Pre-therapy · Atlas

1. Introduction

Version followed: Garry Prouty's Pre-Therapy as set out in Prouty, Van Werde & Pörtner (2002), Pre-Therapy: Reaching Contact-Impaired Clients (PCCS Books): Prouty's five contact reflections, three contact functions and contact behaviour, plus Dion Van Werde's "Contact Milieu" ward version and his "grey zone" use. The book itself is not drawn on. Its content is reconstructed from its table of contents and from secondary accounts by Prouty's colleagues: Degraeve 2005, Dekeyser, Prouty & Elliott 2008, Van Werde 2006/2021, Dodds 2009, Faixová 2014 and Coffeng 2009. [uncertain: wording and fine detail of Prouty's own chapters]

Pre-Therapy is a person-centred (Rogerian/experiential) approach for people whose psychological contact is too impaired for ordinary talking therapy. This includes people with chronic or acute psychosis, catatonia, severe intellectual disability, dementia, autism, and dissociative or trauma-related loss of contact. Garry Prouty (1936–2009) began developing it from 1966. It is "pre" because it comes before therapy proper: it aims to restore the preconditions for therapy, namely contact with the world, with one's own feelings and with other people. [source: Degraeve 2005; pcaInstitut 2025; Coffeng 2009]

How change happens. Rogers named psychological contact as the first condition of therapy but did not develop the idea. Prouty set it out as three contact functions: reality, affective and communicative contact. He held that behaviour which looks meaningless (echolalia, word salad, hallucinations, rocking, mutism) is pre-expressive: it carries latent meaning that has not yet reached a communicable form. The therapist offers very concrete, literal contact reflections of the person's surroundings, face, body and words. These help the person re-find reality, feeling and communication, and the changes show up as observable contact behaviour. As contact strengthens, psychotic or withdrawn functioning lessens, which Van Werde puts as "more contact implies less psychotic functioning". Ordinary person-centred or experiential therapy can then begin, although restored contact can also be a worthwhile outcome in itself. [source: Degraeve 2005; Dekeyser et al. 2008; Van Werde 2021]

Pre-Therapy is a set of contact-restoring reflections and a theory of contact. It is not a manualised, session-by-session protocol. The sources also describe three settings: one-to-one therapy, everyday work by nurses and care staff, and whole-ward milieu work. [source: Coffeng 2009; Degraeve 2005; Van Werde 2006]

2. Framework

The sources give no fixed phases or session counts. The four-stage structure below is my own way of organising what they describe. [synthesis]

Stage A: Assess the level of contact.

Goal: decide where the person is functioning now. They may be pre-expressive (little or no contact with reality, self or others); in the "grey zone", meaning usually in contact but losing it in certain situations such as dissociation or trauma reactivation; or expressive (able to use ordinary therapy). [source: Degraeve 2005; Van Werde 2021; pcaInstitut 2025]
Format: observation over minutes to a few contacts, in the person's own setting (ward, room, day room, while walking).
Note: Dodds found this hard to judge in dementia, and people sometimes swing between states. A person who is aware of feelings but cannot express them may wrongly be treated as pre-expressive. [source: Dodds 2009]

Stage B: Restore contact through contact reflections.

Goal: produce moments of reality, affective and communicative contact.
Format: one-to-one, at the person's pace. The work may happen in planned sessions, in brief everyday moments (meals, walks, care tasks) or in crises.
Duration varies widely in the case material. A ward crisis was resolved in one short conversation. A catatonic man was reached during a reported 12-hour marathon session (Prouty & Kubiak). Long-stay patients were seen over months, with Van Werde describing a process that "may take years". [source: Degraeve 2005; Van Werde 2006]
Move on when contact behaviour appears and recurs. Examples: eye contact, a turn toward the therapist or an object, naming something real, a congruent feeling word or facial expression, a coherent phrase, the person expanding their speech.

Stage C: Consolidate and anchor contact.

Goal: strengthen fragile contact functions and widen healthy functioning. Van Werde distinguishes restoring contact (Stage B) from strengthening it. [source: Van Werde 2006]
Format: repeating the reflections that worked (reiterative reflection); a ward "contact milieu" in which all staff use reflections; weekly ward meetings centred on concrete shared reality; simple structured activities; strengthening the "roots" (sleep, food, daily structure, social ties). [source: Degraeve 2005; Van Werde 2006, 2021]
Move on when contact is stable enough that the person can talk about feelings and experience with some coherence across a session.

