers, this followed directly on to the case history of my client. This contextualised the paper. Following this I considered the role and the core conditions of person centred counselling to facilitate change when working with a client with a diagnosis of schizophrenia and with complex needs. Person centred counselling facilitated changes for my client such as improved self awareness, a reduction in the symptoms of delusional beliefs leading to his improvement in functioning resulting in fewer admissions to hospital with psychosis. During this process and in order for me to facilitate change I highlighted the importance of the core conditions of the person centred approach. I explored listening skill, empathy and reflection and unconditional positive regard these were the principles that needed to be adopted in communications to assist in facilitating change. Unconditional positive regard was always adopted in sessions this enabled open and honest communication from my client which was important if change was going to take place. Empathetic understanding was always practiced to gain deeper insights in to my client and to allow reflection techniques to occur. I had adopted the theory of content reflection and emotion reflection. I implemented this theory by reflective communication, reflecting on what my client had said and by showing that I had understood his emotion. By reflecting content and emotion back to him my client could see himself in own situation or reflection. Ultimately he understood himself better and could see his problems for himself increasing his sense of self awareness (this concept is also supported in the work of Rogers, 1963). Listening skills I used were vital in person centred counselling. In order for me to facilitate change I had to be aware of the types of listening that I had to avoid. In avoiding certain listening types I was able to listen sensitively and actively placing me inside of the private world of my client. This kind of listening skill gave me the advantage of having deeper insights enabling me to facilitate change. From our communications my client adopted healthier ways to reduce his delusional symptoms; achieving this through my application of the person centred core principles. He reported that some distortions are completely cleared from cognitive delusion but some of his distorted beliefs which were still regarded to him as not delusional remained. A recommendation would be that further long term person centred counselling structured and frequent sessions would root and deepen further lasting positive cognitive change .
Freud, S., (1963) My contact with Josef Popper-Lynkeus. In Character and culture (eds.) Strachey, J., New York: Crowell-Collier (Original work published 1932).
Farber, B.A., Lane, J.S., (2001) Positive regard. Psychotherapy: Theory, Research, Practice, Training. 38:4 pp390-395
Farson, R. (1974) Carl Rogers, quiet revolutionary. Education, 95:2 pp197–203.
Garety, P.A., Fowler, D Kuipers, E., (2000) Cognitive behavioural therapy for medication-resistant symptoms. Schizophrenia Bulletin. 26 pp73-86
Garety, P.A., Kuipers, E., Fowler, D., Freeman, D., Bebbington, P.E., (2001) A cognitive model of the positive symptoms of psychosis. Psychological Medical. 31 pp189-195
Gillan, E., (2007) Person Centred Counselling Psychology: An Introduction. London: Sage Publications
Hewitt, J., Coffey, M., (2005) Therapeutic working relationships with people with schizophrenia: literature review. Journal of Advanced Nursing, 52:5 pp561-570
Larsen, J.A., (2007) Understanding a complex intervention: Person-centred ethnography in early psychosis. Journal of Mental Health. 16:3 pp333-345
Lidz, T., (1980) Long term treatment of psychotic state. Journal of American Psychoanalytic Association. 28:3 pp719-721
Maslowski, R., Morgan, L.B., (1973) Interpersonal Growth and Self Actualization in Groups. USA: MMS Information Corporation
Mearns, D., Thorn, B., (2007) Person Centred Counselling in Action (3rd ed.) London: Sage Publications
Patterson, F., Ferguson, E., Lane, P., Farrel, K., Martlew, J., Wells, A., (2000) A competency model for general practice: Implications for selection, training and development. British Journal of General Practice. 50:452 pp188-193
Patterson, C.H., (1984) Empathy warmth and genuineness in psychotherapy: A review of reviews. Psychotherapy: Theory Research, Practice, Training. 21:4 pp431-438
Prouty, G., Van Werde, D., Pörtner, M., (2001) Pre-therapy. Ross-on-Wye: (PCCS).
Raskin, N.J., (1948) The development of non-directive therapy. Journal of Consulting Psychology. 12:2 pp92-110
Rogers, C.R., (1942) Counselling and Psychotherapy: Newer Concepts in Practice. Boston: Houghton Mifflin.
Rogers, C.R., (1957) The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology. 21:2 pp95-103
Rogers, C.R., (1959) A theory of therapy, personality, and interpersonal relationships, as developed in the client-centred framework. In. Koch, S., (Ed.), Psychology: A study of a Science. Vol. III: Formulations of the Person and the Social Context. New York: McGraw-Hill.
Rogers, C.R., (1961) On Becoming a Person: A Therapist’s View of Psychotherapy. Boston:
Rogers, C.R., (1963) Actualizing tendency in relation to “motives” and to consciousness, in Nebraska Symposium on Motivation, (eds.) MarsFhall, J. Oxford: Nebraska Press.
Rogers, C.R., (1965) The therapeutic relationship: Recent theory and research. Australian Journal of Psychology. 17:2 pp95-108
Rogers, C.R., (1967) The therapeutic conditions antecedent to change: A theoretical view. In The Therapeutic Relationship with Schizophrenics. (eds.) Rogers, Gendin, Kiesler, Truax. Wisconsin: University of Wisconsin Press
Rogers, C.R., (1975) Empathetic: An unappreciated way of being [online]. Available at: URL<http://www.elementsuk.com/libraryofarticles/empathic.pdf> Accessed on 07th June 2012
Rogers, C.R., (1979) The foundations of the person centred approach [online]. Available at: <URLhttps://www.centerfortheperson.org/pdf/1979__Foundations_of_a_Person_Centered_Approach.pdf> Accessed 07th June 2012
Rogers, C.R., Raskin, N.J., (1989) Person centred therapy, in Current Psychotherapies (eds.) Corsini, R.J., Wedding, D., (4thed.) pp155-194. Illinois, US: Peacock Publishers
Rolfe, G., (1990) The assessment of therapeutic attitudes in the psychiatric setting. Journal of Advance Nursing. 15:5 pp564-570
Singh, K., (2007) Counselling Skills for Manger. India: Prentice Hall of India
Spinellie, E., (2005) The Interpreted World: An Introduction to Phenomenological Psychology. (2nded.) London: Sage Publications
Thorne, B., Lambers, E., (1998) Person Centred Therapy: A European Perspective. London: Sage Publications.
Tolan, J., (2003) Skills in Person Centred Counselling and Psychotherapy. London: Sage Publications
Vandershot, G., (1990) The Process of empathy: Holding and letting go, in Client Centred and Experiential Psychotherapy in the Nineties (eds.) Lietaer, G., Rombauts, J., Van Balen, R pp269-291 Belgium: Leuven University Press.
Watson, J.B. (1924) Behaviourism. Chicago: University of Chicago Press.
Whithorn, J.C., Betz, B.J., (1975). Effective Psycho-therapy of Schizophrenic Patients. New York: Aronson
Wilkins, P., (1999) The relationship in person centred counselling, in Understanding the Counselling Relationship (eds.) Feltham, C., pp55-96 London: Sage Publications
Wilkins, P., (2000) Unconditional positive regard reconsidered. British Journal of Guidance and Counselling. 28:1 pp23-36
Wilkinson, M., (1992) How do we understand empathy systematically? Journal of Family Therapy. 14:2 pp193-205
Wood, J., (2012) Communication in our Lives. Boston, USA: Wadsworth
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