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INTRODUCTION TO CONTACT WORK PRE-THERAPY AND THE WORK OF GARRY PROUTY

INTRODUCTION TO
CONTACT WORK

PRE-THERAPY
AND THE WORK OF
GARRY PROUTY
INTRODUCTION TO CONTACT WORK: PPRE -THERAPY
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What is Pre-Therapy?
If you want further information
regarding Pre-Therapy in the UK Pre-Therapy or ‘contact work’ was developed by American
please contact psychologist Garry Prouty. It is a method for bringing people back
• Catherine Clarke into psychological contact who are normally ‘contact-impaired’
cclarke@ntlworld.com due to learning disability, psychosis, dementia, terminal illness, or
(general information) brain damage due to illness or injury. Such people seem ‘beyond
• Pete Sanders human contact’, in vegetative or catatonic, autistic or otherwise
pete@pccs-books.co.uk non-communicative states. It is also effective with people who are
(general information, contact-impaired through states of high agitation and confusion. It
publications and is difficult if not impossible to assess such patients for diagnostic
introductory workshops) purposes, to ask questions and understand their everyday care needs,
• Dave Deady to engage in therapy and other negotiated activities.
david.deady@paisley.ac.uk
(applications in mental Pre-therapy can be used by all staff and carers supporting and
health nursing and training working therapeutically with such patients and service users. Whilst
mental health nurses and it is effective in facilitating one-to-one communication in the here
carers) and now, it is even more effective when it permeates the ward or
• Penny Dodds institutional milieu. When an all-embracing contact-milieu is
p.dodds@brighton.ac.uk established, all aspects of care are made easier, more effective and
(applications in dementia more rewarding.
care and research into use
of pre-therapy in dementia It is effective with the most challenging patients in situations where
care) high levels of agitation, confusion and distress are debilitating for
• Stephen Joseph staff and contribute to a high-stress environment.
s.joseph@warwick.ac.uk
(general information and
summary of academic
research using single case
studies)

• Useful website with basic


information:
Pre-Therapy and contact work in general use in
http://www.psychological-
wellbeing.co.uk
healthcare settings

What we call Pre-Therapy, or ‘contact work’ is part of good effective


communication per se. Pre-therapy work calls people to think how
we actually engage with people and is new and unique in the sense
that it gives this neglected issue the attention it deserves. It requires
consideration of how to approach people who are in an altered state
or ‘pre-expressive’ state, which is why it has such potential for use
in communication with people with a range of mental health and
general health issues.

By drawing on Pre-Therapy we can integrate the more formal aspects


such as ‘contact reflections’ into the general communication skills
INTRODUCTION
INTRODUCTION TO PRE-THERAPY
TO CONTACT
CONTACT WORK PRETHE
WORK AND -THERAPY AND
WORK OF GTHE
ARRY OF GARRY PROUTY
PROUTY
WORK

used to engage with a wide range of patients and service users. It Chapters from recent books
is teaches staff to be explicit about something that was, and is still describing the use of
perhaps, taken for granted. The new and different angle is that Garry Pre-Therapy in psychiatric
Prouty gives the theoretical and philosophical foundations of how to settings, available attached
engage with people who are not in psychological contact, or who are to email as PDF documents.
difficult for staff to engage with. He provides specific instructions on
how to talk. This is why his ideas have such instant resonance with • Facing psychotic functioning:
nurses who get rather stuck on what to say to patients whether they Person-centred contact work
are withdrawn due to a severe depressive state, withdrawn or difficult in residential psychiatric care.
to understand in dementia, expressing ideas that are unusual to staff Dion Van Werde
in psychosis, or are less coherent due to a delirium or stroke. • A contact milieu. Dion Van
Werde
If it is generally accepted ‘evidence’ that a wide range of professionals • The Pre-Therapy Project
and carers in psychiatric services offer an empathic presence and at Sint-Amandus. Marlis
develop a rapport with patients as part of their communication skills, Pörtner
then ‘contact reflections’ are simply part of this and Pre-Therapy
helps further develop their ability to offer an empathic presence. In Web link to book ‘Pre-Therapy:
Pre-Therapy training this is done by being explicit and very detailed Reaching Contact Impaired
about the communication process with ‘out-of-contact’ patients Clients:
using the contact reflections. This puts contact work in the same http://www.pccs-books.co.uk/
realm as listening, understanding and developing a therapeutically product.php?xProd=20&xSec=31
oriented relationship. Contact reflections can be seen as a way of
using helpful communication skills, rather than a ‘new therapy’.

It is unlikely that anyone in the healthcare professions would say:


‘Where is the evidence base for listening to people?’, ‘We can’t
implement being empathic until the evidence base is there,’ or
‘We won’t do understanding till there is more evidence’. Contact
reflections are the concrete minutiae of how we try to offer empathy,
understanding and listening.