Stage D: Move to ordinary person-centred or experiential therapy.

Goal: work with experiential content in the usual way, including empathic reflections, exploring frightening experiences, and decoding and integrating psychotic material and the trauma that may lie behind it. [source: Faixová 2014; Van Werde 2006, 2021]
How to decide: in Faixová's first case, the therapist switched from contact reflections to empathic reflections once the patient made a meaningful link himself. Van Werde says to approach frightening material only gradually, once the person is stronger. [source: Faixová 2014; Van Werde 2006]
Moving back: if contact is lost again (grey-zone moments), go back to contact reflections, then return to ordinary therapy. [source: pcaInstitut 2025; synthesis for the explicit back-and-forth rule]

3. Guiding principles

Contact is the precondition for therapy. Do not attempt exploration, interpretation or problem-solving until contact is present. [source: Dekeyser et al. 2008; Faixová 2014]
Contact has three functions. Reality contact (people, places, things, events), affective contact (moods, feelings, emotions) and communicative contact (putting the first two into words for others). Track which one you are supporting. [source: Degraeve 2005; Dekeyser et al. 2008]
Behaviour is pre-expressive, not meaningless. Treat fragments, gestures and symptoms as possible carriers of meaning to be met, not suppressed. [source: Degraeve 2005; Van Werde 2021]
Point at the concrete. Reflections are literal and duplicative, which Dekeyser et al. call "pointing at the concrete". In practice: say what is observably there, with no interpretation, inference or symbolism. [source: Dekeyser et al. 2008; Degraeve 2005]
Meet the person at their own level of expression. Use their words, their pace and their channel (non-verbal if language is impaired). [source: Dekeyser et al. 2008; Dodds 2009]
Stay non-directive and non-evaluative. Do not steer, reassure, praise or correct. Faixová adds that "supportive" comforting and positive reframing are not person-centred work. [source: Faixová 2014]
Respect psychotic experience. Do not argue with or dismiss hallucinations and delusions; reflect the person's experience of them. [source: Faixová 2014; Van Werde 2021]
Repeat what worked. Reflections that produced contact are deliberately re-used. [source: Degraeve 2005; Dekeyser et al. 2008]
Be congruent. Psychotic people quickly sense whether a worker is genuine and in control of their own emotions, so work from real presence rather than technique alone. [source: Van Werde 2006]
Assume a healthy core. Build an alliance with the person's healthy part, however fragile, and strengthen their anchoring in everyday reality. [source: Van Werde 2006]
Balance the tree. Van Werde's image has symptoms at the top and roots (sleep, food, structure, relationships) below. When the top is large, feed the roots. [source: Van Werde 2006, 2021]
The person is not the problem. Help create distance between the person and their symptoms, which allows a "trialogue" between person, therapist and problem. [source: Van Werde 2006, 2021]
Go in small steps. Change is gradual. Do not overload the person, for example by offering only one simple outing a week. [source: Van Werde 2006, 2021]
Contact work is everyone's work. On a ward, every staff role (nurse, occupational or psychomotor therapist, therapist) contributes to restoring contact. [source: Van Werde 2021; Coffeng 2009]
Use contact reflections only when contact is impaired. Contact reflections are not the essence of person-centred therapy. Drop them once ordinary empathic contact is possible. [source: Faixová 2014]
Prefer open reference when concrete labels intrude. In dementia work, a vague phrase ("you're holding it") sometimes kept people in their own experience better than a precise label ("the shirt"). [source: Dodds 2009]
Avoid coercion. In the ward crisis example, contact work replaced restraint, forced medication and seclusion, and the person chose their own next step. [source: Degraeve 2005]

4. Intervention inventory

The core method is Prouty's five contact reflections. The sources say together they create "a web of psychological contact" (American Journal of Psychotherapy, 2007). The other entries below cover how the reflections are combined, assessed and carried into crisis, hallucination, ward, dementia and grey-zone work, as described by Prouty's collaborators. Unless marked "(source)", all example wording is my own and illustrative. [source: Degraeve 2005; Dekeyser et al. 2008; Pre-Therapy: The Application of Contact Reflections, 2007, abstract only]

