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Meeting with Older People as CAT Practitioners: Attending to Neglect

Laura Sutton and Alistair Gaskell, 2016. Meeting with Older People as CAT Practitioners: Attending to Neglect. Reformulation, Summer, pp.22-28.

This article was published in Reformulation in 2009. We would like to republish it but without the first section that has been grayed out - due to it discussing topics that were current at the time – whereas we want to focus more on the clinical practice elements of the article. Eds.

Neglect in Clinical Practice: A CAT Approach

Working psychologically with older people, questions of emotional care and neglect present themselves to us in several ways. We will argue that a CAT framework is useful in understanding the connections between these types of neglect and in negotiating a response which offers something different from a re-enactment of neglect – what we will call offering a “meeting eye.”

Alistair’s interest in the issue of neglect grew out of his experience of beginning to work psychologically with older people. He found himself slightly unexpectedly struggling to reconcile “adult-centric” ideas about therapy with clients for whom the ideas did not quite seem to fit. In particular he saw more often people who did not seem interested in understanding their distress psychologically. They might be referred because a husband or wife or doctor thought it was a good idea rather than coming of their own accord, or they might express their distress physically or in terms purely of psychiatric symptoms rather than emotions. They sometimes expressed the view that there is “no point in talking,” or even that they are “not worth bothering with.” Of course these presentations are not absent from work with younger adults but they seemed to be occurring much more. He began to conceptualise this apparent detachment from emotional needs as a kind of self-neglect.

He also began to wonder if these detached presentations were connected to the experiences of neglect he was hearing in the life-stories of his clients. For people growing up in the 1930s and 1940s, certainly in Britain and most parts of Europe, experiences of childhood emotional neglect seem to be commonplace. These can range from adoption into impersonal institutions, or into families where the adoptee felt rejected or uncared for, through experiences of being one of a large families where the parents were struggling to put food on the table, to losses of mothers or fathers, permanent and temporary, through illness and war, to more subtle forms of emotional neglect in families where the parents were experienced as “cold” or overly critical or harsh. The common factor in these experiences is of repeatedly not having one’s emotional communications received and attended to, by an attuned other. Such experiences are perhaps clearest in childhood but they may also occur in adult life. There may have been times in adult life when, particularly traumatic emotional experiences such as the loss of a child, could not be heard or attended to.

Thirdly Alistair was facing the question of whether the emotional care that he and the services around him were able to offer was adequate. Whether, given the histories of neglect and presentations of self-neglect, not to mention the context of ageism and shortage of money, the care that was being offered was adequately attuned to clients’ emotional experiences. All too often it seemed not. Instead emotional neglect was being re-enacted, often almost unnoticed. There seemed to be a danger of neglect itself being neglected.

Emotional Neglect in Childhood

Rather paradoxically, the place to start in understanding these particular clinical issues of old age may be childhood. In thinking about presentations of detachment the place to start may be attachment. Although there is a danger of uncritically applying ideas from attachment theory, which was of course developed with childhood in mind, to old age, equally it may be neglectful to ignore ideas that may help us to understand the older people that we meet.

The importance of a close and attentive relationship for the emotional development of children has been recognised by psychologists now for over fifty years, and as Bowlby notes by poets and mothers for far longer. Bowlby (1969) uses as an epigraph to a chapter in Volume One of Attachment and Loss a brief poem by George Elliot, used by Elliot again as an epigraph in her novel Middlemarch.

“A child forsaken, waking suddenly, Whose gaze a’feard on all things round doth rove And seeth only that it cannot see The meeting eyes of love”

(Elliot 1872)

Bowlby and his colleagues’ work was at least partly inspired by the dislocation in children’s lives caused by the second world war. Ironically, of course this dislocation was experienced by many of today’s generation of older people There were studies such as Freud and Burlingham (1944) which documented the difficulties experienced by children separated from their parents.

Bowlby and his colleagues conducted studies based on systematic observation of children separated from their parents often for shorter periods, such as those cared for within a residential nursery while a parent was in hospital. They noticed a characteristic progression of child’s emotional state through stages of Protest, Despair and Detachment.

