Person-Centered & Experiential Psychotherapies

ISSN: 1477-9757 (Print) 1752-9182 (Online) Journal homepage: http://www.tandfonline.com/loi/rpcp20

“She’s talking to me!” Training home carers to use

Pre-Therapy contact reflections: an action research
study

Pam Courcha

To cite this article: Pam Courcha (2015) “She’s talking to me!” Training home carers to use
Pre-Therapy contact reflections: an action research study, Person-Centered & Experiential
Psychotherapies, 14:4, 285-299, DOI: 10.1080/14779757.2015.1058291

To link to this article: http://dx.doi.org/10.1080/14779757.2015.1058291

Published online: 21 Aug 2015.

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 Person-Centered & Experiential Psychotherapies, 2015
Vol. 14, No. 4, 285–299, http://dx.doi.org/10.1080/14779757.2015.1058291

“She’s talking to me!” Training home carers to use Pre-Therapy

contact reflections: an action research study
Pam Courcha*
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Counsellor, supervisor and trainer in private practice, Inverness, Scotland

(Received 2 December 2013; final version received 1 June 2015)

This paper describes an action research study which asked “what happens when home
carers are trained to use contact reflections.” Pre-Therapy contact reflections aim to
facilitate psychological contact with people who are contact-impaired. Home carers
offer care and support in people’s own homes and social care is increasingly offered in
this community setting. Training home carers to use contact reflections may have some
impact on the quality of care offered. Three home carers from a home care agency
participated in training and subsequent group meetings. For the study they all chose to
work with clients who had dementia. Home carers developed a different way of
communicating with their clients, including some use of contact reflections, but mostly
used more direct language and became more attuned to their clients. This way of
relating helped carers to achieve the care tasks more easily and without causing distress
to clients. This was a small sample of three home carers from one agency and the
findings cannot be generalized but the study did identify possibilities for further
research.
Keywords: Pre-Therapy; contact reflections; carers; home carers; training

“Sie redet mit mir!” - die Schulung ambulanter Pflegefachleute im

Gebrauch von Kontakt-Reflexionen aus der Prä-Therapie: eine
Feldstudie
Dieser Artikel schildert eine Feldstudie, die fragt: “Was passiert, wenn ambulante
Pflegefachpersonen darin geschult werden, Kontakt-Reflexionen zu verwenden?”.
Prä-Therapie-Kontaktreflexionen zielen darauf ab, den psychologischen Kontakt
mit Menschen, die eine Kontaktbehinderung haben, zu erleichtern. Ambulante
Pflegefachpersonen bieten Pflege und Unterstützung zuhause bei den Leuten an.
Soziale Pflege wird immer mehr in dieser Art von kommunalem Setting angeboten.
Ambulante Pflegefachpersonen darin zu schulen, Kontaktreflexionen zu benutzen,
kann die Qualität der Pflege beeinflussen. Drei Pflegefachpersonen einer Pflege-
Agentur nahmen am Training und den darauf folgenden Gruppentreffen teil. Für
diese Studie entschieden sich alle, mit Klientpersonen zu arbeiten, die an Demenz
litten. Die ambulanten Pflegefachpersonen entwickelten dabei eine andere Art, mit
ihren Klientpersonen zu kommunizieren, einschließlich der Verwendung einiger
Kontaktreflexionen. Meistens aber verwendeten sie eine direkte Sprache und konn-
ten sich mehr auf ihre Klientpersonen einstellen. Diese Art, in Beziehung zu treten,
half den Pflegefachleuten ihre Pflegeziele leichter zu erreichen und ohne dass sie
dabei ihre Klienten in Stress versetzten. Dies war eine kleine Stichprobe von drei
ambulanten Pflegefachkräften einer Agentur. Die Befunde können daher nicht
generalisiert werden. Aber die Studie lieferte Ansätze für weitere Forschung.

*Email: pam@courcha.co.uk

© 2015 World Association for Person-Centered & Experiential Psychotherapy & Counseling
 286 P. Courcha

“Ella me está hablando a mí!” Entrenando cuidadores caseros para

utilizar de reflejos de contacto de Pre Terapia: un estudio de investigación
de la acción
Se describe un estudio de investigación sobre la acción que preguntó “¿Qué pasa
cuando cuidadores hogareños están entrenados para utilizar reflejos de contacto?”.
Los reflejos de contacto de la Pre terapia apuntan a facilitar el contacto psicológico
con personas que padecen un deterioro en el contacto. Los cuidadores hogareños
ofrecen atención y apoyo en los hogares de las personas y cada vez más se ofrece
asistencia social en esta comunidad. Formación cuidadores caseros para utilizar
reflejos de contactos puede tener algún impacto en la calidad del cuidado ofrecido.
Tres cuidadores caseros de una agencia de cuidado en el hogar participaron en
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entrenamiento, formación y posteriores reuniones de grupo. Para el estudio todos