Terminology note: the sources draw the line between situational and body reflections slightly differently. Degraeve and Coffeng use "situational" for the surroundings (place, objects, events, people present). Faixová labels a reflection of the client's own behaviour ("you are looking at the floor") as situational. Dekeyser's situational example describes a person in a place. This guide follows Degraeve's (Prouty's) usage: situational means the world around, body means the person's posture and movement. [uncertain]

4.1 Situational reflection (SR)

Purpose / when: restores reality contact by naming concrete people, places, objects and events in the shared present. Use it first when the person seems absent, absorbed in hallucinations, agitated, or does not respond to questions. [source: Degraeve 2005; Dekeyser et al. 2008]
Steps:
1. Notice something concrete and present that the person can perceive: the room, an object near them, the weather, a sound, another person, what you are both doing.
2. Name it in a short, plain, present-tense phrase. A single word is enough (Degraeve's example is just "table").
3. Pause and watch for any response: gaze, a turn of the head, touching the object, a word.
4. If there is a response, reflect it (see 4.5). If not, offer another situational reflection, or switch to a facial or body reflection.
Example language: Degraeve's examples are "table", "it is raining" and "we are sitting in your room" (source, translated). Illustrative: "We're in the dining room." "There's a cup on the table." "A car is going past outside." "We're walking. There's the railing."
Watch for: speaking too much or too fast; sliding into questions ("Do you see the table?"), which demand a response the person may not be able to give. Signs it is working: the person's gaze moves to what you named, they touch or pick it up, they name it themselves, or they place themselves in time and space.

4.2 Facial reflection (FR)

Purpose / when: supports affective contact by naming feeling that shows on the face before the person can put it into words (pre-expressive affect). Use it when the face shows something (tears, a smile, a frown, tension) and the person cannot name a feeling. [source: Degraeve 2005; Dekeyser et al. 2008; Faixová 2014]
Steps:
1. Watch the face closely: eyes, mouth, tears, tension, direction of gaze.
2. Reflect what is visible in the most concrete form you can. Dekeyser et al. contrast an inferred feeling ("you look sad") with the more concrete "there are tears in your eyes" (source). Prefer the concrete form unless the emotion is unmistakable.
3. Reflect it verbally, or non-verbally by gently matching the expression yourself (for example, a returned smile).
4. Pause and observe.
Example language: Degraeve's examples are "Paul is laughing" and "tears" (source, translated). Illustrative: "You're smiling." "Your eyes are wet." "Your forehead is wrinkled." "You're looking at me."
Watch for: do not label feelings you are only guessing at. A mismatched label pulls the person out of their experience. Signs it is working: the emotion deepens or becomes congruent (for example, the person cries or laughs openly), they make eye contact, or they produce a feeling word of their own ("scared", "nervous").

4.3 Body reflection (BR)

Purpose / when: supports reality and self-contact through the body. It is especially useful with catatonic or rigid postures, rocking, repetitive movements and clenched hands, and in severe intellectual disability, dementia or deep withdrawal. [source: Degraeve 2005; Faixová 2014]
Steps:
1. Observe the posture or movement: sitting, hunched, rocking, an arm raised, a fist.
2. Either describe it in words, or mirror it with your own body (rock gently with them, raise your arm, take a similar posture). Degraeve and Dekeyser both describe the non-verbal mirroring option. [source]
3. Keep mirroring respectful and partial. The aim is meeting, not copying for effect.
4. Observe whether the person notices you, changes posture, or begins a movement toward contact.
Example language: Degraeve's example is "Paul is rocking back and forth" (source, translated); Dekeyser's is "your arm is in the air" (source). Illustrative: "You're sitting very still." "Your hand is a fist." "You're curled up in the corner."
Watch for: mirroring can be felt as mockery. Staff in Dodds' study worried about this, and one resident became angry and walked away. Stop and switch to a verbal or situational reflection if the person seems irritated. Signs it is working: the posture loosens (a fist opens), the person looks at your body or face, or they begin a new movement directed at you or an object. [source: Dodds 2009; Degraeve 2005]