From these observations and his understanding of human and animal development Bowlby developed attachment theory, which at its base is a theory of how human beings are adapted to ensure the care and protection of children through the development of relationships with caregiving adults, most usually their parents. A secure attachment is based upon the care-giving figure’s ability to be adequately “attuned” (a term introduced by Daniel Stern, 1985) to the emotional state of the child and to develop strategies to, for instance, soothe a child when it is distressed. To attunement is added a care-giver’s ability to give meaning to behaviour through dialogue with a child, enabling him or her to develop “reflective functioning” (Fonagy and Target 2000) From a secure attachment, a child has a source of comfort when distressed and from this “secure base” is able to boldly explore the world and relationships with other children and adults.

In CAT terms this kind of relationship can be modelled as a Reciprocal Role Procedure (Ryle and Kerr 2002) which is something like Attentively Protecting to Safe and Protected. According to attachment theory, the experience of this kind of relationship is internalised into an “internal working model” of attachment, which is thought to have a key role in allowing a child to develop its ability to regulate its own emotions (Fonagy et al. 2002). In CAT, the infant is considered to contribute to the development of ‘role procedures’ for relating to her/his mother/caregivers on the basis of inborn attachment behaviours and sensorimotor intelligence (Ryle 1991). This is before the discrimination of self and other, yet the infant is learning two parts, namely the part which derives from their own response and the part that derives from the other. Through this process of internalisation, that is, ‘learning’, the child can be thought to develop a self-to-self reciprocal role, of self –protective to self-protecting (as the process is a dialogic one, it doesn’t require the positing of internal working models).

When a child experiences emotional neglect, however, when an attuned relationship is not possible, either through the physical unavailability of a parental figure or inability or unwillingness to attend to the child’s as opposed to the parent’s emotional state the child does not develop a secure attachment / RRP. A great deal of work has gone into understanding different “styles” or strategies of insecure attachment, which are essentially ways of adapting to the lack of an attuned parental figure. (eg: Ainsworth et al. 1978) “Organised insecure” strategies include ambivalent attachment in which a child amplifies its distress signals in an attempt to evoke care from a poorly attuned parental figure, and avoidant attachment in which the child minimises its emotional reactions in an attempt to evoke approval and protection from a parent with a dismissive parenting style. Again these responses can be modelled fairly simply in CAT terms – as the development of a Conditional to Striving Reciprocal Role in the case of avoidant attachment (the child learns that he / she only receives care and protection if he/ she denies emotional need) or the development of a controlling to clinging reciprocal role in the case of ambivalent attachment. (The child learns that he or she only receives care or protection if he / she amplifies emotional needs.) It is notable that implicit in the avoidant strategy is the development of a controlling / restricting self-to-self reciprocal role – that is that the child is not able simply to express needs but must control or restrict the expression of need in order to achieve care.

Disorganised attachment styles occur when care is below a level of consistency which allows an organised strategy, or when a caregiver is a source of anxiety as well as a figure to be turned to in distress. Children in such relationships are unable to find a consistent strategy to evoke care and protection from adults and so are forced to rely on their own inadequate resources to regulate their emotions. David Howe (2006) has observed that they usually do this by adopting a form of controlling behaviour. such as parentified behaviour, passiveness or aggressive attempts to dominate. These strategies too, can be simply modelled using Reciprocal Roles. (figure 4) It is worth noting that although the self- controlling reciprocal role that may be adopted is similar to that in an avoidant strategy, there may be more dissociation from emotional experience which may have implications for therapeutic intervention.

So in many instances the child is forced to respond to the partial or substantial deficit in emotional care by adopting a controlling self-to self Reciprocal Role. There are individual differences in the way in which the controlling strategy works, if it is through denying needs and presenting a front of apparent not-needing, then this can be seen as a form of self-neglect (perpetuating the neglect which has been experienced.) The extent of the neglect may affect the amount of anxiety which underlies the strategy; the more neglect the child has experienced, the more anxiety he or she may feel and the more rigid the strategy is likely to be. Equally, other experiences positive and negative will affect the formation of reciprocal roles, and perhaps the rigidity of the roles. If there are attentive relationships outside the home they may facilitate the development of healthier reciprocal roles, whilst abuse and trauma on top of neglect will lead to further layers of complication and dysfunction.

