The person-centered approach and schizophrenia

From the start, diagnosis was a matter of little account in client-centered therapy. Rogers (1951) spoke about the ‘detrimental effects’ of diagnosis that ‘places the clinician in a godlike role’ (p. 221) and that ‘lead to a basic loss of confidence by the person himself ’ (p. 224). To be sure, Rogers spoke about psychological diagnosis — in contrast ‘physical diagnosis is the sine qua non of treatment’ (p. 219, original emphasis). The only rationale he offered for psychological diagnosis is that some therapists feel more secure in the relationship with the client (Rogers, 1957, p. 102).

By and large this opinion about diagnosis holds until today in person-centered therapy. Mearns (2003, p. 53) states that ‘knowledge and theory about specific client groups is not a prerequisite for person-centered work with clients from those groups’ although, ‘it can considerably aid the counsellor’s understanding of the client experience’. This last nuance is often to be found with contemporary person-centered authors. Lambers (2003, p. 116) emphasizes that ‘working with deeply disturbed clients requires skill, depth, a certain amount of knowledge and understanding as well as acceptance of limitations’. Berghofer (1996) remarks that ‘a diagnosis emerges as by itself, especially when the therapist deals with schizophrenic patients’ (p. 484) and further on that ‘a diagnosis leads towards the person and not away from him’ (p. 491). Sommerbeck (2003, p. 3) states that ‘psychiatric diagnoses are not an issue for the client-centred therapist’; in psychiatric contexts, however, there are ‘some rather characteristic features and difficulties for the therapist, which are related to the psychiatric diagnosis [sic] of the client’. This is a remarkable kind of duality, which Sommerbeck (2003, 2005) calls complementarity — that enables her to work as a client-centered therapist within psychiatry.

Another ardent opponent of diagnosis in client-centered therapy is Sanders (2005), who says with Shlien that diagnosis is ‘not good, not even neutral, but bad’ (p. 34). Clientcentered therapists working with diagnosis are compared with lambs waiting in the lion’s den (the medical model) to be served as breakfast. There is some accommodation with authors like Margaret Warner who, Sanders says, ‘presents an alternative psychopathology … based on client-centred and experiential theory’ (p. 36). But even then Sanders criticizes that ‘Warner’s position is founded on the pragmatism of compromise and revision’ (p. 36). Warner (2005) describes three kinds of difficult process: fragile process, dissociated process and psychotic process, which indeed can be read as a client-centered/experiential translation of conventional psychopathology.

Rogers had some tough experiences with counseling and schizophrenia. From 1949 to 1951 Rogers had a young woman with schizophrenia in therapy. After a good start, this woman came to see Rogers a lot. Things got out of hand. The therapy wasn’t working anymore, but he obviously didn’t know how to finish it. She was often psychotic and Rogers was brought to the edge of being psychotic himself. At last he handed her over to a young psychiatrist and immediately took a leave for two or three months (Kirschenbaum, 1980, pp. 191–192). When he came back, Rogers went into therapy, which came to be a turning point in his life (Rogers & Russell, 2002, pp. 164–165).

At the University of Wisconsin (1957–1963) he was leading the Mendota State Hospital Study. It was an ambitious project, aimed at studying the effect of client-centered therapy with people with schizophrenia. The result was disappointing: there was no significant difference between the treatment group and the control group (Rogers, 1967b, p. 80). One of the problems in therapy with people with schizophrenia appears to be that, ‘regardless of the degree of understanding, acceptance, and genuineness offered by the therapist, schizophrenic patients tended to perceive a relatively low level of these conditions as existing in the relationship, and only slowly over therapy did they perceive somewhat more of these therapist attitudes’ (p. 75). The most striking features in the therapy process with people with schizophrenia were ‘the lack of self-exploration’ (p. 76) and the reservations about becoming involved in their own experiencing (p. 79).

Looking back, Rogers (Rogers & Russell, 2002, p. 175) stated that the project was very ambitious, maybe too ambitious, ‘we were going to do research to end all research’. The interpersonal qualities of the staff could have been better. Another important impediment in this project stated by Rogers was that ‘most of the group had not worked with a schizophrenic individual, so we would have done better, had we spent a year or two working with schizophrenics without any attempt to do research’ (Rogers & Russell, 2002, p. 175).

In the past, client-centered therapy followed the so-called disordered-person model (Davidson & Strauss, 1995) in its approach to schizophrenia. In the disordered-person model one ‘focuses on how the lives of persons with disorders are different from the lives of healthy individuals, viewing this difference usually in psychological terms’ (1995, p. 45). In the earlier mentioned disorder model the illness is an entity in itself. A (medical) diagnosis is crucial in the treatment of the person. This is a remarkable thing in the client-centered approach to schizophrenia: by trying not to use a (medical) diagnosis for people labelled with a severe mental disorder, the person themselves is described as disturbed. In the end the person receives a dubious psychological diagnosis because one is reluctant to give a medical diagnosis.