eligieron trabajar con consultantes que tenían demencia. Los cuidadores hogareños
desarrollaron una manera diferente de comunicarse con sus clientes, incluyendo uso
de reflejos de contacto, pero sobre todo utilizaron lenguaje mas directo y lograron
estar más en sintonía con sus clientes. Esta forma de relación ayudó a los
cuidadores a lograr las tareas de cuidados más fácilmente y sin causar sufrimiento
a los clientes. Esto fue una pequeña muestra de tres cuidadores caseros de una
agencia y no pueden generalizarse los resultados, pero el estudio identificó posibi-
lidades para futuras investigaciones

“Elle me parle !” Formation de soignants à domicile et utilisation de

réflexions de contact de la pré-thérapie : une recherche-action
Cet article présente une recherche-action qui pose la question suivante : « Que se
passe-t-il lorsque des intervenants à domicile sont formés à l’utilisation des
réflexions de contact ». Les réflexions de contact de la pré-thérapie visent à
faciliter le contact psychologique avec des personnes dont les capacités de contact
sont détériorées. Les intervenants à domicile prodiguent des soins et du soutien aux
personnes dans leur propre lieu de vie. Ce type de soins communautaires, ancré
dans le milieu social, est de plus en plus fréquemment rencontré. Former les
intervenants à domicile à utiliser des réflexions de contact peut influencer la
qualité des soins. Trois soignants travaillant pour un bureau de soins à domicile
ont participé à une formation ainsi qu’à des rencontres de groupe qui ont suivi.
Pour cette étude, ils ont tous choisi de travailler avec des clients en état de
démence. Les intervenants, adoptant le plus souvent un langage direct mais ayant
de temps à autre recours à des réflexions de contact, ont développé une manière
différente de communiquer avec leurs clients et se sont mieux adaptés à ceux dont
ils s’occupent. Cette façon d’entrer en relation a aidé les intervenants à accomplir
plus facilement les tâches de soins, sans créer de détresse chez leurs clients. Il est
ici question d’un petit échantillon de trois intervenants à domicile issus d’un seul
bureau. Les résultats ne peuvent pas être généralisés. Cette étude identifie les pistes
possibles pour de futures recherches.

“Ela está a falar comigo! O treino de cuidadores domiciliários para o uso

das respostas de compreensão empática de contacto da Pré-Terapia – um
estudo de investigação ativa
Este artigo descreve um estudo de investigação ativa em que se perguntava «o que acontece
quando os cuidadores domiciliários são formados para usarem as respostas de compreensão
empática de contacto»? As respostas de compreensão empática de contacto visam, na Pré-
Terapia, facilitar o contacto psicológico com pessoas com dificuldades no estabelecimento
de contacto psicológico. Os cuidadores domiciliários prestam cuidados e apoio na casa das
próprias pessoas e, neste contexto comunitário são oferecidos mais apoios sociais. Formar os
 Person-Centered & Experiential Psychotherapies 287

cuidadores domiciliários no uso de respostas de compreensão empática de contacto pode ter

algum impacto na qualidade dos cuidados prestados. Participaram na formação e nas sessões
de grupo que se seguiram três cuidadores domiciliários de uma empresa de apoio
domiciliário. Para a investigação, todos eles optaram por trabalhar com clientes com
demência. Os cuidadores domiciliários desenvolveram uma forma diferente de comunicar
com os seus clientes, incluindo o uso de algumas respostas de compreensão empática de
contacto, mas recorreram essencialmente a uma linguagem mais direta e ficaram mais em
sintonia com os seus clientes. Esta forma de relacionamento ajudou os cuidadores a
conseguirem levar a cabo com maior facilidade as tarefas de prestação de cuidados e sem
provocarem stresse nos clientes. Esta foi uma pequena amostra de três cuidadores
domiciliários de uma única agência e os resultados não podem ser generalizados.
Contudo, o estudo identificou possibilidades de pesquisa futura.
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Care at home
The balance of social and health care is now in the community rather than residential care.
Government policy is to continue to support more people at home. For example the Scottish
Government’s National Dementia Strategy: 2013–2016 (Scottish Government, 2013)
includes a commitment to enabling more people with dementia to live a good quality life at
home. In Scotland in March 2014 nearly 62,000 people received care in their own homes
(Social Care Services, Scotland, 2014) and 82% were aged over 65. Of these 2.6% had
diagnosed mental health problems, 8.3% dementia and 1.4% learning disabilities. They
receive support from home carers who work on their own in people’s homes.
Home care clients include people who are frail or with physical disabilities and not all
will be contact-impaired. However it is likely that some will be and others may experience
moving between expressive and pre-expressive states as in the grey zone described by Van
Werde (2002). With an ageing population it is possible that more people with severe
impairment such as advanced stages of dementia will be living at home.

