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A first experience of using Cognitive Analytic Therapy with a person with a learning disabilit

Westwood, S., & Lloyd, J., 2014. A first experience of using Cognitive Analytic Therapy with a person with a learning disabilit. Reformulation, Summer, pp.47-50.

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This article is designed to share with the reader reflections on my first experience of using Cognitive Analytic Therapy (CAT) with a person with a learning disability. I will detail the challenging elements of the work and thread the themes of my development as a Trainee Clinical Psychologist throughout the account. I aim to emphasise the value of learning about CAT and demonstrate the applicability of it when working with a person with a learning disability.

Introduction

At the time of writing this article I was a third year Trainee Clinical Psychologist. I had recently completed a six month placement in a multidisciplinary community team for people with learning disabilities where I was given the opportunity to learn about CAT (Ryle, 1967, 1975, 1982) and apply this to my clinical work.

Themes of my development as a Trainee Clinical Psychologist

Prior to clinical training I worked as an Outreach Support Worker for people with learning disabilities and mental health difficulties. Some relational difficulties arose with my clients during this time and without the appropriate supervision or support available, I was left feeling upset and frustrated. Applying CAT to these incidents has enabled me to think about the relational dynamics and cultural factors, such as ethnic diversity and working with people from disadvantaged backgrounds, that affected my relationships with these clients.

As I will attempt to outline in this article, CAT, an integrative therapy, allowed me to work with Oliver using a flexible, tailored and empathic approach. I believe this was crucial to the success of our work. It also enabled me to reflect on the wider social and political factors at the individual, organisational and societal level that affect Oliver and people with intellectual and physical disabilities. For example, a person with learning disabilities may be discriminated against by peers in the community, have difficulty accessing public sector services, and fail to achieve societal expectations of 'success' through the accumulation of knowledge and financial wealth.

Oliver

Oliver was a man in his twenties with a ‘moderate’ learning disability which had been assessed at a young age. I observed his difficulties with attention and concentration, and abstract thinking and we were able to work with written materials using simple and clear language and pictures. He had experienced physical health problems and subsequent hospital admissions since birth. Oliver was unemployed and not engaged in any meaningful activity. He brought to therapy themes of abandonment and loss: Oliver had learnt during his teens that the man who he had thought was his natural father was his step-father. His natural father had abandoned Oliver when he was a young child. A previous therapy experience during his teens had ended after only the first session when Oliver had thrown a chair at the therapist. Oliver reflected that he had felt angry at the time and was now ready to address his anger with clear motivations for attending therapy. I was mindful of Oliver's past behaviour and considered this in my risk assessment.

Oliver was referred by his support worker for difficulties managing his emotions, especially anger, in response to on-going relational difficulties with Lucy, his girlfriend. Consent for therapy was obtained by discussing with Oliver the number of sessions available and timings of these; how he might travel independently to the sessions, and the principles of therapy.

Preparation for the assessment

I was fortunate enough to have the opportunity to attend a weekly twohour CAT supervision group for Multi- Disciplinary Team (MDT) members of the service I was placed in. ‘Change for the better’ (Wilde-McCormick, 2002) and ‘Introducing Cognitive Analytic Therapy’ (Ryle & Kerr, 2002) became my bibles to developing my knowledge of CAT. A particularly challenging aspect of my reading was to try and understand the theoretical underpinnings of CAT (see Ryle & Kerr, 2002, for review). In particular, I tried to remain mindful of the ‘Zone of Proximal Development’ (ZPD; Vygotsky, 1978), the difference between a person’s actual and potential ability, and the role of ‘scaffolding’ (Wood, Bruner & Ross, 1976), a process whereby a teacher will provide the appropriate support and tools for a student to reach their potential ability. This was crucial to working with Oliver. My weekly individual CAT supervision helped me to integrate this knowledge and apply it to my work.

The assessment

During an initial assessment with my clinical supervisor, Oliver had stated that he wanted his situation with Lucy changed in therapy and was was ambivalent about attending our first therapy session. On my Clinical supervisor's suggestion, I used a pie chart as a visual diagram to display to Oliver the 16 sessions that were available to us (each section of the pie was coloured-in at the end of each session). This prompted discussion of what might be realistically achieved in therapy. Despite his initial ambivalence about coming to therapy, Oliver was very open with me in our first session and it seemed that he was relieved to have someone to talk to.

