The effectiveness of the personcentred approach with people

suffering from psychotic illnesses

Panagiotis
Giannakis
March 2013

Historical review of psychosis and the talking cures

While psychosis has been a subject of study in the psychoanalytic literature that
dates back to Freuds re-reading of Schreber case and Jungs own experience of a
psychotic break up (although I have reasons to believe that it wasnt), up to the midfifties, the main approach up to that time, was a diagnosis based on a symptomillness base. The first major departure from this approach came in 1956 with the
delivery of Lacans seminar on psychosis (Lacan, 1997). Lacan saw psychosis not
only as a state that someone is in but more importantly as a relationship between the
person and language. This shifted the attention away from the symptoms a person
experience, to a way someone relates to language, implying that someone might
have a psychotic relationship with language without experiencing any psychotic
symptoms. Although there are differences in the way the psychoanalytic and personcentred approach define the interventions needed when dealing with people suffering
from psychosis, I believe that the similarities in this field outweigh the differences.
Before moving on to some of the characteristics of psychosis, I would like to talk
about the clients frame of reference in psychosis. Sommerbeck (Sommerbeck,
2003) discussed the difficulty in accessing the inner frame of reference when
working with people who experience psychosis. What is the inner frame of
reference? According to

Rogers (Rogers, 1951) the frame of reference is the way we understand the world
and this understanding is based on our experiences. We are constantly re-interpreting
the world through our own personal values system and those experiences. My view
is that this pool of experiences and meanings are based on language. Without
language we wouldnt be able to make sense of the world, we wouldnt be able to
signify. Alain Miller (Miller, n.d.) following Lacan (Lacan, 1997) stated that in
psychosis, there is a language impairment, which means that words do not create
meaning, they words are loosely connected to each other and in the case of
schizophrenia, there are only words disconnected from one another. Based on this, I
would argue that in psychosis, the inner frame of reference is fragmented and
unstable and in the severe end of schizophrenia there is probably no inner frame of
reference at all.
But I think that we need to draw our attention not only in schizophrenia but also in
the so called latent psychosis. The clients with a psychotic relationship with
language might have an internal frame of reference and they might appear coherent
to the therapist and some of them might appear to be very committed to the therapy
too. I think that this brings to the fore one of the limitations of phenomenology just
because psychosis is not experienced, it doesnt mean that it is not there. Working
with those clients and especially with material at the edge of their awareness can
have a destabilizing effect that can easy lead to a full psychotic break up. Therefore I
believe that I need to discuss some of the characteristics of the relationship those
clients have with language and how does that appear in the counselling room so that
the counsellor can be more alert when trying to approach these clients.

The characteristics of the psychotic relationship with language

First of all, lets talk about the difference between triggered and untriggered (or
latent) psychosis. While the triggered psychosis can easily be observed through the
signs of visual and auditory hallucinations, pressure of speech, disorganisation or
just the clients withdrawal from the outside world in the case of schizophrenia, the
latent psychosis is far more difficult to be identified. Since counsellors have speech
as the only medium of communication to work with, then some of the signs of latent
psychosis can be traced into the clients speech. Although there is a variety of signs
that might indicate that the client has a psychotic relationship with language
(transference, relationship with object, lack of the symbolic dimension, using words
as objects etc), I will limit my scope to what might be useful for a person-centred
counsellor to notice. Fink (Fink, 2007) provides a brief discussion of some of the
main characteristics of this type of speech. Some of the characteristics include the
lack of Freudian slips, no stuttering when talking about traumatic events and no sign
of statements like I know this will sound silly but or I know this is crazy
but. More importantly, in many cases, meaning appears to be too fixed or too
loose; if an event takes some sort of meaning through the therapeutic process, the
client will never return to it and examine it under the light of new memories, facts or
ideas that might surface later on in therapy. Once a meaning has been fixed, it cannot
be undone (and hopefully will not). This difficulty of the client to create metaphors
has a significant impact on the way they speak. They appear to be blind to
metaphors, idioms and metonyms, their speech can appear to be blunt and only on a
needs-base. When working with clients material that is at the edge of their
awareness, the counsellor will notice that stressing a line of events that could be
somehow connected

with the clients difficulties, is doomed to fail to be noticed as the client cannot see
anything beyond that happens within his field of awareness. Finally, while those
clients will experience many different feelings during the sessions, guild will not be
one of them. Guild requires repressed material and there is no repression in
psychosis, everything is out there, in public view (Fink, 2007).

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