Humanising Psychiatry and Mental Health Care

The Challenge of the Person-Centred Approach

Rachel Freeth

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315347837
• Edition: 1
• Topic: Medicina
• Subtopic: Teoria, pratica e riferimenti medici

This book explores, in depth, the link between modern psychiatric practice and the person-centred approach. It promotes an open dialogue between traditional rivals – counsellors and psychiatrists within the NHS – to assist greater understanding and improve practice. Easy to read and comprehend, it explains complex issues in a clear and accessible manner. The author is a full-time psychiatrist and qualified counsellor who offers a unique perspective drawing on personal experience. Humanising Psychiatry and Mental Health Care will be of significant interest and help to all mental health professionals including psychiatrists and psychiatric nurses, social care workers, occupational therapists, psychologists, person-centred counsellors and therapists. Health and social care policy makers and shapers, including patient groups, will also find it helpful and informative.

Section One:

Theoretical and philosophical challenges of the person-centred approach

Chapter 1

What is the person-centred approach?

‘The central hypothesis of this approach can be briefly stated. It is that the individual has within himself or herself vast resources for self-understanding, for altering his or her self-concept, attitudes, and self-directed behaviour - and that these resources can be tapped if only a definable climate of facilitative psychological attitudes can be provided.’

(Rogers, 1990/1986, p. 135)

Introduction

Not long ago I saw a job advertisement on an NHS Trust website for a project manager, aiming to attract someone who was ‘passionate about ensuring a “person centred” approach to working practice’. I was immediately curious. Was the NHS really looking for someone who, like me, was an advocate of the person-centred approach as formulated by Carl Rogers? Responding to my curiosity, and willing to challenge my scepticism, I replied to the advertisement asking what was meant by the term ‘person centred’. My scepticism was confirmed. It was simply a direct reference to Standard Two of the ‘National Service Framework for Older People’ (DH, 2001). This states that ‘older people and their carers should receive person-centred care and services which respect them as individuals and which are arranged around their needs’ (p. 23).

The National Service Framework (NSF) for Older People is not the only Department of Health (DH) document that uses the term ‘person centred’. More recently, guidance on developing a psychiatric workforce, whose contributors include the Royal College of Psychiatrists and the National Institute for Mental Health in England (NIMHE), refers to providing ‘developmentally orientated, person-centred, socially inclusive and recovery-orientated services’ (DH, 2004a, p. 6). There has been a veritable proliferation of person-centred terminology within health care settings, but it is rarely used with reference to the person-centred approach as outlined by Carl Rogers, his co-workers and person-centred practitioners today.

This is a significant barrier to promoting an accurate understanding of the person-centred approach in mental health and other NHS settings, making it difficult for person-centred counsellors and psychotherapists to establish themselves and their approach. In this chapter I shall review in more detail some of the ways in which the terms ‘person-centred’ and the similar sounding terms ‘patient-centred’ and ‘patient-centred care’ are used within the NHS and other health care organisations.

However, other major challenges for the person-centred approach are that it runs counter to the prevailing culture within health care organisations, as this book will regularly demonstrate. I also believe that an accurate understanding of the approach rests on an appreciation of its underlying philosophy and values. Put another way, a great deal of misunderstanding and superficial treatment of the approach results from the absence of a basic grasp of its fundamental philosophical principles. It is unfortunate that even graduates of some counselling training courses claiming to have as their core theoretical model the person-centred approach, lack an appreciation of basic philosophical principles. Many mental health professionals are offered even less opportunity to explore the foundation of person-centred theory and practice, receiving only a cursory introduction to the ideas of Carl Rogers and the person-centred approach. Psychiatrists, according to Gask (2004), are not routinely educated in cultural and philosophical concepts at all, let alone the philosophy of the person-centred approach and other humanistic approaches.

In this chapter then, I shall also present the key philosophical principles and values of the person-centred approach. The final section will introduce the major contribution of Carl Rogers and provide an overview of person-centred theory and practice that will be explored in more depth in subsequent chapters.

Patient-centred, person-centred care and the person-centred approach: are you confused?

Uses of the term ‘patient-centred’

The terms ‘patient centred’ and ‘patient centred care’ are now used frequently in policy documents and guidelines. For example, The NHS Plan states that ‘the NHS must be redesigned to be patient centred’ (DH, 2000, p. 17). Indeed, developing patient-centred services is a major theme of the current Labour government’s health policy. So when health care professionals use the term ‘person-centred’ do they mean ‘patient-centred’?