The aim of the assessment was to form a picture of Oliver’s ‘target problems’ i.e. the difficulties that therapy will address (Ryle & Kerr, 2002). This meant difficulties managing emotions in stressful situations for Oliver. As part of exploring his difficulties during the assessment, Oliver and I explored the concept of ‘reciprocal roles’ (RR) in pictorial form. He responded well to this format as evidenced by his comments and stories following the presentation of particular RRs. My Clinical supervisor described RR’s to me as ‘the way a person tends to be, treats themselves and others, and the way they invite others to treat them which originates in childhood’. Whilst in a role, reciprocation is sought or experienced from another or the internalised ‘voice’ of another (Ryle & Kerr, 2002). Roles can be seen as themes of a person’s character which can become over-expressed and problematic. I utilised adapted CAT therapy materials to explore with Oliver the three different positions of RR’s in his life: ‘desired’, ‘chronically endured’ and ‘dreaded’. Oliver identified with ‘accepting-accepted’, ‘putting others in the bin-being put in the bin’, and ‘abusing-abused’ RR’s and we used his language to describe them. The first RR represented his desired relational position with his girlfriend and peers. I suspected that this RR also related to his desire to be accepted as a man and an individual in the community and wider societal context. The latter RRs were the dreaded, or chronically endured, positions that had been enacted in Oliver's life. Together we explored the origins of these.

Our next challenge was to explore the ‘procedures of the target problem’ which involved exploring the mental, behavioural and external events and other people involved in Oliver’s target problem (Ryle & Kerr, 2002). This formed a sequence which served to confirm Oliver’s negative beliefs and maintain his target problem. Having spent a large amount of time during my clinical psychology training creating formulations using Cognitive-Behavioural Therapy units of observation i.e. thoughts, feelings, behaviours, physical sensations, I now had to learn to shift my thinking to slightly different units of observation. My Clinical supervisor pointed out that CAT doesn’t focus too closely on the division between thoughts and emotions: it is more about validating feelings and changing behaviours rather than attempting to get rid of or change the emotion.

Oliver and I created a ‘sequential diagrammatic reformulation’ (learning CAT terminology was another challenge altogether for the author) of his target problem, otherwise known as a ‘map’, which contained the procedures of his target problem and centralised the RR’s as Oliver’s ‘core pain’. We called this Oliver’s ‘vicious circle’. This was helpful as a focus of our work especially given that during the assessment it was evident that Oliver struggled to maintain concentration and attention to tasks. As Oliver and I developed the map together over three to four sessions, I was mindful of his ZPD and, in parallel, my Clinical supervisor was mindful of my ZPD in supervision.

I wrote Oliver a ‘reformulation letter’ at the end of the assessment phase (session 6) as a summary of our work together thus far. I asked him how he felt about it after having read it through with him. He said ‘fine’ and quickly folded it up and put it away in his pocket. I reflected that this might represent his difficulties with expressing emotion and processing this through discussion with others. Equally, he may have also disagreed with the letter or perhaps found it difficult to absorb all of the information at once and been too embarrassed or ashamed to tell me.

Interventions

Oliver and I collaboratively decided on an exit point in his vicious circle. Rather than ‘having a go’ or ‘walking away’ when wanting Lucy to ‘stop going on at’ him, Oliver and I created a list of strategies displayed on a poster to help him keep ‘my calm and cool’ and ‘learn to stand up for myself in an assertive way’. Some of these strategies were similar to CBT techniques, hence CAT’S integrative nature. Of these strategies, some were more helpful than others. For example, I attempted to teach Oliver the ‘DEAR MAN’ Dialectical Behaviour Therapy (Linehan, 1993) skill as a means of developing assertiveness in communication. Oliver was unable to follow the steps sequentially or stay focused on the task. This seemed to reflect his difficulties with attention and concentration.

I was reminded of the importance of Vygotsky’s ZPD whilst Oliver and I were practicing the ‘soles of the feet’ mindfulness exercise for managing anger (Singh, Wahler, Adkins, Myers & The Mindfulness Research Group, 2003). Oliver had seemed unsure about its helpfulness however a few sessions later he spontaneously told me that he had been using this his adapted version of the technique and it proved helpful. By providing the initial support and tools and using a trial and error method, we were able to tailor therapy to suit Oliver's needs.

Ending

Using the pie chart with Oliver as a prompt to discuss the ending of our work from session 12 was helpful. We spent time exploring his feelings and discussed how the ending of our therapy might be different from other endings in his life.

Oliver completed the Clinical Outcomes in Routine Evaluation measure for People with Learning Disabilities (CORE-LD; Marshall, & Willoughby-Booth, 2007) as a pre and post therapy measure. Although Oliver’s total clinical score had reduced from 17 to 14 and his risk score had reduced from 5 to 1, I was unsure of the validity of the measure. There are no standardised norms for people with learning disabilities and I observed that Oliver hadn’t been able to fully consider the concept of ‘over the past week’ when completing the CORELD. I focused on the value of Oliver’s qualitative feedback in which he told me ‘it’s helped me to get the painful emotions out…to have someone to talk to and listen to me’.

I wrote Oliver a goodbye letter to outline our achievements together, challenges for the future and my reflections of our work together. I read it aloud to him during our penultimate session and Oliver gave me more feedback following this than after I had read the reformulation letter to him. I saw this as representing the positive growth in our therapeutic relationship. I perceived our relationship to be one in which Oliver could begin to express his emotions. I tried to be sensitive to enactments of the procedure detailed in the 'vicious circle' and it was likely that I may have missed subtleties of this.