Pre-Therapy and contact reflections

Rogers (1990) stated that psychological contact was a pre-condition for therapy
which suggests that a person experiencing psychosis or severe learning disability,
for example, would not be able to engage in a therapeutic encounter. Prouty (2008)
developed Pre-Therapy, described by Sommerbeck (2006) as a “way to be together
with these clients. Pre-Therapy can improve their capacity for being in contact with
others” (p. 1). Prouty developed an approach which involved three elements; contact
functions, contact reflections and contact behaviors. Contact functions include rea-
lity, affective and communicative contact. Sanders (2007), explaining Pre-Therapy,
says Prouty used the term “expressive functioning” to describe when someone is
fully in contact with themselves, others, their environment and able to communicate
this. Someone who is contact-impaired and unable to make contact is referred to as
“pre-expressive” but Sanders states that the “difference between pre-expressive and
expressive functioning is not always clear” (p. 27). Contact behaviors indicate the
extent to which the client is in psychological contact although Sanders stresses the
challenges. “The helper has to have their antennae up and sensitivity set to high to
pick up expressive signs and contact behaviours” (p. 29). Van Werde (2002) devel-
oped the concept of “grey zone” functioning to describe when people seem to move
between expressive and pre-expressive functioning.
 288 P. Courcha

Contact reflections aim to restore psychological contact. Krietemeyer and Prouty

(2003) gave examples of the different types of reflections. Situational, “John is
looking out the window,” reflects the client paying some attention to their situation
or environment. Facial, “You look sad,” aims to facilitate affective contact in the
client. A Body reflection can be verbal, “You are sitting stiffly,” or the therapist may
use their own body to mirror the client. Word for word is reflecting the actual words
used by the client and Reiterative reflection is repeating a reflection which has earlier
facilitated contact.
Prouty uses Buber’s phrase (as cited in Prouty, 2008, p. 15) to describe contact
reflections as “pointing at the concrete.” Krietemeyer and Prouty (2003) say they are
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“extraordinarily literal” (p. 153). Sanders (2007) suggests readers prepare themselves for
the “shock of seeing how simple the techniques of Pre-Therapy are” (p. 30) when reading
a description because in practice it may not be so easy. Sommerbeck (2006) stresses that
working “at this concrete level is not easy” and when she first started to work in this way
“I felt almost condescending to clients” (p. 3). Warner (cited in Sanders, 2007, p. 11),
referring to Pre-Therapy, understands contact as a continuum and Kreitemeyer and Prouty
refer to a contact rhythm in that contact moves back and forth between the therapist and
client (p. 160).

Contact reflections and care giving

Contact reflections are used to facilitate engagement in therapy but have also been used in
a number of other settings where the “aim may be to increase a person’s interaction,
communication and quality of life” (Brooks & Patterson 2011, p. 162). The use of contact
reflections by carers in different settings was highlighted by Pörtner (2002). Referring to
residential care she described how reflections can help in daily interaction with people
who are contact-impaired. “No where are there so many opportunities to facilitate contact
than in daily life” (p. 167). Using contact reflections when working with care givers who
supported people with dementia in a residential setting, Dodds (2008a) talks of the
“gentleness that flows from attempting to establish contact prior to performing care
tasks” (p. 70).
Clarke (2007) describes using contact reflections with her son who experienced
mental health problems. She concluded that the “key to psychological healing lies
within the relationship between the clinician and the client” (p. 47) but that using
contact reflections at home supported the family carer in making contact and “made
everyday care more humane” (p. 47). This echoes Dodd’s reference to gentleness.
Contact reflections are embedded in a person-centered approach. Carrick and
Mckenzie (2011) developed a module in Pre-Therapy for students on a Postgraduate
Diploma in Autism Studies. They concluded that students who used a person-centered
approach didn’t just use contact reflections as new “tools” to help them in their support of
young people with autism but developed a phenomenological perspective. The training
included person-centered counselling skills and this approach allowed “students to move
beyond merely using the contact reflections in isolation, as a set of contact tools, to a more
relational way of working” (p. 86).
Dodds, Morton, and Prouty (2004) emphasize the phenomenological nature of Pre-Therapy.
They say the focus is on “exploring with the person their lived experience of the world they are
in” (p. 25). The person-centered approach underpins the use of contact reflections as a way into
the world of people with dementia. Milwain (2010) in the Journal of Dementia Care stresses the
 Person-Centered & Experiential Psychotherapies 289

