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A Dog in the World of ACAT

Gray, M, 2014. A Dog in the World of ACAT. Reformulation, Winter, pp.11-14.

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Six years ago I got a border terrier puppy and started taking her to my work in an outpatient department of the Royal Edinburgh Hospital. This was initially to facilitate training her and was totally in my own interest. In order that she didn’t interfere with the work of the unit she had a large comfortable crate in the staff room and got used to staying in this when I was busy with patients and meetings though she joined me in my office when I was writing up notes or doing administration. She was encouraged not to bark and was friendly with all the new people she was meeting. Her name is Matilda and I want to talk about how she became part of my therapy so that now that I have retired from the NHS she comes with me every day, interacts with my patients and gives me another way to see enactments of reciprocal roles. The more benign RRs are often not displayed in therapy particularly with patients who have had lots of contact with services and are angry about not being helped.

There is a lot of information around about pets generally making our life better, reducing stress and extending the life of the elderly. I will quote only one of the many interventions to use pets in helpful ways. It is called “Paws against Stress” and took place at Edinburgh University and St Andrews University. It involved setting up sessions prior to exams where students could meet with therapet dogs for short periods. There were 5 events, 15 different dogs took part and 435 student were seen. The first 3 sessions were audited with 90% of 223 respondants recommending the event and 94% saying that they felt less stress after the event. (Ruthven 2014 pp7 -11)

What we at the Centre started to notice with Matilda was the way that the staff would come to visit her after difficult sessions, stroke her and hold her while talking about their cases.

As I was taking her out for a walk patients who were waiting to be seen would call her over to talk to them and take the opportunity to reassure themselves that they were in the right place or hadn’t been forgotten. Generally the stress levels in the unit went down. As Matilda was always on a lead in public places those patients who were allergic or fearful of dogs were able to indicate that they didn’t want to be approached and Matilda quickly learnt who to avoid. The most useful piece of work in
which Matilda was involved was with a very difficult and distressed patient with a diagnosis of Borderline Personality Disorder.

During this time I had gradually tried involving Matilda in varying ways. I had several low weight anorexic patients and the sessions always felt very empty and often became anxious, coercive to anxious, defended. Talking in the supervision group elicited similar reactions in others and various less direct interventions had already been tried by others with some success.

Some of these young women liked animals so I started taking Matilda into the room and we were able to find other things to talk about and sometimes to see a different RR between the patient and Matilda. I found that if I asked before I took Matilda into the room I would be met with refusal so I would have Matilda in the room and then ask if I should take her out. This allowed inertia to work in favour of the new intervention. I also took Matilda into the DBT group wind down on some occasions and we talked about using animals as part of a soothing, mindfulness practice.

It seemed to me to be important that Matilda was my dog and not a general pet of the unit. Perhaps this allowed the positive RR of caring to cared for without words or physical contact with me. About this time I found an article in the British Journal of Psychotherapy by Anita Sacks entitled The Therapeutic Use of Pets in Private Practice which I recommend to anyone interested in this area. She says,

“Patients who might benefit from a companion animal being present include those who suffer from intense ambivalence and have difficulty in developing a therapeutic alliance. Positive feelings will get transferred to the pet and may even help the
patient to remain in treatment if the negative transference remains with the therapist.”

Anita Sacks goes on to say
“Also with patients with intimacy difficulties who are unable to establish a relationship with a significant other, and find themselves alone and lonely, the animal is a social lubricant that can be touched and gives unconditional love and acceptance. The therapist does not gratify these physical needs and desires. The companion animal also may be a mediating influence for inhibited and constricted patients who find it painful to relate verbally to a therapist. Pressure to do so is reduced
and the pet can be a deflection in a positive sense.” This was my experience with the patients with anorexia who were gradually able to talk about emotions and be more lively in the sessions.

Unfortunately things changed at work. A blind eye had been turned by the hospital authorities to Matilda being in the unit but someone brought it formally to their attention and I was told to stop bringing her to work. This raised mixed feelings in me. On the one hand I can see that I was being “special” which leads to envy and rivalry but I also felt that we were beginning to see improvements in the patients and if we do not take the risk of being “special” then nothing new develops. I thought a middle ground might be to have Matilda registered as a therapet and work out some way that we could follow the hospital guidelines. It proved impossible to meet these guidelines so the experiment was put aside and Matilda stayed at home. It was gratifying that patients and staff asked about her and were sad that the rules had been applied so rigorously.

Since I have retired from the NHS I have started taking Matilda to work with me on all occasions. Before deciding to do this I thought I might have more patients who had problems with a dog and more defined splits between the reaction to her and to me. Matilda is now a registered Therapet and I make sure that patients know that she will be with me before they attend so that they can inform me if they don’t like dogs or are allergic. To date I have only had one patient who didn’t want Matilda in the room though,of course, individuals may well have decided against seeing me when they get the handout. Mostly people are happy to see her and greet her rather than me at the door. Some then ignore her and she sleeps under one of the chairs. Some encourage her to sit on their lap and stroke her while they talk about the problems. The most interesting are those who are different with Matilda either in different self states or at times when they are more or less distressed. 