Critical evaluation and reflections

I considered the relatively limited evidence base for using CAT with people with learning disabilities. The current favoured evidence-based paradigm, namely the use of randomly controlled trials, is difficult to apply to people with learning disabilities (Royal College of Psychiatrists, 2004). Practice-based evidence can be clinically useful and there are over 20 case studies outlining the efficacy of using CAT with people with learning disabilities and there have been calls for more robust research to expand the evidence base (Breckon & Simpson, 2011).

I felt that 16 sessions had been too short (due to my length of time on clinical placement) for therapy with Oliver and I had been anxious during therapy about taking too long to learn how to deliver CAT. My Clinical supervisor assured me otherwise but stated that 24 sessions would usually be offered. I thought that 24 sessions would have enabled Oliver and I to continue to develop his skills in recognising the vicious circle as it happens and applying the strategies to exit it.

In terms of outcome measures, Oliver and I developed rating scales of his ability to recognise his vicious circle and use his strategies to exit it. This might have served as another outcome measure of our work although we developed this in the latter part of therapy. We might have used the Interpersonal Inventory-32 (Barkham, Hardy & Startup, 1996) however this has not been adapted for people with learning disabilities and it would have been time-consuming for Oliver and I to complete. These issues with outcome measures represent wider issues of using reliable and valid outcome measures with people with learning disabilities.

Being mindful of Oliver’s and my own ZPD enabled me to learn in a way that was manageable and stimulating. Using a trial-and-error method with feedback from Oliver to assess the suitability of therapy materials enabled us to create a trusting therapeutic alliance over time. I believe CAT allowed us to refl ect on the social barriers, such as limited access to vocational opportunities, that Oliver faces in his life and I thought this also helped to strengthen our therapeutic relationship. Working with Oliver and using CAT has allowed me to continue to develop my knowledge and skills in addressing the social and political issues that affect individuals with learning disabilities (and to consider its applicability for those without learning disabilities) in addition to developing as an integrative practitioner to provide therapy for people with complex and challenging mental health needs.

Disclaimer

The views expressed in this article are solely those of the authors and not the organisations they are employed by.

Acknowledgements

Thank you to Oliver for his consent to write this article, MDT members of the CAT Supervision Group and my Clinical supervisor for her patience, warmth and expertise in addition to editing of this manuscript.

Affiliations

Sophie Westwood, Clinical Psychologist, University of Surrey.

Julie Lloyd, Clinical Psychologist, South West Surrey Community Team for People with Learning Disabilities, Surrey and Borders Partnership NHS Foundation Trust.

Address

Dr Sophie Westwood, Clinical Psychologist, email: sewestwood@ googlemail.com.

References.

Barkham, M., Hardy, G., & Startup, M. (1996). The IIP-32: A short version of the inventory of interpersonal problems. British Journal of Clinical Psychology, 32, 21–35.

Breckon, S. & Simpson, J. (2011). The case for a role for cognitive analytic therapy in learning disability services. Clinical Psychology & People with Learning Disabilities, 9, 2-7.

Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.

Marshall, K. & Willoughby-Booth, S. (2007). Modifying the Clinical Outcomes in Routine Evaluation measure for use with people who have a learning disability. British Journal of Learning Disabilities, 35, 107-112.

Royal College of Psychiatrists, (2004). Psychotherapy and Learning Disability. London.

Ryle, A. (1967). A Repertory Grid Study of the Meaning and Consequences of a Suicidal Act. British Journal of Psychiatry, 113, 1393-1403.

Ryle, A. (1975). ‘Self-to-Self, Self-to-Other: The World’s Shortest Account of Object Relations Theory’, New Psychiatry, 12-13.

Ryle, A. (1982). Psychotherapy: A Cognitive Integration of Theory and Practice. London: Academic Press.

Ryle, A. & Kerr, I. B. (2002). Introducing Cognitive Analytic Therapy: Principles and Practice. Chichester: Wiley.

Singh, N. N., Wahler, R. G., Adkins, A. D. & Myers, R. E., & The Mindfulness Research Group (2003). Soles of the feet: a mindfulness-based self-control intervention for aggression by an individual with mild mental retardation and mental illness. Research in Developmental Disabilities, 24, 158–169.

Vygotsky, L. S. (1978). Mind in society: The development of Higher Psychological Processes. Cambridge: Harvard University Press.

Wilde-McCormick, E. (2002). Change for the Better: Self-help through practical psychotherapy. London: Continuum.

Wood, D., Bruner, J. S. & Ross, G. (1976). The role of tutoring in problem solving. Journal of Child Psychology and Psychiatry, 17, 84-100.

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Westwood, S., & Lloyd, J., 2014. A first experience of using Cognitive Analytic Therapy with a person with a learning disabilit. Reformulation, Summer, pp.47-50.

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