demands made on caregivers when asked to work with people with dementia in a person-
centered way. She writes about the person-centered approach being “the only viable option for
dementia care” (p. 28) but that staff need to be emotionally supported in this work. Sanders
(2007) refers to staff being prepared to address their own needs because using Pre-Therapy is an
“essentially human” activity (p. 21). Carrick and McKenzie conclude that whilst some students
found using Pre-Therapy skills difficult “almost all the students described changes in their
attitude to clients, to their practice, and to the lives of their clients” (p. 80).
Pörtner (2000), referring to the use of contact reflections in everyday situations in
residential care, stresses that although there are many opportunities any use, must be
“based on an attitude of empathy, acceptance and congruence and never appears
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disrespectful” (p. 84). It is about helping clients to develop contact functions and
“not criticising their behaviour” (p. 84).
Dodds (2007) highlights the context within which contact reflections can be used and the
impact this may have on nursing staff. Nurses are often working in a public space and
therefore supporting people in front of colleagues. Where some but not all have been trained
to use contact reflections, this may leave them feeling self conscious or anxious about
communicating in a different way to usual conversations. Van Werde (2002) created a
“contact milieu” where all nursing and support staff in a hospital psychiatric ward are trained
in using contact reflections. This approach contrasts with Dodd’s experience where only some
staff were trained and raises the question of whether it is of greater benefit if all caregivers with
a client try to work and communicate in the same way. Along this line, McCormack, Dewing,
and McCance (2011) focus on the organizational culture as the challenge in developing
person-centered approaches to care and say that it is not just up to the individual worker.
There are some considerations in training staff to use contact reflections. Dodds (2008a)
comments that she hadn’t expected staff to find using contact reflections so challenging. “The
initial feeling of familiarity changed when rehearsing the contact reflections with their own
residents; using contact reflections felt awkward and unnatural” (p. 203).
Dodds concludes that staff need to be supported to reflect on their practice. Prouty and Van
Werde (2007) spell out advice for students of Pre-Therapy with headings such as “be with the
client,” “be empathic without knowing the frame of reference,” “don’t think you know” and
“don’t underestimate the strength of the client” (p. 78). This underlines Dodds suggestion that
staff need ongoing supervision.

Reflexive comment
In 1994 I attended a workshop on Pre-Therapy as a counselling student on a Person-
Centered Diploma course. Pre-Therapy resonated with me and I subsequently attended
three workshops with Dion Van Werde. Pre-Therapy spoke to my passion about people
being heard and valued no matter what their personal challenges might be. I have two
adopted children (now adult) with additional needs. One had been abused and has a
diagnosis of Asperger syndrome. The other had been abandoned at birth and has severe
learning disability and autism. My mother developed dementia. Could Pre-Therapy offer
me a key to help open the doors into their complex worlds?
Prouty (2002a) wrote of living with his brother who had autism and mental health
problems. “The actual living experience is layered, having pain, empathy and a sense of
defensive creativity” (p. 3). This sharing of his personal life had a profound impact on me
and his offering of a way to be helped informed my counselling and training practice and
supported me with my family challenges.
 290 P. Courcha

Existential empathy is for the human condition. It is a bearing witness to human suffering with
humility and acceptance. It is where the last response is to “be with”. (Prouty, 2002b, p. 13)

My mother had received care at home and I had worked with carers as a trainer in
areas such as bereavement and communication skills for a number of years. I knew that
home carers were asked to perform care tasks, including personal care, with people who
may be in distress or despair and who may be contact impaired. I hoped that the research
might help them to “be with” with their clients.
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Method
Co-operative enquiry
A qualitative approach was adopted using co-operative enquiry within an action
research framework. Interpretive Phenomenological Analysis (IPA) was used to
analyze the meeting and interview transcripts. The overall aim was to enable the
voice of the home carers to be heard, based on the lived experiences of their client
work.
Action research is context specific (home care), focuses on introducing change (what
happens) and is participative (home carers are actively involved). The co-operative approach
lent itself to this enquiry as it is “research ‘with’ rather than ‘on’ people” (Heron & Reason,
2008). It was about how home carers could learn together with the researcher and with their
clients.
Co-operative enquiry is essentially a dialogical approach to research (Macleod, 2006). This
fits with a contemporary dialogical person-centered approach (Schmid & Mearns, 2006) and is
congruent with asking carers to use contact reflections which have a strong base in person-
centered theory (Sanders, 2004). Co-operative enquiry sits well with a person-centered approach
sharing characteristics such as meeting the other as a partner and the relationship between the
researcher and co-researchers being seen as an evolving process (Mearns & Macleod, 1984).
McNiff and Whitehead (2009) state “the underpinning values and logics of action research
are living, inclusional and emancipatory” (p. 51) and continue “these are stories of real life” (p.
51). The research was about home carers going about their daily work with their clients,
developing a living theory of practice.
IPA is “concerned with an individual’s personal perception or account” (Smith & Osborn,
2008, p. 53).The carers self-reported their caring activities and IPA facilitated an understanding
of the work from their perspective. Smith and Osborn state that IPA is a “dynamic process” (p.
53) with the researcher being active as interpreter in the analysis. I engaged empathically with
the carers’ contributions as well as asking critical questions in the analysis. I aimed to both stand
in the carers’ shoes and also to “stand alongside the participant, to take a look at them from a
different angle” (Smith, Flowers, & Larkin, 2009).
The research followed a cycle of reflection and action (Reason, 1994) moving through
phases of knowledge (Figure 1). It began with “presentational knowing” as initial training
introduced the home carers to contact reflections. The next phase, “practical knowing,”
involved carers applying their learning to their daily care work with the clients in the
study. Carers “experiential knowing” was shared when they returned for group meetings
with the researcher. Challenges, sense of achievement, disappointments and what might
be done differently were shared with each other and with myself as co-facilitator.
There were eight cycles of reflection and action, that is, eight periods of practical
knowing each followed by a group meeting to share experiences.
Figure 1 aims to shows Reason’s approach applied to the research study.
 Person-Centered & Experiential Psychotherapies 291

