D. Mark Perkins, M.Ed., LPC
When I was being trained in client-centered psychotherapy, my supervisor, Dr. C.H. Patterson, required that, for the duration of my training with him, I suspend any reservations I might have about practicing purely in the client-centered, non-directive mode, and that I refrain from practicing in any other mode. This served very well the purpose of training an intern, thoroughly and in a disciplined fashion, in a practice that tends to be defined by its lack of rigidity or adherence to protocols. I continued to observe his prescriptions for some time after I began to practice therapy on my own, determined that I would be a genuine and disciplined client-centered therapist, and not one who does a little of this and a little of that, depending on what felt comfortable.
In time, real life has weathered away some of the bark that seemed to grow on my professional skin during my graduate training. Even in the five years since my earlier article in this publication (Perkins,1993), my own style of practice, while remaining firmly grounded in the person-centered approach, is perhaps a little different, at least in its application, than it was then. I suggest that this is as it should be; clinical practice ought to develop and, hopefully, improve over time, particularly in a specialty area that is as dynamic as dual diagnosis. I have also found, as have many who work with people who have dual diagnosis, that we more often than not have to operate a little outside the box in order to be effective. This is due not only to the nature of the population itself, but also to the fact that more traditional service providers may not be as willing or able to serve this population. This leaves those of us who do serve the population occasionally having to stretch into other roles.
The following is an attempt to try to convey some of the adjustments that I find myself making in applying the core conditions of client-centered therapy to real life situations with dually-diagnosed people.
The Core Conditions
There are four conditions that must be present for a relationship to be therapeutic. The argument of the client-centered school is that, not only are these conditions necessary, but in fact, they are sufficient to bring about therapeutic change. Training in client centered therapy consists largely of learning to maximize these conditions in the context of a relationship with the client, and to studiously avoid doing anything else. (For example, we were cautioned against asking questions, since that action assumes taking the initiative away from the client, where it belongs. Dr. Pattersons oft-repeated admonishment was, Anything that you can gain by asking a question, you can gain in a more meaningful way by other means, namely, by sticking to the core conditions, and by listening rather than talking!)
Very briefly, the core conditions are described as follows. (For a more detailed discussion, see the NADD Newsletter, Sept. 1993 issue; also, Patterson, C.H., The Therapeutic Relationship, Monterey, CA: Brooks/Cole, 1985.)
This is perhaps best described as the degree to which the therapist can set aside his or her own values, experiences, observations, and opinions, and walk in the clients shoes. That is, to see the world as the client sees it, without the filters that we might otherwise apply, with names such as objectivity, reason, basis in reality, etc.
Perhaps a rarity in the experience of a person with mental retardation, this is the condition of one person (the therapist) holding the other in a position of esteem without regard for mitigating factors such as disability, flawed thinking, etc., and treating that person as one would wish to be treated, simply because he or she is a human being.
The therapist in client-centered therapy is not the blank screen , nor the parroting reflector of the clients words, as is sometimes caricatured. In the context of a relationship, each person, client and therapist, must be free to fully and authentically be himself or herself, and to exercise that freedom with the other person. The caveat here is that the therapist does not simply blurt out whatever first comes to mind in the name of honesty, but expresses his or her own experience of the client in a way that is therapeutic to the client. Thus, the therapist may need to reserve a critical comment or observation until the client is ready to hear it and incorporate it.
Also, self-disclosure takes place readily but only in the context of being applicable to the clients own experience of the moment, and not purely in order for the therapist to be open and revealing for his or her own gratification.
Rather than allow the relationship just to remain comfortable and intimate, the therapist must push for some clarity and definition in the matters that come to the fore in the relationship. This is where the meat is in terms of dealing with the issues of therapy, and it requires a real balancing act for the therapist to achieve the level of specificity needed in order to be therapeutic without unduly taking the initiative away from the client. However, particularly when working with people who have a degree of mental retardation, this can be one of the most valuable aspects of engaging in therapy, in that the client is able to more clearly conceive of, and thus to grapple with, the issues that are of concern.