Rogers describes a psychosis in psychodynamic terms, ‘acute psychotic behaviors appear often to be describable as behaviors which are consistent with the denied aspects of experience rather than consistent with the self ’ (Rogers, 1959, p. 230). Teusch (1990, p. 637) starts his paper on client-centered therapy with schizophrenic patients as follows: ‘a fundamental aspect of schizophrenic disorders is a deep disturbance in the relationship with other human beings. Schizophrenic patients withdraw in an autistic way to a poor or to a bizarre and strange inner world’. Gendlin (1966, p. 12, original emphasis) states, ‘it is not so much what is there, as what is not there’. The interactive, experiential process is lacking, stuck, deadened in old hurt stoppages, and in disconnection from the world. Rogers continues, (1967d, p. 185) ‘our schizophrenic individuals tend to fend off a relationship’. Finally Binder (1998, p. 220) states that ‘a core problem for psychotic persons is the fact that they have not developed adequate discrimination in the understanding dimension’.

With respect to these statements about people suffering from schizophrenia, I can only conclude that in person-centered therapists there is clearly a considerable lack of (unprejudiced) Verstehen (understanding) of the person with schizophrenia and that this lack is filled up with all sorts of Erklärungen (explanations). The characteristics ascribed to people with schizophrenia are highly hypothetical and do not justify the earlier-pictured image of people with schizophrenia who are trying their best to hold their own ground in our society given their illness. Erklärungen are unlimited but Verstehen is bounded (Jaspers, 1973, p. 253). There is so much uncertainty concerning schizophrenia that we really need to be reserved in our explanations of it. This reserve is a fundamental attitude of phenomenological philosophy.

A special case is the work of Prouty (1976, 1994; Prouty, Pörtner & Van Werde, 1998). A lot of contemporary client-centered therapists find Prouty’s Pre-Therapy very helpful in their work with psychotic persons (Sommerbeck, 2003; Warner, 2002, 2005; Van Werde, 1998, 2005; Prouty, Pörtner & Van Werde, 1998). Prouty grew up in very difficult circumstances, with a mentally retarded brother and a mother who had psychotic experiences. He struggled to gain his education, during the course of which he was taught by Eugene Gendlin, who touched his creative therapeutic soul in a personal way enabling him to develop his own therapeutic approach at clinics and hospitals dealing with psychotic and retarded clients. In 1966 Pre-Therapy was born in a sheltered workshop, where Prouty did counseling with mentally retarded and schizophrenic persons (Prouty, Pörtner & Van Werde, 1998, pp. 3–8). Prouty states that Rogers’ first condition of psychological contact is insufficiently met in therapeutic relationships with clients with schizophrenia. ‘Unfortunately, Rogers provides no theoretical definition of psychological contact’ or ‘any technique for restoring psychological contact if it is impaired’ (Prouty, 1994, p. 26). Prouty (1994) claims that mentally retarded and schizophrenic persons live in a state of existential autism, their existence has become a ‘void of significance’ (p. 34). In Pre-Therapy there is, with the help of contact reflections, ‘empathic responses that are very concrete and close to the clients’ actual words and facial and body gestures’ (Warner, 2005, p. 97), a ‘movement of consciousness from existential autism to existential contact’ (Prouty, 1994, p. 34).

Although it is a very good thing that client-centered therapists, through the work of Prouty, are invited to work with clients with schizophrenia, I have to make some critical remarks. First of all, I find it remarkable that Prouty in his publications nearly always puts the retarded and schizophrenic patients together. People with schizophrenia have to deal with a lot of stigma, one of them that they are mentally underdeveloped; I think it is important to acknowledge the distinctive nature of their illness. Secondly, I do not experience this ‘void of significance’ in persons with schizophrenia (neither in mentally handicapped persons); on the contrary psychotic persons have often to deal with an overload of meanings which makes their experiential process so complicated. Again, persons with schizophrenia are saddled with a very dubious psychological diagnosis. To be sure Prouty has done invaluable work with a complicated group of persons who suffered mental retardation and a psychotic disorder or who were severely regressed, but that is a very small sample of the people with schizophrenia and not at all representative for this group as a whole. Unlike Prouty (2002, p. 596) I do not think that the ‘modestly supportive [findings] of Rogers’ view’ are ‘limited to the higher end of the psychotic continuum’ and that for ‘the more chronic regressed populations’ Pre-Therapy is more fitted. When we read the sessions of Sommerbeck (2005), Van Werde (2005) and Warner (2002) with persons with schizophrenia, we find them engaged in a rather normal person-centered conversation under the circumstances that the clients are dealing with a ‘psychotic style of processing’ (Warner, 2005). I agree with Warner (2002) that it is possible to ‘operate within Rogers’ core conditions’ in conversations with psychotic persons and that these conversations ‘are genuine therapy rather than a precursor to some more ‘real’ kind of client-centered therapy’ (p. 464).

When we are willing to acknowledge schizophrenia as an illness that justifies a medical diagnosis, then there is no need for all kinds of dubious psychological diagnosis and explanations. Persons with schizophrenia are afflicted by a severe illness. This illness has a profound influence on the way they relate to themselves and the world. We need to recognize this influence of the illness on the person. Then we can see right through the paranoid thoughts, the delusions, the disorganized speech and incoherent thinking, that there is always a longing for contact and an acknowledgement of the other person. Because of their illness this contact is at risk. But even in the worst psychotic episodes there is the possibility of contact and acknowledgement and even care for the other.