Recent work in developmental psychobiology has shown that the experience of neglect can have a physical effect on the development of the endocrine system. (Fries et al. 2008) Imaging studies have shown with the effect of neglectful experiences on areas in the frontal lobes which are linked to the regulation of emotions and social relationships. (De Bellis 2005) Thus the experience of neglect can have a very physical effect on a person’s ability to care for both others and him or her self.

Ironically too, children who have experienced violence or emotional neglect also find it harder to construct coherent narratives of their experiences. (Osofsky 1993) Without an attentive other it may be hard to attend to one’s own experiences sufficiently to make sense of them. So the experience of neglect becomes hidden and neglected, making it easier for it not to be noticed by those around them.

Although the organisation of reciprocal roles described can be used to model the effects of childhood neglect, it is also notable that traumatic events creating high levels of distress in adult life, particularly trauma which is unattended and unprocessed can lead to a similar organisation of reciprocal roles. This can be seen for instance in the experience of losing a baby, which for the current generation of older people was often an unattended tragedy, unrecognised and unspoken.

The kind of restrictive / self-depriving organisation of RRPs (figures 2/4) in the current generation of older people would also have been reinforced by the cultural context of the 1930s-1950s, particularly in Britain and other countries in Western Europe. During a period of economic and military turmoil, the cultural values were of communal struggle not attending to individual distress. Older people often remember injunctions to “not make a fuss,” “don’t be a cry-baby,” “don’t feel sorry for yourself,” or countless variations. Public policy tended not to be informed by or attentive to emotional need, As an example, the organisation of the evacuation of children from London and other major cities, during the second world war, was not carried out in a way which would have reduced the emotional damage to refugees, for instance by evacuating children with parents. This evacuation has been shown to have had a long-term disruptive effect on evacuees attachments and well-being. (McKee 2005) Distress for these children was not attended to and the cultural message that was given to them was that it was not important for it to be attended to. This seems to have been repeated for many experiences of neglect both large and small.

The Effects of Neglect in Older Age

In adult life this kind of restrictive organisation of reciprocal roles can be relatively functional. While the focus of life is on work or on caring for others, difficulties in recognising and attending to emotional needs may not be too disabling. However Old Age (and perhaps particularly advanced old age) is a time when life events may mean that issues of care and emotional need come to the fore once again. The experiences of loss of role in retirement, the loss of partners and friends through bereavement, loss of capability through ill health and cognitive losses, and the prospect of dying, are all things which may evoke feelings of emotional need and distress. Old ways of managing need may break down, and it is often at this point that someone may come into contact with older peoples mental health services.

A person in this kind of situation could be seen as being, in CAT terms in a dilemma. Emotional need, without adequate internal resources to manage it may be experienced as shaming and terrifying, so there may be a strong urge to re-establish old ways of coping, in CAT terms through a restrictive RRP. However this leaves the needy feelings unattended and particularly with a progressive problem may become increasingly hard to manage.

Again the social and cultural context surrounding Old Age may intensify the difficulty in facing emotional needs at this point. The culture of ageist neglect of the emotional needs of older people, is likely only to intensify feelings of shame and fear regarding emotional needs, and make it harder to move away from responses which are no longer functioning. For instance there is almost no consideration given in research or practice to the emotional experience common to older people of moving out of home into a care home. In this context it is not surprising if an older person should feel that they should detach from this experience.

Coming for psychological help at this point there may be a great deal of ambivalence. It may not be a person’s own idea to seek psychological help, they may be following the advice or responding to pressure from a family member or doctor. There may be a view, implicitly or explicitly expressed that it is “not worth bothering with.” (understanding the problem.) A therapist may feel his or her efforts to understand a problem and empathise with a client are being rejected, and there is a temptation, particularly in hard-pressed health services to shrug one’s shoulders and conclude that the client does not want help or is not “psychologically minded,” or is otherwise unsuited to our services. However this merely perpetuates the chain of neglect.