The situation is confusing. It is often by no means clear what health care professionals and the government mean when they use the term ‘patient centred’ (with or without a hyphen). In my reading of the health care literature, I have noticed two main ways in which the term is used. First, it is used to describe a value or philosophy of health care (a guiding principle) that informs policy development. The Committee on Quality of Health Care in America (2001) provides an example of this when it gives ‘patient centred’ as one of six key characteristics of ideal health care. In their report, ‘patient centred’ refers to respecting and responding to individuals’ preferences, needs and values. There are clear similarities here with The NHS Plan, in which one of the core principles of the NHS is described as follows: ‘The NHS will shape its services around the needs and preferences of individual patients, their families and their carers’ (DH, 2000, p. 3).

The second way in which the term ‘patient centred’ is used is as a description of the nature of the relationship between a doctor (or other helping professional) and their patient, and of what the doctor-patient consultation should achieve (Schofield, 2000). This is sometimes referred to as ‘patient centred medicine’. As a clinical method, this has become an academic subject and also a focus of research. Various forms have been developed in recent years, initially as a reaction to the paternalistic consultation style. Essentially ‘patient centred care’ represents a change in the mindset of the doctor from the traditional authoritarian and controlling stance, towards one of shared decision-making and patient empowerment (Stewart, Brown, Weston et al, 2003). The striving towards partnership between patients and professionals lies at the heart of such care. Built into a ‘patient centred consultation’ is an attempt on the part of the professional to understand the whole person. ‘Patient centred’ denotes a focus on the patient rather than the problem or disease. By listening to the patient’s perspective, the helper will also develop an understanding of the patient’s subjective experience of illness. The conversation will not, in other words, be dominated by the language and process of making a diagnosis. Patient-centred communication skills include active listening and providing empathy and support.

Whilst it is clear what is meant by ‘patient-centred’ as a clinical method and type of relationship, it is less clear what ‘patient-centred’ and ‘person-centred’ mean when describing a value or philosophy of health care. What attitudes and values are actually being referred to? Or are these just convenient, ‘feel good’ terms that have now become highly favoured by politicians, managers, and those charged with making policy and writing guidelines and mission statements?

The meaning of ‘person-centred’ within health care settings

The term ‘person centred’ in UK health policy seems to have undergone changes in its meaning. It now has as its main focus not only the concept of partnership, but also that of patient choice. Furthermore, when referred to by politicians, choice is often wrapped up in the language of consumerism. For example, Prime Minister Blair in ‘The NHS Improvement Plan’ refers to the public as expecting ‘high-quality products, better services, choice and convenience’ (DH, 2004b, p. 3), and asserts that the NHS must be modernised accordingly. In The NHS Improvement Plan, patient choice has become linked to providing ‘personalised care’ when it refers to ‘giving people greater personal choice and empowering them to personalise their care to ensure the quality and convenience that they want’ (p. 9). In the Executive Summary of The NHS Improvement Plan the words ‘personal’ or ‘personalised’ are mentioned no less than 22 times. Thus, ‘person centred’ comes to be equated with notions of personal and personalised care, and seems to represent an ideology in which consumerism, choice, ‘plurality of provision’ of services, and market forces are viewed as the drivers of health care delivery in the public as well as private sector. In addition to being linked to choice, ‘person centred’ and ‘patient-centred’ services describe services that are interested in giving patients more say through patient surveys and the development of strategies for patient and public involvement in service planning.

In the academic literature of the helping professions, the term ‘person-centred’ is often used to convey humanistic ideas in general. For Barker (2003) ‘person-centred care’ means focusing on the person - the human being - rather than the pathology. It conveys attitudes of respect for the individual with his or her unique experience and needs. For Watkins (2001), ‘person-centred’ conveys a holistic approach, particularly with reference to the assessment of mental health problems. Watkins also uses the term ‘person-centred’ with reference to Carl Rogers, but like many other authors, misses the full distinctiveness and radical nature of the person-centred approach. For example, the non-directive nature of the person-centred approach is not emphasised. Watkins and Barker provide good examples in mental health literature of authors who refer to the person-centred approach when in fact they are describing the broad sweep of humanistic ideas and philosophy, or simply notions of holistic care. A gross example of the misleading use of the term ‘person-centred approach’ can be found in the title of a book that has nothing to do with the person-centred approach of Carl Rogers. ‘Psychotherapy with Suicidal People: A Person Centred Approach’ (Leenaars, 2004) is simply concerned with developing a holistic approach to suicidal ideation.

It should now be clear why it is impossible to formulate a definition of ‘person-centred’ as applied in health care settings. The best one can do is to generate a list of possible meanings or concepts with which it is associated.