Learning

Reflection Action

Presentational Practical Experiential

Knowing Knowing Knowing
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Figure 1. Action research cycle of learning.

Participants
Three home carers were recruited through engagement with a home care agency. All
were aged over 55-years-old and had worked in home care for between three and 18
years. They had no training in dementia or communication skills and did not have
professional qualifications.
They attended five training sessions held fortnightly to fit with carers’ work rotas.
Following an introductory session carers were invited to think about a current client
whom they would invite to participate. All chose people with dementia.

Outline training content

Introduction The research approach

Thinking about clients
Session Two Person-centered listening skills
Communicative contact
Session Three Person-centered listening skills
Pre-Therapy theory: contact functions, contact behaviors, contact reflections
Session Four Expressive/pre-expressive/grey zone functioning
Contact reflections
Session Five Contact reflections in carer work context
Role play
Focus on “the technique is easy but the art is difficult”

Once the training sessions were concluded the carers then met fortnightly as a
group with the researcher. There were eight meetings over a four-month period. At
these meetings carers self-reported on their experiences with their clients. Challenges,
sense of achievement, disappointments and what might be done differently were
shared and discussed. Individual interviews at the end of the meetings cycle provided
an opportunity for further reflection.

Ethical considerations
A co-operative enquiry approach is respectful of all participants and therefore appropriate for
involving vulnerable groups and the home care clients were not observed or asked to do
 292 P. Courcha

anything. The Adults with Incapacity (Scotland) Act 2000 specifies certain conditions to be
met when involving participants in research who are unable to give consent. They include:
similar research cannot be carried out on adults who can give consent; the research is likely to
produce real and direct benefit to the adult; the research entails no foreseeable or only a
minimal risk. The research design met all the conditions.
Where a client was not able to give informed consent a family member or guardian did so
but Cameron and Murphy (2007) emphasize that for people with learning and communication
disabilities consent is an ongoing process. The research recognized this and home and family
carers were advised to be alert for any indication that the client didn’t want to be involved.
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Findings
Themes were identified using IPA to analyze meeting and interview transcripts. Carers
were focused on performing care tasks within the context of developing their relation-
ship with their clients and the theme Achieving care tasks was highlighted at all
meetings and interviews. Three themes were identified in all but one of the meetings
and in all the interviews; Using a contact reflection, Anxiety and building confidence
and Developing reflective practice. These are discussed below. (All names have been
changed) (Table 1).

Table 1. Carer themes across meetings and interviews.

Meetings/Interview 1 2 3 4 5 6 7 8 Int

The care task

Achieving care tasks * * * * * * * * *
Good care practice * * * *
Trying out a different way of communicating
Stop and think * * * * *
Using concrete/minimalist statements * * * * * *
Here and now/being present * * * * *
Non verbal communication * * * *
Being open to client * * *
Quiet calm and simplicity * * * * *
Building relationship * * * *
Making time * * *
Valuing client response * * * * * *
Using contact reflections
Making contact with client * * * * * *
Judging when to use a CR * * * * *
Using a contact reflection * * * * * * * *
The learning task
Anxiety and building confidence * * * * * * * *
Reference to pre-training communication approach * * * * *
Developing reflective practice * * * * * * * *
Commitment to research task * * *
Developing skills *
Personal development/reflexivity *
 Person-Centered & Experiential Psychotherapies 293