4.4 Word-for-word reflection (WWR)

Purpose / when: supports communicative contact by repeating the person's own words exactly. With fragmented, echolalic or word-salad speech, pick out and repeat the intelligible words or phrases. [source: Degraeve 2005; Dekeyser et al. 2008; Faixová 2014]
Steps:
1. Listen for any word or phrase that is understandable, even within confused speech.
2. Repeat exactly those words, in the person's own form. Do not tidy them into a sentence, add meaning or ask about them.
3. Match their tone loosely, without exaggeration.
4. Wait. People often expand their speech once they sense real interest. [source: Faixová 2014]
Example language: Degraeve's examples are "Cameras… running", "broken" and "you want to leave" (source, translated); Coffeng's is "you just said 'I want to get out of here'" (source, translated). Illustrative: Client: "...the bus... green... they take..." Therapist: "Bus. Green. They take."
Watch for: paraphrasing too early ("you're worried someone will take you") goes beyond what was said and is no longer a contact reflection. In dementia, Dodds' carer repeated "Mum", was drawn into the resident's grief and felt overwhelmed, so be ready for strong feeling (see 5.6). Signs it is working: longer and more coherent utterances, the person correcting or adding to your repetition, or turning to you as a listener. [source: Dodds 2009]

4.5 Reiterative reflection (RR)

Purpose / when: re-uses any earlier reflection that produced contact, to strengthen that contact and build on it. Use it straight after a reflection gets a response, and later in the same or a following contact. [source: Degraeve 2005; Dekeyser et al. 2008]
Steps:
1. Note which reflection produced contact behaviour, and what that behaviour was.
2. Repeat that reflection, often linked to the response it produced ("I said X, and you looked at me").
3. In later contacts, open again with reflections that worked before.
Example language: Degraeve's example: "You're laughing… I said 'you're laughing' and you looked at me" (source, translated). Illustrative: "There's the window. I said 'the window' and you turned your head." At the start of the next meeting: "Last time we looked at the picture of the tiger."
Watch for: Prouty is said to distinguish an immediate form from a long-term form (across sessions), but the terms are [uncertain]. Signs it is working: contact returns faster, lasts longer, or extends to a new channel (for example, from gaze to words).

4.6 Combining reflections into a sequence (the "web of contact")

Purpose / when: in practice the reflections are mixed and layered moment to moment, following whatever produces contact. [source: 2007 abstract; Dodds 2009]
Steps (modelled on Dodds' walking vignette with a man with advanced dementia):
1. Start with what you are doing together and what is around you: "We're walking" (BR/SR), "there's the railing" (SR).
2. If there is no response, combine channels: words plus gesture, for example touching the wall so your hand enters the person's field of vision.
3. When a micro-response appears (he looked at the hand), reflect it at once and re-use what worked (SR + RR).
4. If contact drops, go back to simple situational or body reflections. Follow the person's lead to new objects (in Dodds' vignette, the picture and its frame).
5. Let contact build. In the vignette it ended with him touching the picture of a tiger, looking at the carer, growling playfully and smiling.
Example language: illustrative: "We're walking... your hands are by your side... there's the wall." (touches wall) "You're looking at my hand." "There's a picture." "Your hand is on the frame." "You're looking at me, and at the picture."
Watch for: contact may be short and fleeting, especially in dementia. Do not chase it with questions. Signs it is working: increasingly active, playful or emotional engagement, and shared attention.