Beyond the Core Conditions: Other Considerations for the Dually Diagnosed
Although it is certainly best to avoid making generalizations about any group of people, it is perhaps fair to say that people who have mental retardation tend to be accustomed to being instructed, guided, corrected, etc. This comes from a lifetime of being subjected to compliance expectations, and being told what is or is not appropriate. To expect such a person to come into a typical therapy setting, and to be able suddenly to take charge of the transaction and to describe what is of concern to them is, at best, unrealistic and at worst, threatening and counter-therapeutic. Most of the time, these folks are not seeking therapy on their own volition anyway, but are there because someone else, a care provider, family member, or case manager thought they had a problem. Therapists: be not afraid to take initiative here! I always introduce myself, using my first name, and say that I am a counselor, and ask them to tell me their idea of what a counselor is and does. This can lead to a dialogue, which will hopefully shed light on how the person came to be in the session in the first place, who was involved in making that happen and why, etc., and end up focusing on the persons own perceptions of the situation and wishes as to how it will be handled. This is not altogether different from a traditional person-centered approach, except that I might have to make more suggestions, trying to avoid yes-no dichotomies, rather than wait for the person to volunteer information and steer the interaction.
Similar to the above, it is more often necessary, when working with people who have mental retardation, to steer the interaction between therapist and client into productive therapeutic territory. Again, a lifetime of social-skills and similar sorts of training might have enabled a person to carry on a give-and-take interaction, and to make all the right sorts of comments (I like that tie youre wearing!) and to ask the right questions (And how are your children doing?) Particularly, once the initial stages of the relationship have established a base of information about each other, the discussion can easily tend toward these easy, social pleasantries, which is fine, unless these tend to exclude opportunities to get into the difficult, emotionally loaded material that is the stuff of therapy. Gently directing or redirecting the focus to these more difficult matters need not be over-controlling or experienced by the client as being instructed or corrected by the therapist.
Appropriate and Inappropriate Silences
I was painstakingly trained to observe therapeutic silences in the session, even so far as to count 1-2-3 before interrupting a silence myself. This remains a valuable technique: the number of times that critical information from the client has been gained in this way is immeasurable. However, it is equally important to realize that a person with mental retardation and a lifetime of practicing conversations and interactions in a particular cadence may be confused and threatened when the therapist does not carry on in the typical conversational style. One must be very sensitive to the feeling of the client and not allow a silence to grow uncomfortable in hopes that a therapeutic breakthrough is about to take place: it probably is not.
Silence can be a gesture of respect. When a person has just disclosed something very painful, a respectful silence, offered along with clear nonverbal signals that the therapist is genuinely with the person, can be therapeutic and beneficial, and imbued with much more meaning than any comment could be.
It should go without saying that silence is much preferable to comments from the therapist that offer solace, reassurance, etc. when the client has just opened up about something painful. I think this tendency dwells within all of us, is based on humanitarian principles, and is a large part of the tendencies that got us into the helping professions in the first place. However, these kinds of comments can come across as paternalistic, or even as minimizing to the affect being expressed by the client. An underlying sentiment such as dont feel may unintentionally be conveyed. We should also be careful about offering reassurance in areas over which we have little or no influence, such as in the clients living situation or in his or her private, internal world.
Silence can also be used to challenge the client. To follow a remark from the client that was provocative or even preposterous in its content with a heavy silence can be a very poignant occurrence in the relationship. The client is then challenged to elaborate or defend the remark.
As with any tool, this kind of silence should be used by the therapist with caution and with care. It is easily experienced by the client as a gesture of non-belief or of ignoring by the therapist. It is good to bear in mind that our clients have much more experience in behavior-management technology than we do: their entire lives have revolved around the experiencing of behavior management. You can bet that they recognize planned ignoring, even when that may not be what we are trying to do!
Performing other therapeutic functions, informed by a client centered perspective
Rarely does one have the luxury, if that is the right word, of functioning purely as a conventional therapist for a person with dual diagnoses. We tend to be drawn in to serve a variety of roles: behavior consultant, case manager, advocate, and a host of other functions. Some of this may be due to the variety of needs that these clients present with, and some because, by virtue of being both mentally ill and mentally retarded, the client does not fit neatly into either camp and thus, the service delivery system has to be custom-tailored. One can argue injustice and the like, or one can set about doing what needs to be done. (Or most likely, a little of both.)