This situation can be conceptualised as a dilemma for the therapist to either to retain an interest in trying to understand the problem and so risk becoming unwelcomely intrusive, or to withdraw and risk perpetuating the neglecting pattern.

Offering a “Meeting Eye”

CAT has a potential to offer a way out of this dilemma, by offering an understanding of the problem which is collaboratively developed and so not intrusive, and attends to rather than neglects emotional needs. Following George Elliot (above) we have termed this offering a “meeting eye.”

At its core this involves finding a way to offer an understanding which is within the client’s zone of proximal development, that is simple enough to be understood and processed by the client and yet does not over-simplify or assume that things are too difficult for them to understand, and so neglect that part of a client that might yet be open to understanding.

One aspect of this is a reformulation letter which offers an understanding of how difficulties in managing intense emotions may have developed in response to gaps in parenting. This may be difficult to piece together given the likelihood that a person who has adopted a restrictive strategy with regard to emotions is unlikely to have a well-developed narrative about their childhood experiences. It may also need to be carefully constructed to avoid unwarranted blame of parents, and which is also mindful of the cultural value of “not making a fuss” It may be useful to explicitly stress that what we are concerned with is witnessing or understanding what a person experienced rather than complaining about it.

Another element is an understanding of present day issues around emotional need and the ways that a person has developed to manage these issues. This may include thinking about the “voices” with which a person addresses themselves when experiencing emotions, and the development of an internal voice which is more congruent with an attentively protecting reciprocal role. The ideas of Paul Gilbert about the development of self-compassion are relevant to this. (eg: Gilbert and Proctor 2006)

There may also need to be ongoing attention to the therapeutic relationship to notice enactments of neglecting to neglected reciprocal roles are not re-enacted. These might be subtle things like a therapist neglecting to be on time or neglecting to put enough effort into a diagram or reformulation letter knowing that the client’s reciprocal roles are such that they will not complain. One client would repeatedly suggest to Alistair that if he was too busy he could cancel his appointments. With another client he found himself being repeatedly a few minutes late in leaving for her home visits.

It is important too, to be realistic about what individual therapy can achieve, particularly within current resource constraints. It may be important to be able to offer longer-term contracts, particularly in situations where a person has experienced severe emotional neglect. Because with this kind of presentation so much of a person’s emotional distress can be hidden, the results may also not be immediately obvious in terms of symptoms although being able to be a little more understanding of and tolerant of one’s distress can feel like a huge relief and can make the business of accepting care so much easier.

Offering a “Meeting Eye” as a Service

The re-enactment of neglecting to neglected RRPs is not confined to therapeutic relationships. It is important to ask how much the services that we work for are able to attend to people’s emotional needs or how much they are neglected, either through not noticing older people’s emotional needs (and hence not referring them or accepting them) or by over-medicalising them, seeing them purely as symptoms of an illness or neurological damage rather than as something to be understood. Reluctance to respond to overtures of help may also be responded to with further rejection rather than attempts to understand.

Personality disorder and alcohol abuse are among the factors associated with a risk of suicide in old age, but less so than for younger adults (Dennis 2008). Rather, ‘personality traits’ convey the greater risk, in obsessionality, neuroticism and lower score for ‘openness of experience’ (Dennis 2008). One wonders whether these processes of neglecting emotions, in favour of striving, and closing down to wider narrative, have contributed; and that the current service and social repetitions are contributing still.

Developments in the services in which we work often seem to work against the need to offer a meeting eye to the emotional needs of older people. Whether it is through the uncritical adoption of adult-centric thinking in IAPTS or the silent cuts in community and day-services or the concentration on quantity rather than quality of contacts, attending to older people’s feelings does not seem to be considered. There may be an important role for CAT-informed professionals to help services to attend to emotional needs, for instance through promoting life-history work and services which allow the time and space to ask how people are feeling and so at least offer the possibility of promoting compassionate and attentive reciprocal roles.

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Full Reference

Laura Sutton and Alistair Gaskell, 2016. Meeting with Older People as CAT Practitioners: Attending to Neglect. Reformulation, Summer, pp.22-28.

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