Contact work is valuable and generally therapeutic in its own right


for the following reasons:

1. It dissolves personal and social isolation and all of the secondary


symptoms associated with such isolation. For specific advice and information
2. It allows communication of everyday needs, thus facilitating about the use of pre-therapy in
more efficient and targeted everyday care. residential psychiatric ward settings
3. It allows emotional expression to develop — an important contact
pre-cursor to therapeutic change in any approach that builds a • Dion Van Werde
working alliance. dion.vanwerde@sint-
camillus.be
afdelingspsycholoog
“VENNEN 3”,
behandelafdeling
psychosezorg, Psychiatrisch
Ziekenhuis St-Camillus,
Beukenlaan 2O, 9O51 St-
Denijs Westrem, België
INTRODUCTION TO CONTACT WORK: PPRE -THERAPY
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Contact reflections as opposed to other forms of


communication

Penny Dodds Research by Penny Dodds at Brighton University shows staff


p.dodds@brighton.ac.uk frequently feel that doing contact work feels different from ‘normal’
patterns of communication. If contact reflections are part of
offering ‘treatment as usual’ empathy, listening and understanding
to a patient/service user and they feel odd or different, then what
does this say of the communication that people are currently
receiving since there is literature which shows that patients/
service users receive unconstructive or ineffective patterns of
communication?

So to some extent contact reflections may offer an alternative to


some of the less than helpful patterns of communication that
exist. Staff have very little opportunity to explore the tiny details
of interactions with their clients and contact reflections draw their
attention to a really detailed examination of what they are really
saying to service users. Contact reflections may in fact offer an
antidote to other forms of communication that may be having a
less helpful effect. An example from Penny Dodds’ research is a staff
member using contact reflections fairly intensively with a person
with dementia who was not eating and drinking and was expressing
distress, with the theme of ‘the babies’ coming up repeatedly.
‘Traditional’ nursing approaches of ‘encouraging’ e.g. ‘Here X
have a drink, you need to drink’ (kindly delivered), were less
successful than the use of contact reflections alongside the gradual
offering her of a drink. The worker did this by acknowledging
the expressed world of the patient, reflecting on her face, body,
words, and including the drink in the situational reflections — the
patient was given the time and space to express and convey her
sadness and anxiety over ‘the babies’ and at the same time drank.
She drank more from the use of contact reflections and the staff
member’s experience was that she felt she had helped the patient
both physically with the drink, and emotionally with the expression
of sadness over the babies. This is simply good care and good
communication — addressing the patient as a person in a more
holistic way.
INTRODUCTION TO CONTACT WORK: PPRE -THERAPY
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Penny Dodds’ research at the University of Brighton: Penny Dodds


‘Can staff working with dementia learn and use Pre- p.dodds@brighton.ac.uk
Therapy contact reflections in their work with people
with dementia?’

Subsidiary research questions:

• What happens when staff learn contact reflections?


• What happens when staff use contact reflections?
• What is the response from people with dementia to contact
reflections?
• What adaptations or modification (if any) to the use of
contact reflections are relevant for dementia?

Preliminary data analysis and themes that have emerged so far can
be summarised below:

• Staff can learn and recognise contact reflections.


• Using contact reflection in practice proves more difficult than
it would first appear for staff as they are engaged in a range of
activities simultaneously in their work, e.g. communicating,
doing practical tasks, being affected by the environment
(phones ringing, calls from other clients).
• Contact reflections allow for the possibility of emotional
expression from people with dementia which may be
uncomfortable to staff, e.g. a person expresses sadness and the
staff member finds dealing with the emotions of the person
difficult in the working environment — staff express a fear of
‘opening a can of worms’ and not knowing how to deal with
this. Although the ‘can of worms’ may only be a person being
sad that they are missing someone, or afraid, or in pain.
• Contact reflections are one of many communication
techniques. Staff have to make decisions about the approach
to use, i.e. respond using a contact reflection, respond by
encouraging reminiscence, respond by using principles of
validation therapy, respond by using a question/statement/
command.
• Staff find it awkward to reflect non-verbally a person’s facial
and bodily expression.
• Staff feel awkward reflecting word-for-word utterances that do
not make sense to the worker but may have meaning for the
person with dementia (thus indicating awkwardness entering
into the world of the person with dementia).
• Staff have existing patterns of communication which may not
include a natural tendency to be reflective of the person with
dementia.
INTRODUCTION TO CONTACT WORK: PPRE
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• Staff have natural tendencies towards being compassionate


which include intuitive tendency to reflect. For example,
compassionate and empathic staff seem naturally to mirror
and reflect which helps them engage and create alliances with
people with dementia.
• Engaging in the emotional world is approved of in theory by
staff but in reality may not occur at all times due to the nature
of nursing people with dementia.
• Staff have defence mechanisms to protect themselves against
being overwhelmed by the emotional distress of people with
dementia.
• Engaging in the emotional distress of people with dementia is
difficult to do and requires support for staff.