However, it is not necessary to set aside ones belief in, and adherence to, the core conditions, even when circumstances demand that other, perhaps more directive functions need to be performed. For example, writing a behavior management plan that involves contingencies and perhaps even restrictive procedures (restraint from self-injury, for example) may seem antithetical to a conventional non-directive therapist. But it can be done, and in fact, can be done better from a person-centered perspective. Technically, elegant behavior management plans need not be cold and impersonal. After all, there is a person at the center of such a plan, and if we write with that awareness and from that perspective, there is all the more chance that the plan will have successful results. It may not be possible, however, for a clinician who is seen by the client as having a directive role, such as designing or implementing a behavior plan, to also be able to sustain a true, person-centered therapy relationship, since that must be hinged on the non-directiveness of the therapist. But as we know, life gets messy, and we do what we must.
Being client-centered with the people in the clients life
Some of the people I see in my practice have families, and some do not. (The nature and extent of a familys involvement in the clients life is also highly variable and , whether present or absent, the family element is a powerful component in the persons constitution.) Some have jobs, and some do not. Some have significant romantic or other interpersonal relationships, and some do not. The list goes on, and indicates what we know to be true: each person is an individual, and each is unique. My relationship as a client-centered therapist is unique with each of them.
But, there is one thing each of them has: staff. Some have many, some have few. Some have the same staff for long periods, some seem to have new staff every week. Some dont have staff with them at all times. But, they all have staff, and the staff comprise a significant part of their lives.
I have learned that it is crucial for me, if I am going to effectively operate in a therapeutic way in my clients life, to develop a good relationship with the staff; if possible, with each one of them. It is all too easy to look past the staff person who accompanies my client each week, particularly if they are new or the latest in a series of staff that turns over constantly. I admit that I have made that mistake. What has become clear to me is that, even though it was unintentional on my part, the message that I was communicating to that staff person whose name I didnt bother to learn, or with whom my interactions were only brief and perfunctory, was one of de-valuing and taking the person for granted. What sort of attitude might I then expect the staff to have toward the client? After all, the staff are with the person much more than I am, and are much more integrated into the day-to-day affairs that make up my clients life. I see the client for maybe an hour a week, if that. The best person-centered attitude in the world, applied faithfully for one hour, can have its beneficial effects undone quickly and substantially if a staff person, who is with the client for the rest of the day, behaves toward that client in a demeaning or de-valuing way, as I had found myself behaving toward some of them.
I now know the importance of learning each staff persons name, and using it. This simple act conveys a message that is more powerful than any other I could try to get across. I try to learn a little bit about them, too. Some are in school and working to make a little spending money, some are trying to raise families on the meager income that is typical of direct care jobs. Indeed, having gotten around a bit in our local area, I find that I see the same staff working at different places, sometimes even on the same day! Just like my clients, each ones story is different, and each is worth my hearing. What may appear to be idle chat between me and the staff is actually part of a bigger whole, wherein he or she is becoming more of a real person to me, and hopefully, I to them. We share a bond, whether we see ourselves as being similar or not, and that bond is our relationship with our client. I have found that my effectiveness as a therapist or consultant is much enhanced when I take the time to cultivate relationships with the staff. Much more information that is pertinent to my work with the client is provided by the staff, and it is of much better quality and thus more useful to me. Not only that, but I find my experience to be a much more relaxed and pleasant one each time I visit.
Regardless of the role the clinician takes or must take, the person-centered perspective can inform, if not dictate, the actions of the clinician, whether those actions are taken in the role of therapist, consultant, advocate, physician, nurse, or direct care provider.
Patterson, C.H. (1985). The therapeutic relationship: foundations for an eclectic psychotherapy. Monterey, CA: Brooks/Cole.
Perkins, D. M. The use of counseling and psychotherapy with dually diagnosed persons. NADD Newsletter, Sept. 1993.
D. Mark Perkins is a County Director for the South Carolina Department of Mental Health, and is also a consultant to providers for the dually diagnosed in North Carolina, where he is known as ...the behavior guy. You can reach him by phone at (704) 408-0243.
For further information contact:
D. Mark Perkins
1618 Fountain View
Charlotte, NC 28203