Some Examples I have recently had 2 young women coming, both of whom have encouraged Matilda to sit on their laps while they were talking. The first one, Miss A, had a procedure of avoidance of both emotion and acknowledgement of problems. It became clear that she was deflecting exploration by fussing with Matilda and the relationship between her and me was quite formal and empty of emotion with nothing being acknowledged or changed. When I raised this in the session we were able to talk about the fear of being criticised which was in the SDR but which Miss A had not experienced in the room as her avoidance was effective. Following this session Miss A had greeted Matilda at the door then was able to work in the sessions with the issues which had brought her to therapy while Matilda sat beside the chair and Miss A only reached down to her when particularly distressed. The atmosphere was more tense and Miss A was more upset but she was starting to change things
in her life and in the room. 

The second young woman had been given a diagnosis of Borderline Personality Disorder (BPD). Miss B used the slight distraction and comfort from stroking Matilda to allow her to talk about her past abusive experiences. In session 8 when I
commented that I had never seen the extreme distress which would usually lead to self harm Miss B told me that she didn’t fall into that state while she was able to ground herself by stroking Matilda. We have been able to talk about the dysregulated states that happen throughout the week though I am not sure whether she will be able to make more changes as she has had previous therapy and has already made improvements. The comfort Miss B gets from Matilda has not prevented us from getting into a negative RR of dismissing to dismissed which we were able to resolve. Having Matilda in the room does
not stop the patient therapist interactions which can be traced on the SDR but provides a constant positive RR for those
patients who have many negative RRs but few or no positive ones.

I have also had an older man in his 60s who reacted to Matilda in very different ways depending on the self state in which he found himself. He was in a very unsettled relationship with a woman who seemed to have problems with
commitment. When with his partner he was in the critical, unloved, betrayed place, seeing her as critical, undermining and betraying and therefore expecting this from me and by extension from Matilda. At these times he would largely ignore Matilda and she would avoid him. However, when he had broken up with his partner he would arrive feeling admired, valued by friends and in his successful career. Matilda would greet him enthusiastically and he would be interested in her and more available in the session. Often the first I knew of the state he inhabited was in the way Matilda greeted
him – she seemed to know at once. What about the changes in me as therapist? Matilda is the first dog I have lived with to feel like my dog and not a family dog or belonging to my daughter with me as alternate caregiver. She is part of my life and comes with me as often as possible. I think she keeps me calm but I also have to think about her needs when I leave her in the
car or go out for the day with her. I find it difficult to remember what it was like not to have her to think about but I remember deciding to get a new puppy at a time when my life seemed too organised and regular. She provided a balance to the demands of work, made me walk and generally reminded me that some relationships can be nourishing.

As a therapist I do a structured CAT with the traditional 4 sessions to the Reformulation letter and a diagram either before or after this letter. I work towards an ending though often the patients I now see do not need the full 16 sessions and we do not meet weekly. I have never been very distant and formal but it is now impossible as all my patients see my relationship with Matilda, both the caring but also the obedience. In the room the focus is on the patient and the problem. There are times when Matilda does something unexpected and I am distracted, checking that she is not annoying the patient or sitting on something inappropriate. However, I can use these times to see if my distraction elicits a state change in the patient and sometimes to clarify the feared position. I’m tempted to say that Matilda is like me or that I am like her in the way we interact with others but I suspect that each individual can see aspects of ourselves in our pets and that this may be projection rather than intersubjectivity or mirroring.

I suspect that my reaction to endings in my life and in therapy is to deny the reality and to look to the future. I do think that the
fact that we are not meeting any longer does not mean the ending of the emotional relationship. I think more about my patients and they often come to mind when I read something or something else triggers a memory. I think that is the same with the patients and when I see someone again after some crises initiates a new contact we can pick up with the knowledge
and diagrams that provide the symbols of the work we have done together. The structure of the ending of a CAT therapy keeps me to task. I do not think that Matilda being part of the therapy frame makes any difference to this task. Of course, some people find it easier to make a fuss of Matilda as they leave and perhaps I also find this easier. Some people leave angry with me and only able to acknowledge that they will miss Matilda but this can be contained within the work towards an ambivalent ending. Both reactions can be named and indicated on the map. Some patients like Polly avoid an ending with both of us.

In therapy we are interested in the relationship between patients and their objects or within the patient as their internal states interact. We explore the Reciprocal Role Procedures and the behaviours that surround them. Matilda provides another object in the room with whom the patients can relate or not as they choose and thus another possibility of seeing the patterns of relationship more clearly.

I have found that the comments from the reviewers have raised many thoughts for me and my internal dialogue will continue. I would be happy to hear further from others.

References
Linehan, Marsha M (1993) Skills
training Manual for Treating
Borderline Personality Disorder
Ruthven,D (2014) Paws Against
Stress. Canine Concern Scotland
Trust. Bulletin 79. 7-11.
Sacks, A (2008) The Therapeutic Use of
Pets in Private Practice. British Journal
of Psychotherapy 24 (4): 501-521

I am Maggie Gray. I live and work in Edinburgh and have been involved in CAT since the mid 90s. I recently retired from the NHS (18 months now) and have continued with a little private therapy and supervision. This gives me time to write up some
aspects of my work which I have found interesting and I hope will provoke interest and discussion from others.
harburnmaggie@aol.com

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Full Reference

Gray, M, 2014. A Dog in the World of ACAT. Reformulation, Winter, pp.11-14.

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