Achieving care tasks

The purpose of a home care visit is to perform tasks such as preparing a meal or giving
personal care and time is limited. Becoming more thoughtful about how to communicate
seemed to help achieve care tasks.
At first Elaine commented “. . . unless you bother to make conversation with her you get
nothing out of her. Bearing in mind we have a job to do as well.” At the fourth meeting she
stressed that it was a learning process being involved in the study, was anxious about having
the time to try out contact reflections and said “you’re under pressure.” But by the sixth
meeting Elaine was able to say: “I’ve found that using contact reflections during the care part
– you are able to do it a lot easier and better with no drama at all, quietly get through it.”
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Elaine also described how it had been hard to get Nancy to put her false teeth back in
her mouth after Elaine cleaned them but then “I handed them back to her and said ‘here’s
your smile back’ and she actually burst out laughing, in a belly laugh.”
Linda referred to a client who she visited for the first time and had been warned by “the
office that not everyone manages to give him a shower” and “he might not co-operate.” Using
a situation contact reflection “the water’s running” seemed to make a difference and Linda
said “ I did manage. And I hadn’t met him before.”
Linda also spoke about Agnes standing in her nightdress in the kitchen in the late
afternoon as the morning carer hadn’t managed to get her up, dressed or fed. The client said
she wasn’t hungry but Linda used concrete language saying “a boiled egg” and the client
agreed to eat. “You don’t have to push people too much” she said.
All the carers at first described how, when they arrived at a client’s house, they would often
go straight to the kitchen to put on the kettle whilst calling out a greeting because of time
constraints. Olive said she now realized the need to find time for “social interaction and it can be
as simple as actually coming down, facing the person (rather) than sort of speaking on the run.”
She would sit beside the bed or their chair and try to make contact.

Using a contact reflection

Carers often described a communication as a contact reflection although it was more often
about using concrete language, making minimalist statements and being more focused on
the client in the present moment.
Making a judgement about whether a carer had used a contact reflection was dependent on
what they said they did and at times this lacked sufficient contextual description. It was difficult
to judge if the client had been expressive or pre-expressive. However there were descriptions of
situations which did suggest use of a contact reflection. Carers used situation reflections more
readily than facial, body or word for word and did not use re-iterative reflections. Table 2 shows
the number and nature of contact reflections that were described. Over a period of eight weeks
the number may seem disappointing but it reflects those that were readily identifiable from

Table 2. Frequency of using contact reflections.

Elaine Linda Olive

Situational 3 5 1
Facial 1 1 0
Body 1 3 1
Word for word 1 2 1
Re-iterative 0 0 0
 294 P. Courcha

carers’ descriptions. As indicated above much of the carers’ approach to communication had
changed which itself impacted on relationships with their clients although not using contact
reflections as such. Carer’s confidence in using contact reflections developed over time,
supported by engagement in discussions at the regular meetings.
Carers found it challenging to make a judgement about whether a client was expres-
sive, pre-expressive or functioning in the “grey zone.” Partly this was anxiety that they
might be experienced by the client as insensitive or even insulting (if the client was
expressive). Also some clients responded quickly to carers using a contact reflection when
they had appeared to be pre-expressive. Peters (1999) says that when a client comes into
contact then “at those moments the therapist must shift the level of responding to give real
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answers” (p. 27) so as to strengthen the reality contact. Dodds (2008b, p. 64) describes
how carers can have a fear of “opening a can of worms” using contact reflections when
people have dementia. She describes how quickly an emotional connection can be made
and refers to Peter’s comments on intersubjectivity and how contact reflections can
“enhance or reflect the client’s momentary level of functioning” (p. 63).
Linda described trying to judge whether to use contact reflections with Andrew. One
day he said he didn’t want her in the room. She wondered whether to use a word for word
reflection but decided against it as she thought his response might be shouting “are you
deaf or something.” She concluded that he was not pre-expressive on that occasion.
At another visit Linda used a body reflection when Andrew was sitting on the toilet
with his hands over his face. “I reflected this by putting my hands over my face.” There
was no response from Andrew and Linda then reflected “you’re not happy” (empathic
reflection) and Andrew banged his zimmer on the floor suggesting that he was then
expressive (affective contact).
Linda also worked with Agnes who was at a more advanced stage of dementia. Linda
would respond to Agnes as if she was expressive but then find that Agnes had moved
back into a pre-expressive state. Agnes appeared to be in the grey zone much of the time.
At the first meeting Elaine had described Nancy as “not communicative at all” and
“vacant, not responding to anything really.” Later Elaine explained how she had used a
body reflection as she was brushing Nancy’s hair and Nancy had replied saying it used to
be black (reality contact). Elaine was delighted at getting a response and commented to
the group “she’s talking to me!” Elaine also described how she would make a situation
reflection about the weather when she arrived and Nancy would respond appropriately
indicating reality contact. Whilst it isn’t possible to judge if Nancy was pre-expressive
when Elaine arrived it does indicate significant change in Nancy’s ability or willingness to
respond rather than appearing “vacant.”
Elaine explained how she used a body reflection with one client who was at a more
advanced stage of dementia than Nancy. The client had been repeating am I alright, am I
alright. Elaine sat and reflected “how she was sitting and holding my hands how she was
holding her hands.” The client then reached out and “caught” Elaine’s hands and they sat
holding hands for a long time. It would seem that the client was then in affective contact.