4.7 Observing contact functions and contact behaviour (in-session assessment)

Purpose / when: continuous, moment-to-moment judgement of whether reflections are producing contact, and in which function. It guides your choice of the next reflection and when to move between stages. [source: Degraeve 2005; Dekeyser et al. 2008]
Steps:
1. After each reflection, watch the next few seconds closely. Researchers coded any change right after a stimulus, from a shift in posture to falling silent. [source: Dekeyser et al. 2008, on the ECPI]
2. Classify what you see. Reality contact: orients to or names people, places, things or events. Affective contact: congruent facial expression, or a feeling word with matching affect. Communicative contact: a socially understandable word or sentence addressed to someone.
3. Keep brief notes after the contact: which reflections led to which contact behaviours. These notes feed reiterative reflection and team handovers. [synthesis]
4. For formal tracking, the research instruments are the Pre-Therapy Rating Scale (PTRS, two versions) and Dinacci's Evaluation Criterion for the Pre-Therapy Interview (ECPI). The PTRS codes transcript phrases for reality, affect, social communication and psychotic communication. The ECPI rates videotaped reactions on indices such as reaction, verbal and physical expressiveness and coherence. Use only the published versions; items are not reproduced here. [source: Dekeyser et al. 2008]
Example language: none; this is observation.
Watch for: reliability of judging non-verbal reflections was lower than for verbal ones in research, so check your impressions with a colleague or on video where possible. [source: Dekeyser et al. 2008]

4.8 Contact reflections in a crisis (de-escalation without coercion)

Purpose / when: an acutely agitated, frightened or psychotic person who is not reachable by instructions or questions. Degraeve's "Ivo" vignette: a young man had thrown furniture in a day room and was crouched in a corner with clenched fists. Prouty & Kubiak reported calming a screaming man with intellectual disability on an outing in a similar way. [source: Degraeve 2005]
Steps (from the Ivo vignette):
1. Reduce stimulation: ask other patients to leave.
2. Position yourself safely and non-confrontationally. In the vignette the worker sat at an angle to the person, not face-on.
3. Anchor the shared situation with situational reflections (where you both are, what is between you).
4. Reflect the person's words word for word, and their posture and fist with body reflections.
5. Wait for contact behaviour. In the vignette, Ivo opened his hand (showing a lighter), made eye contact and named feeling nervous and restless.
6. Once contact is present, move to ordinary dialogue. Ask what would help, offer options, and let the person choose (Ivo chose extra medication and a rest period).
Example language: Degraeve's examples are "here we are sitting now... there's a table between us", "broken" and "you want to leave" (source, translated). Illustrative: "You're in the corner. Your fist is tight." ... "You looked at me."
Watch for: your own and others' safety comes first. Follow local violence-prevention policy, keep exits clear and have colleagues nearby [synthesis]. Signs it is working: muscles relax, the person looks at you, and they name a feeling or a need. In the vignette, restraint, forced medication and seclusion were avoided and the relationship stayed intact. [source: Degraeve 2005]

4.9 Working with hallucinations (pre-symbolic approach)

Purpose / when: Prouty treated hallucinations as pre-symbolic experiences with latent meaning that can be processed, not just symptoms to suppress. Van Werde quotes him calling them a "royal road" to the unconscious. The book has a chapter on "pre-symbolic theory", which is not drawn on. [source: Van Werde 2006; Prouty et al. 2002 table of contents; uncertain about Prouty's exact procedure]
Steps (the process as Van Werde 2021 describes it; it is not a fixed protocol):
1. Establish basic contact first with situational, facial, body and word-for-word reflections (4.1–4.6).
2. Help the person be with the voices or images. Listen in an accepting, concrete way, reflecting what they report seeing or hearing literally, without challenging or interpreting it.
3. Help them look at the experience of hearing voices and become willing to talk about it.
4. Help them integrate the feelings that come up, using facial and word-for-word reflections and later empathic reflections.
5. Allow therapeutic unfolding, which may link the hallucination to relational history or trauma. Van Werde's example: a man realised his voices echoed his ex-wife's insults, after which they lost intensity and he could work on self-worth. Prouty described a woman who had hallucinated a python for years and later worked through real-life trauma. [source: Van Werde 2021]
Example language: illustrative: "The voice is saying 'useless'." "You're looking over there, at the corner." "The snake... you're holding your arms tight." Later: "That word 'useless'… it sounds like someone you know." (A link like this should come from the person, or be offered only once contact is solid.)
Watch for: go slowly. Van Werde advises approaching frightening material only once the person is stronger. Keep reflections literal so you neither endorse nor dispute the content. Monitor distress and risk, and coordinate with the psychiatric team about medication. [source: Van Werde 2006, 2021; synthesis for risk coordination]