The person-centred approach in health care settings

Despite the wide use of the term ‘person centred’, both in mental health and other health care settings, it is rare, in my experience, for it to be used with direct reference to the person-centred approach as a major theoretical system, philosophy and practice developed by Carl Rogers, his co-workers and practitioners of person-centred counselling and psychotherapy today. Perhaps this is unsurprising given the fact that it is mainly counsellors and psychotherapists who are likely to study this approach in depth. Training courses for many mental health professionals will usually include on their curriculum something about Carl Rogers and the person-centred approach, but in recent years ‘skills-based’ approaches such as that of Gerard Egan (1994), cognitive-behavioural approaches, and approaches that lend themselves more easily to measurement, structured working and evidence-based practice, feature more heavily.

There are many aspects of the kinds of person-centred and patient-centred care just described that person-centred counsellors and psychotherapists will recognise. Carl Rogers and the development of person-centred therapy from the middle of the last century have undoubtedly been massively influential in the helping professions. Sometimes the influence of Rogers is acknowledged, for example in the development of the patient-centred clinical method by Stewart, Brown, Weston et al (2003). More often than not though, the term ‘person centred’ is used loosely and without an understanding of where its ideas and philosophy have originated. Worse is when the term is used simply as a catchphrase with no particular meaning. Sometimes it simply seems to be a term of political correctness.

Advocates of the person-centred approach often struggle to explain their way of working and make a claim for its distinctive and radical nature. The widespread and varying use of person-centred terms is a significant impediment that makes it even more essential for person-centred practitioners to be rigorous in checking their own use of language and terminology, and to be clear about what they mean and what they want to convey. It also doesn’t help that some therapists describe themselves as person-centred when their actual practice reveals that they have departed from the fundamental values of the person-centred approach and consists of an eclectic mixture of techniques, thus misrepresenting the person-centred approach. It is also necessary for the person-centred practitioner, in attempting to explain their way of working, to check what the listener has understood, since adherents of the medical model may find it difficult to comprehend an approach that adopts an altogether different paradigm.

More than a type of therapy

The person-centred approach is most often associated with a type of counselling or psychotherapy. This is understandable since Rogers and his colleagues spent much of their working lives as therapists, and much of what Rogers writes is in the context of therapy. Furthermore, most texts with ‘person-centred’ in the title, academic or otherwise, are concerned with the approach as it relates specifically to counselling and psychotherapy.

It is, however, becoming increasingly recognised that, whilst the person-centred approach may have originated as a very distinctive type of therapy, revolutionary even, it is also an ‘approach to life both in and beyond therapy’, as described by Embleton-Tudor et al (2004, p. 3) in their recent book ‘The Person-Centred Approach. A Contemporary Introduction’. In this book the person-centred approach is further described as ‘a comprehensive, coherent and holistic approach to human life and concerns’ (p. 3). In other words, it can be applied to all aspects of life and living, and this book is one of the first post-Rogers to examine the person-centred approach to aspects of life and living outside therapy.

Rogers himself recognises that the person-centred approach can be embraced outside the therapy room when he writes ‘... I am no longer talking simply about psychotherapy, but about a point of view, a philosophy, an approach to life, a way of being ...’ (1980, p. xvii). It is recognition of this that leads him to use the term ‘person-centred approach’ where previously he and his colleagues would always have referred to ‘client-centred therapy’.

What Rogers formulates is a philosophy of human beings and relationships ‘which fits any situation in which growth - of a person, a group, or a community - is part of the goal’ (Rogers, 1980, p. xvii). This means that the person-centred approach can be taken into any situation involving human beings. It can therefore be viewed, in Rogers’ words, as a ‘philosophy of living and relationships’ (1980, pp. 37-38, original italics), or as ‘a practical philosophy of living’ (Van Kalmthout, 2004, p. 197). Van Kalmthout is keen to highlight the approach as a philosophy to be lived rather than one just to intellectualise. Specific fields outside therapy to which Rogers devoted his energies, particularly in his later years, include group work, leadership, international peace work (realising his ideas had powerful political implications), and the fields of education and learning. In addition, many have testified to how Rogers embodied the person-centred approach in the way he lived his life and related to others, in both his personal and professional life.

For me, the person-centred approach also involves entering the challenging terrain of ethics and values. Ethics is essentially concerned with morals and values. A summary definition of values is that they are ‘conceptions of the morally desirable’ (New, 2002, p. 20). Living the person-centred approach certainly involves embracing a set of values. The approach can therefore be described as an ethical engagement with life, living and relationships. I also regard this as much more than working from a professional, ethical code of practice to which most health professionals are required to subscribe, since clearly I am again referring to the approach as one that can be lived outside the workplace. Put another way, the values with which I live my life are also those I bring to my work.

As a psychiatrist I am conscious daily of the ethical issues th...