Anxiety and building confidence

Early on carers acknowledged the learning process and that changing how they commu-
nicated with clients would take time and experience. Carers demonstrated respect for their
clients’ autonomy and dignity and expressed anxiety about how using contact reflections
might impact on their clients. At the first meeting Olive asked with some concern “I think
using this approach you’re still giving them the choice?” She later understood that it was
 Person-Centered & Experiential Psychotherapies 295

about helping clients to be in communicative contact and therefore be able to make

choices if they wished.
There was some anxiety about using facial and body reflections. Olive was anxious
about Isabel’s reactions especially using body reflections. She felt that Isabel would get
cross and say “what are you doing that for?” Although Olive acknowledged that this
would in itself be a response which could open communication it was difficult to judge
was this because the client was brought into contact or was she already in an expressive
state.
Despite their anxieties carers did develop in confidence. Elaine described how Nancy
was “responding back to me. I wondered how this was going to work . . . yes I am
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surprised” and demonstrated her increasing confidence. At the final meeting she said
“There aren’t any problems getting her to eat her lunch now or do anything.” Elaine
expressed her satisfaction that she was working in a different way with clients and really
valued the interactions.
Linda admitted “it was difficult at first.” However she found that communicating
differently did make a difference and it became “easier the more I did it and the more I
thought about it.” The increasing confidence came from carers being able to engage with
clients in ways that facilitated the care tasks and enabled communicative contact.

Developing reflective practice

Carers developed a reflective approach to their work which was previously absent. This
brought rewards to both clients and carers. The group meetings provided a space and
encouragement for reflection; it provided an opportunity for mutual support in which
carers shared openly with each other and offered empathic comments on situations they at
times found hard to manage. Elaine said “I felt I could take anything I didn’t quite
understand.”
Carers started reflecting before visiting their client and thinking how something might
be said or how they might respond to how the client is that day. Carers became more
aware that communicating isn’t just about saying the first thing that comes into their head.
Elaine said “you’re stopping to think how can I communicate and you’re just taking that
little bit extra time.” Olive and Linda also emphasized that they were more reflective
about their communication.

Olive: I mean what I’ve found is it’s made me think

Linda: Definitely made me think
Olive: Really thinking about it and doing it more
Linda: Yeah instead of saying “what are you doing standing there” you say “look at
all the snow.”

Carers became thoughtful about changes which they experienced in their clients’
behaviors and paid closer attention to their presence. Olive said “in the past I wouldn’t
have (even) thought about it” and laughed because she was delighted with the connection
she seemed to be developing with Isabel.
Reflective practice related to self reflection and the carers’ personal development.
Linda felt more valued as a carer and this had contributed to her increasing sense of self
worth in relation to her work. She said she “felt like I’m giving something.”
Elaine had previously experienced traumatic loss of a close family member. She
thought now that in a way she had used contact reflections at the time without having
 296 P. Courcha

the understanding. It had been an intuitive way to try to communicate with someone who
was dying. She said “it’s like reaching out to somebody who can’t communicate and
letting them know you were there.”

Discussion
Client focus, task focus
The home carers participated because they wanted to explore new ways of making a
difference to the care they gave to their clients. Discussions at meetings had an underlying
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sub text – is this helping the client to have their needs met? The carers’ main concern was
to achieve care tasks in the time available in a way that didn’t diminish their client. There
is a strong sense of the carers reaching out to their clients and staying focused on them as
individuals rather than just having a job to do. Although carers did try using contact
reflections, mostly they offered respectful, natural and simple communication. The home
carers found that using contact reflections and communicating differently facilitated
apparently straightforward, but potentially more complex, care tasks. Brooker (2007)
describes the care task for someone with dementia as “the maintenance of personhood”
(p. 20). The home carers’ focus on the person as they experienced them in the present led
to a sense of achievement in engaging with the client and great pleasure from the
interaction. This reflects Carrick and Mackenzie’s findings about staff changing their
attitudes and their practice which “led to a more unconditional, accepting and positive
way of viewing their clients” (Carrick & Mckenzie, 2011, p. 86).
The above begs the question about whether training home care staff to use contact
reflections led to efficiencies and a higher quality of care. It seemed that the care task
could be achieved more effectively and maybe more quickly whilst concurrently offering
the client more empathic and respectful communication. To understand more about the
impact of the training on caregiving would need further research focusing on this aspect of
the findings.