4.10 Shifting from contact reflections to empathic reflection

Purpose / when: carrying a client from Pre-Therapy into ordinary person-centred or experiential therapy once contact is present. [source: Faixová 2014]
Steps:
1. Notice sustained contact behaviour: coherent speech, congruent affect, the person making links themselves.
2. Begin offering ordinary empathic reflections of felt meaning, still within the client's frame of reference.
3. If contact drops again (stammering, dissociation, losing the thread), go back to concrete contact reflections, then return. [synthesis, consistent with the grey-zone concept]
4. Resist the urge to fix things through reassurance or medication changes. Faixová says this takes discipline. [source: Faixová 2014]
Example language: illustrative, moving from "You're shaking. Your hands." to "Being among people again brings up a lot of fear."
Watch for: in Faixová's case, the patient then linked a shop-queue panic to his present fear, mentioned contacting his family, and asked for discharge within two weeks. [source: Faixová 2014]

4.11 The Contact Milieu (whole-ward application)

Purpose / when: an inpatient or residential unit for people with psychosis, run so that the whole team restores and strengthens contact (Van Werde, at Sint-Amandus, Belgium). [source: Van Werde 2006, 2021; Prouty et al. 2002 table of contents]
Steps:
1. Agree a shared team mission: contact before content, and restoring versus strengthening contact.
2. Train all staff (nurses, occupational and psychomotor therapists, therapists) to use contact reflections in everyday moments: mealtimes, care tasks, corridors, outings.
3. Combine therapy with widening "healthy functioning": daily structure, simple activities, cultural or community objects that support belonging.
4. Keep the load low, for example only one simple outing per week.
5. Use the weekly ward meeting (4.12) to strengthen contact as a group.
6. Consider medication pragmatically. Van Werde describes it as not systematic but considered in problematic situations. [source: Van Werde 2006]
Example language: illustrative, from a nurse at breakfast: "Bread. You're holding the knife. Butter."
Watch for: it requires a high level of professionalism and a phenomenological, welcoming stance from everyone. Inconsistency across staff undermines it. [source: Van Werde 2006]

4.12 Contact-oriented weekly ward meeting

Purpose / when: a weekly group meeting on a psychosis ward, designed to restore and consolidate reality, affective and communicative contact. It works as a counterweight to drifting into private, idiosyncratic realities. [source: Van Werde, Tijdschrift voor Psychiatrie abstract; Degraeve 2005]
Steps:
1. Hold it at a fixed time each week.
2. Centre it on concrete shared reality: the news, the weather, ward events, planned activities. Activities are planned here. [source: Degraeve 2005; Van Werde 2006]
3. Do not use it to work on individual emotional problems.
4. The facilitator reflects contributions concretely and links them to the shared here-and-now. [synthesis: role detail]
Example language: illustrative: "It's Monday. It rained this morning. Thursday is the outing to the market."
Watch for: the full article (structure, rules, chair role) is not drawn on. [uncertain]

4.13 Anchoring and the "tree" image (psychoeducation for patients and families)

Purpose / when: helps patients and families understand psychotic functioning and the work of anchoring. Van Werde presented it in group sessions for patients and families. [source: Van Werde 2006, 2021]
Steps:
1. Introduce the image of a tree. The crown is symptoms, fantasies and hallucinations; the roots are food, sleep, social ties and daily structure.
2. Explain that when the crown grows large, the work is to feed and strengthen the roots, not to attack the crown.
3. With the person, identify which roots need strengthening now.
4. Use the image to separate person from problem (the "trialogue").
Example language: illustrative: "Right now the top of the tree is very busy, with the voices and the worries. Let's look at the roots: how are you sleeping, eating, and who are you seeing?"
Watch for: it is a conversational aid in plain language. Van Werde claims it travels across cultures. [source: Van Werde 2021]

4.14 Grey-zone use inside ordinary therapy

Purpose / when: for clients who are normally in contact but lose it in certain moments, for example in dissociation, re-activated trauma or a brief psychotic slip. [source: pcaInstitut 2025; Van Werde, as trainer]
Steps:
1. Notice the loss of contact: a fixed gaze, fragmented speech, stammering, a frozen posture, apparently not hearing you.
2. Switch to contact reflections: the room, the person's posture, their exact words, and that you are here.
3. Check, without pushing, that they can perceive you. In Faixová's second case, the therapist stayed beside a crying man and checked he still knew she was there.
4. Once contact returns, resume empathic work, letting the client choose whether to go further ("we can stay on the surface"). [source: Faixová 2014]
Example language: illustrative: "You're on the sofa in my room. Your feet are on the floor. I'm here, next to you." "'Slippery,' you said."
Watch for: for trauma-related dissociation, this sits alongside your usual grounding and stabilisation practice. [synthesis]