Current Pre-Therapy training in the UK

Psychiatric nurse training

Dave Deady Dave Deady, Paisley University, writes:


david.deady@paisley.ac.uk • We present the theory and practice of pre-therapy in Years 2 and 3
to student nurses undertaking both the higher diploma and degree
courses. Because there are no formal mentors familiar with Pre-
Therapy if the work is undertaken within an acute clinical setting
I would normally try to support the learner in both the clinical
setting and care plan structure or assignment structure.

In Year 2 the focus of activity addresses client experiencing


‘functional psychosis’. In Year 3 the students are presented with the
practice of Pre-Therapy in relation to dementia and the subtleties of
associated care.

• Certain acute and long term psychiatric staff who have attended
the various therapeutic modules within the University have been
introduced to the practice of Pre-Therapy.

• Twelve students have just completed our first named


pathway leading to a minor title — BSc in Health Studies
[Psychotherapeutic Interventions] — in which all students
successfully completed 4 modules that integrate both cognitive
therapy and person-centred practice. All are now very familiar with
Pre-Therapy and incorporate it in their practice — some more so
that others — we are about to formally request that this group have
further training so that they can be incorporated into a supervisors’
training programme. This group will form the core supervisors for
future training.
INTRODUCTION TO CONTACT WORK: PPRE -THERAPY
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In 2006 we will be presenting a three-day workshop in which


theory and skill development will be addressed. This is the repeat
of a very successful programme that we presented in 2004. That
included social workers, mental health nurses in the acute and
long-term setting, counsellors, psychotherapists and a psychiatrist.
The programme will enable participants to explore their practice
within their own clinical setting and a follow-up day will permit
exploration of subsequent derived and reflected practice.

• Pre-therapy is also being presented to students attending modular


degree courses both at Paisley and in Lanarkshire — colleagues
at Bell College in Hamilton include Pre-Therapy as part of their
module training of students who care for patients experiencing
dementia.

• The Gerontology Study Group (based at the University of Paisley)


composed of various academics and post-graduate researchers
provided funding enabling a two-level study for all interested
parties in the practice of Pre-Therapy for patients experiencing
cerebrovascular accidents and linked dementia.

• The adolescent unit at Gartnavel Royal Hospital have now


incorporated Pre-Therapy into the nursing care plans. I have not
been able to revisit the unit, but I am assured the work continues.

• Hospitals who have nursing staff that I believe now use pre-
therapy include Lochgilphead Hospital — Argyll and Bute
Hospitals, Dykebar Hospital in Paisley, Vale of Leven Hospital in
Alexandria, various community nurses located in Renfrew, Paisley,
Dumbarton, Oban and Ayrshire.

Other applications of Pre-Therapy in the UK— a


growing list Further reading
Dementia care Morton, I. (1999). Person-Cen-
tred Approaches to Dementia Care.
Erskine Hospital in the high dependency dementia care ward now Bicester, Oxon, Winslow Press,
have staff who use Pre-Therapy on a regular basis, valuing both its 139-166.
benefits to patients and the sense of contact established between
carer, patient and relative. This has been formally recognised by Dodds P., Morton I., Prouty G.
the staff in a shared presentation that highlighted strategies for (2004). Using Pre-Therapy Tech-
new ways of working with the severely demented. Further to this, niques in Dementia Care. Journal
private nursing homes in the Paisley area have been increasingly of Dementia Care Vol.12, No.2, p.
expressing interest in the practice of Pre-Therapy and have freed 25–28
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staff to attend short focused workshops. These well-supported


events have led to the staff realising how relatives could be included
easily within its practice.

Psychiatric settings

See attached PDFs for further The adolescent unit at Gartnavel Royal Hospital have now
reading incorporated Pre-Therapy into the nursing care plans. I have not
been able to revisit the unit, but I am assured the work continues.
• Facing psychotic functioning:
Person-centred contact work Hospitals who have nursing staff that now use Pre-Therapy include
in residential psychiatric care. Lochgilphead Hospital, Argyll and Bute Hospitals, Dykebar
Dion Van Werde Hospital in Paisley, Vale of Leven Hospital in Alexandria, various
• A contact milieu. Dion Van community nurses located in Renfrew, Paisley, Dumbarton, Oban
Werde and Ayrshire.
• The Pre-Therapy Project
at Sint-Amandus. Marlis
Pörtner

Web link to book ‘Pre-Therapy:


Reaching Contact Impaired
Clients:
http://www.pccs-books.co.uk/
product.php?xProd=20&xSec=31