Finding a voice
Over the research period all participants found their voice. Clients were enabled to find
their voice and express verbally or otherwise their needs and choices, and at times their
emotions. The home carers found their voice in discovering that they could learn for
themselves as part of their care practice and share their learning without judgement. As
the researcher I felt at first de-skilled (and losing my voice) because carers had chosen to
work with clients with dementia but soon I found my passion about trusting each aspect of
the process – the clients, the home carers, the research and my own personal journey. It
felt as if I made contact with the carers and they made contact with their clients.
Carers brought to the meetings their experiences of being with their clients. The
quality of the data was affected by the carer’s ability to reflect as this was something
they were not used to doing but respecting what they did bring facilitated open discussion
and shared understanding. Whilst they weren’t using words like “pre-expressive” they
brought detailed descriptions and their wonder at how their approach had changed the
relationship or facilitated the care. They had developed a living theory of practice.
Mostly carers spoke with clients with more respect, more patience, and more simply
“instead of bamboozling them with all this nonsense that I talk about normally” as Elaine
 Person-Centered & Experiential Psychotherapies 297

put it. Carers were more able to relate to the humanity of the individual to whom they
offered care.

Learning together
McNiff and Whitehead (2009) say that action research knowledge “can’t be generalised
although it can be shared” (p. 13). The meetings facilitated the sharing of experiences and
learning in a safe environment which provided a forum for a rich mixture of personal
reflections and descriptions of the actual tasks of caring. The learning together was an
iterative process bringing support and challenge. Carer confidence increased and the
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clients benefitted as carers integrated new ways of communicating and relating. They
shared their learning by changing the way they worked with all their clients.
There were limitations to the research which could have affected the outcomes.
Although more carers were interested in participating, only three were able to commit
to the time and rota changes. A concurrent study with carers from another home care
agency would have given more data and from a different agency perspective and prior
training.
The time available for training and meetings was restricted to accommodate staff rotas
and agency requirements. At meetings it sometimes meant time pressure impacting on the
development of an idea or a carer’s concerns. However working co-operatively often led
to negotiating within the group to allow sufficient time for individual contributions.
The carers were all mature and experienced in home care. Less experienced carers or
younger people might have used the learning in a different way. None had previous
communication skills training or training around dementia and outcomes might have been
different if they had. All three carers chose to work with clients with dementia although
the research only asked them to choose a client.
The lack of video evidence and or observation meant a reliance on carers’ descriptions
of their interactions. Corbin and Strauss (2008) say that people may not be “aware of, or
be able to articulate, subtleties of what goes on in interactions” (p. 29). They point out that
people may describe what they have been doing but may have been doing something else.
Given the environment in which home care takes place and the nature of the clients in the
study it would have been challenging to find an ethical and acceptable way of observing
or filming. However the phenomenological approach illustrated how the carers perceived
changes in their relationships with clients and how it touched them personally.
No research instruments were used for data collection. These might have produced
interesting data but it is debatable if the home carers would have wished to engage with
this.

Conclusions and further research

The research asked what happens when home carers are trained to use contact reflections.
Home carers described using some contact reflections but mostly their way of commu-
nicating with clients changed. They worked from a person-centered perspective and
placed high value on being accepting and respectful. They used few words and straight-
forward sentences. They made efforts to communicate non-verbally, to engage with the
client and to involve the client in their own care.
Of note was the apparent improvement in the achievement of care tasks when using
contact reflections or just simple concrete language. Clients responded to the carers and
were more co-operative, for example in washing, and more motivated, for example to eat
 298 P. Courcha

a meal. There was a sense of a developing relationship between the client and carer and
this could include having fun or sharing sad times.
The action research approach facilitated the carers learning by allowing them to bring
their own understanding of their experiences and to learn together with others. The
findings and discussion suggest that there could be value in further research looking at
using Pre-Therapy contact reflections in community settings. With increasing numbers of
people with complex needs living in their own homes, the challenge will be to find ways
of supporting them to ensure quality of life and care.
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Acknowledgement
I would like to thank the home carers who gave so much of themselves in participating in the
research and their manager Stephen Pennington who was very supportive of the work we were
doing.

Notes on contributor
Pam Courcha works as a counsellor, supervisor and trainer in private practice. She has over twenty
years’ experience of working in the person-centered approach and is committed to supporting front
line care and health staff to engage with those they care for from a person-centered perspective. I
have two (adult) children with complex health and care needs.

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