4.15 Contact work in dementia and intellectual-disability care

Purpose / when: carers reaching people with advanced dementia or severe intellectual disability, in everyday care. [source: Dodds 2009; Degraeve 2005; Coffeng 2009]
Steps:
1. Rely mainly on non-verbal reflections (facial, body, touch, gesture) when language comprehension is impaired.
2. Use situational reflections linked to sensory cues (touching the wall, the frame, the cup).
3. Consider vague pronouns ("you're holding it") rather than labels, to stay in the person's world.
4. Accept that contact may be brief, and that there may be no response.
5. Fit it into care tasks. Staff reported less resistance to care and easier practical tasks.
Example language: illustrative: (mirroring a smile) "Hello." "You're holding it." "Mum."
Watch for: misjudged state, anger, and strong grief (see section 5). [source: Dodds 2009]

4.16 Extended ("marathon") contact session

Purpose / when: reported once in the sources. Prouty & Kubiak worked with a catatonic man, mute for months, for about 12 hours, after which realistic dialogue and regular person-centred therapy became possible. [source: Degraeve 2005]
Steps: the sources give no procedure beyond sustained contact reflections. [uncertain]
Watch for: this is an exceptional case report, not a standard format. It needs medical oversight, physical care (food, fluids) and team planning. [synthesis]

4.17 Training staff in contact reflections

Purpose / when: introducing Pre-Therapy to a team. [source: Dodds 2009; pcaInstitut 2025; Coffeng 2009]
Steps:
1. Teach theory briefly: contact functions, the reflections and pre-expressive meaning.
2. Use demonstrations and role-plays.
3. Video-record real interactions and review them as a team.
4. Hold regular team discussions on difficulties.
5. Explain the approach to colleagues and relatives so it is not mistaken for odd behaviour.
6. Allow time to practise; it often feels artificial at first.
Watch for: staff fear of looking foolish, and time pressure. Person-centred training is suggested as a prerequisite. [source: Dodds 2009]

5. Handling problems

5.1 No response at all (the "stuck" pre-expressive client). Dodds reports that sometimes nothing comes back [source: Dodds 2009]. Responses:

Slow down and shorten your reflections.
Change channel: from verbal to non-verbal, or from situational to body or facial.
Use sensory anchors such as touching objects in the person's field of view.
Re-use anything that once got a flicker of response (reiterative reflection).
Plan several short contacts rather than one long one, and record micro-responses across days. [synthesis]

Degraeve's and Van Werde's material implies that progress is counted in small steps over long periods. [source: Van Werde 2021]

5.2 Irritation, anger or aggression in response to reflections. In Dodds' study, a mirrored resident became angry and walked away, and a non-verbal resident hit a carer. Dodds links this to misjudging the person's state: they may have been more expressive than assumed. [source: Dodds 2009] Responses:

Stop mirroring.
Acknowledge in ordinary adult language, for example: "I'm sorry, that was annoying" (illustrative).
Step back to give physical space.
Reassess whether the person is in the grey zone or expressive, and if so use ordinary empathic conversation instead.
Follow local safety procedures. [synthesis]

5.3 The client experiences reflections as mockery or as being treated like a child (a rupture). Responses:

Repair openly and briefly.
Explain plainly that you are trying to follow what they are experiencing.
Ask, if they can answer, whether they want you to keep doing it.
Make reflections less literal, or move to empathic reflections.

The repair steps are [synthesis]. The concern itself is reported by staff in [source: Dodds 2009].

5.4 Overwhelm from emerging affect (the client's). Facial and word-for-word reflections can quickly open intense grief, fear or trauma material. Examples are the long crying episode in Faixová's second case, and the resident calling for her mother in Dodds' study. [source: Faixová 2014; Dodds 2009] Responses:

Stay present, do not push, and check that the person still perceives you.
Sit alongside them so they are less alone.
Offer the option of "staying on the surface".
After the peak, reflect what the person says about it, for example shame at crying. [source: Faixová 2014]
If dissociation deepens, return to situational and body reflections in the here-and-now (4.14). [synthesis]

5.5 Hallucinations or delusions intensify during contact. Responses:

Keep reflections literal: reflect what the person reports, not what you think is real.
Do not argue and do not elaborate the content.
Bring in situational reflections to re-anchor in shared reality.
Defer deeper processing until the person is stronger. [source: Van Werde 2006, 2021 for pacing; synthesis for the specifics]
Liaise with the psychiatric team on medication and risk. [synthesis]

5.6 Overwhelm in the worker. Carers reported feeling helpless or hopeless, being "drawn into" a resident's grief, and fearing they would open "a can of worms" they could not manage on a busy ward. [source: Dodds 2009] Responses:

Provide regular supervision or team reflection, and video review.
Agree in advance what a worker does if strong emotion surfaces and they must leave, for example handing over to a named colleague or returning at an agreed time. [synthesis]

5.7 Feeling artificial, too simple, or self-conscious in front of colleagues. This was common in Dodds' study [source: Dodds 2009]. Responses:

Build the skill through role-play and practice in low-stakes moments.
Keep the team informed of what you are doing and why.
Remember that the simplicity is deliberate: the reflections are meant to meet a person who cannot yet use complex language. [source: Dodds 2009; pcaInstitut 2025]

5.8 Time pressure and "non-adherence" by the system. Ward and care-home workloads crowd out one-to-one contact [source: Dodds 2009]. Responses:

Embed reflections in tasks you already do (care, meals, walks) rather than adding sessions.
Use the weekly ward meeting.
Make contact work part of the shared team mission, so it is not left to one enthusiast. [source: Van Werde 2006, 2021; synthesis for the embedding advice]

5.9 The therapist's urge to fix, reassure or medicate. Faixová names the pull to solve the problem (for example by adjusting medication) and to comfort or reframe. Both break the non-directive stance. [source: Faixová 2014] Responses:

Notice the urge, return to concrete reflection, and let the client lead.
Keep medical decisions separate from the contact work where roles allow. [synthesis]

5.10 Misjudging the client's level (under- or over-estimating). Responses:

Check the client's responses regularly.
If they answer reflections with coherent, contactful speech, move up to empathic reflection (4.10).
If ordinary empathic responses get no contact, move down to contact reflections.
Expect people to oscillate between levels. [source: Dodds 2009; Faixová 2014; synthesis for the explicit rule]

5.11 Agitation and risk of violence. Use the crisis sequence in 4.8: reduce the audience, take an angled position, give space, and reflect the situation, words and body. Prioritise safety, and use your service's de-escalation policy where reflections do not work. [source: Degraeve 2005; synthesis for the safety framing]

5.12 Suicide and self-harm risk. The sources do not address this. With a contact-impaired client, standard risk assessment may not be possible in words, so rely on observation, collateral information from staff and family, and the clinical team. When contact returns, carry out a standard risk assessment, including safety planning and lethal-means counselling (safe storage or removal) as indicated. Contact restoration does not replace risk management. [synthesis]

5.13 Consent and capacity. The sources do not address consent with people who cannot communicate. Treat Pre-Therapy as low-intrusion contact offered within the person's care plan. Watch for non-verbal refusal, such as turning away, leaving or pushing away, and respect it. Involve legal representatives or family according to local capacity law. Avoid touch without clear acceptance. [synthesis]

5.14 Ending and relapse. Contact can be lost again under stress or during relapse. Hand over the reflections that worked (reiterative material) to the team and family, and keep the person's "roots" strong (sleep, structure, relationships) as relapse prevention. [source: Van Werde 2006, 2021 for the roots image; synthesis for the handover advice]

5.15 Collusion worries from colleagues ("you're feeding the delusion"). Explain that contact reflections are literal acknowledgements of what the person reports or shows. They neither agree with nor dispute the content, and their purpose is to restore shared reality. Use the tree image (4.13) to frame the work for colleagues and families. [synthesis, drawing on Van Werde 2006, 2021]

Sources

Sources: