Musings on Doing CAT with Couples

Gray, M., 2006. Musings on Doing CAT with Couples. Reformulation, Winter, pp.29-31.

These thoughts arose out of interactions with 3 couples and two workshops in which the participants raised some questions but also answered some of mine. 

My first experience of couple therapy was when I worked for the NHS in the 1970’s. This meant that one partner of the couple had sought help as an NHS patient. I mention this because some of you will feel that this is not really couples therapy. I always worked with another therapist, which helped prevent collusive relating and allowed different alliances to develop and transference to be revealed.

I think we helped these couples to see what was happening between them and sometimes to change things. We certainly allowed expression of pent up emotion and that led to each being able to listen more attentively to the other. We used object relations theory and we talked after the sessions about our own counter transference and identifications.

So when Vanessa asked at the end of a private session if I would see Mike, her fiancé, for therapy and also see them together I was intrigued but cautious. She was 32 years old and waiting for NHS treatment for Borderline Personality Disorder. She was determined to change her behaviour and had read everything she could about CAT and particularly CAT for BPD. You can imagine how intimidating this was. I started the therapy with many “expert voices” in the room. We had been meeting for 10 sessions out of an arranged 24 and she responded positively to boundaries about time and about how much of her copious written work I could read between sessions. However, she was still acting egregiously in all her social and emotional relationships.  She had met Mike some 2 years before at a self help group designed to improve their lives but not specifically for BPD and their first contact had been him following her out of a group as she rushed away to carve the word “guilty” into her arm. He had helped her through that day and a relationship had developed which meant that he was currently staying with Vanessa. They were talking about getting married and had plans to emigrate.

I needed time to think about it. Mike had his own problems and through what Vanessa had told me I felt he would benefit from some therapy but I would normally have suggested he find someone else. We could then perhaps meet in a foursome with his therapist present also. That seemed cumbersome but possibly manageable. That was my preferred option as – it would protect Mike’s therapy and also allow us to explore the relationship. However, Vanessa was convinced by CAT and had convinced Mike. I knew no-one else doing CAT privately in the area and waiting for the NHS would take too long as they were planning to emigrate.

I then thought that I was being too precious. Surely I could hold confidentiality boundaries and the diagrams should provide me with a way to think about the interaction instead of the co-therapist that I had been used to. Was I in danger of allowing the rules to dictate the solution rather than working towards a truly ethical decision?  I was also interested in trying to work with a couple with CAT and, I guess, also wanted to be helpful. Vanessa did elicit caring behaviour in others and she had not yet pushed me into feeling overwhelmed and punitive.

So, we decided to try, and laid out what in retrospect seems like an unnecessarily complicated plan. I agreed to see Mike for therapy. He and I would decide how many sessions that should be. I would not talk about his therapy to Vanessa or Vanessa’s therapy to him. It was inevitable that my counter transference to the other would affect the therapy but the content of the sessions was confidential. In the event they seemed to tell each other everything in a possibly enmeshed way. By this I mean that both of them were aiming to know everything about each other and to be involved in every area of the other’s life.

Once Mike also had an SDR we would have 5 joint sessions and arrange that Vanessa’s individual therapy would finish after the joint sessions ended. Each therefore had a prose reformulation, an SDR and an individual goodbye letter. I was aware of the potential for rivalry and for Mike to see the therapy as a way of helping Vanessa but neither of these issues derailed the sessions. Actually it went well, they used the SDR’s between the sessions and we were able to name the rivalry and helping behaviour as it arose. Mike had his own problems and naming them in the individual sessions allowed the joint sessions to be more equal and Vanessa to see that she often rescued Mike in her competent state and that drove him around his SDR as he then felt like “damaged goods” and responded by closing down and freezing her out.

I was driven into being controlling and very directive (possibly punitive) by an incident which they reported to me. After some hours of winding up to this, Vanessa had cut herself with a screwdriver on her face and ran out of the flat because she was angry with Mike and he had been so angry in response that he followed her and tried to run her over with the car. She was hanging on the bonnet and continuing to taunt him. I felt it necessary to say very directly that if they couldn’t stop this behaviour then there was no way that they should get married (though I have no idea how I would have been able to stop them) and to talk about using medication (Carbemazipine) to contain the extreme nature of Vanessa’s acting out. I felt very like a mother with two naughty, angry children but it seemed to contain the behaviour and it was never so bad again. I think it was helpful because they were both out of control and therefore both needed to change. The positive part of their relationship was this acceptance of the need to help each other change.  I was also able to use the SDR’s to talk to them about pushing others into being directive and continuing to be “out of control” themselves. 

When I talk about this therapy in the workshops there are lots of questions. Why didn’t I do a joint letter and a joint SDR since I was working with a couple? Mostly because I was keen that both Vanessa and Mike felt fully heard and maybe over complicated things as a way of ensuring that. However, I think in this instance separate SDR’s was the right way to go. This couple have a tendency to become enmeshed and then react against this in an egregious way. Separate SDR’s helped them to see this happening.

I have thought about when I might use separate or joint SDR’s. There seems no good reason that CAT can’t be used with any couple but I might use separate SDR’s with parent/ child couples if the child is struggling to individuate and perhaps also with friends or with couples early in a relationship. If a couple has been together for a long time then there is more reason to suppose that they have created a joint world where each fulfils the self-object needs of the other so the likelihood is that a joint SDR will naturally develop. Maybe it also implies that the work is in healing the couple rather than the individual within the couple.

I then started thinking about patient – therapist couples and wondered if it was possible to share the therapist SDR early in the therapy, before one has been recruited into the joint relationship which develops later in the therapy. Would this help patients see that everyone has an internal map and be more collaborative? Would it only overwhelm patients with a sense of responsibility for the therapist? Would you need a third person to help look at the therapeutic couple? I am aware that we hold some knowledge of our own maps but this is not usually shared. Does not sharing feed into the power based relationship so that the therapist is seen as a superior being who has no unhelpful procedures. Do we need some anonymity to retain essential authority? I am reminded of an acquaintance telling me some 20 years ago that her 14 year old daughter wanted to know what a vagina looked like and this woman showed her own vagina to her daughter. Too much information?! I certainly thought so.

My next experience with a couple SDR was the consequence of feeling stuck. I had been seeing Alex, a man who had PTSD and whose main problem was irritable outbursts which started with swearing and escalated into banging about and verbally abusing his wife. I had been seeing him on his own and using CBT techniques and he was reporting some improvement. Then Louise, his wife, asked if she could attend a session and it was clear that things were essentially unchanged. She was worried about the effect on their 18 month old daughter and was contributing to Alex’s outbursts with some of her own behaviour. We met together after that and got into a pattern. Louise said that everything was dreadful and itemised each outburst in minute detail, Alex got angry and shouted, sometimes walked out, and I was left increasingly helpless and hopeless. I needed a way to think about this and to talk to them about it so I decided to try to map it.

I thought I would use different colours to look at the different RR’s and procedures that came from each of them but I found that as I drew it out it seemed to fit both of them. I was surprised because they seemed so different from each other in the session but looking at the SDR I could see that Alex enacted his needy demanding part at home and Louise enacted it in the session. I already knew that couples create joint interactions. I often recommend that my supervisees read Joyce McDougall’s Theatre of the Mind, especially Chapter 3 – The Transitional Theatre and the Search for Players.  However, this couple had stopped me thinking – I had felt overwhelmed, anxious about the child and caught by Louise’s nagging demands. Looking at the SDR again I could see that they were both “striving to do well” in front of me and seeing me as the “perfectionist judge” so we could never move into recognising and discussing their fear of being abandoned or of being “explosively demanding” of care.

Using the SDR I was able to talk about this interaction with me and to name the underlying fear and hurt. They both settled down and were more open with each other, Louise was less prolix in her descriptions and we were able to do some work. I want to point out how helpful the diagram was and how it provided a way of discussing the difficult 3-way transference with a couple who would usually fill the time with activity and prevent thought – at least my ability to think. As I was unable to think in the room, I did the SDR by myself in the first instance then added to it when I introduced it to the couple.

However, Alex developed a severe psychotic depression. Maybe they had been right to avoid the underlying pain/ abandonment. Maybe he needed the ongoing battle to keep him “strong”.

Questions from this case centre around the lack of a letter and a time contract. Should I have written a letter to them both at the point when I introduced the SDR and also created a time boundary? I think that a letter would have been intrusive and undertaken for my own reasons in relation to the “voice” of CAT. They were engaged with me and had already recruited me into their ongoing patterns. I was trying to find a way of naming those patterns and the diagram seemed enough. We were able to talk about where the original fears arose in childhood and these sessions seemed mutually helpful. Perhaps I should have put that into a letter but I am not sure.  I suppose my general position is that the tools of CAT should be used to forward the therapy rather than in a routine manner.

The time boundary is a different issue. I think that they would both have benefited from an ending. As it turns out Alex was admitted to hospital and they have now both moved away. So there was an untidy ending for two who both profoundly feared abandonment.

The final case I want to use to illustrate my thinking is of a couple who came together to see me. They were having interpersonal problems which felt insoluble. Giles wanted to live in a remote community in Scotland and did not want to have children. Linda wanted to have children and to stay near her friends and her mother. They had an 18 month old child as the result of an accidental pregnancy. Linda had not been prepared to have a termination. Giles felt that she had everything she wanted and he was being dictated to by her needs. Linda felt that she had already restricted her life in order to support him and she was not prepared to live in a community where he would be admired but she would be only his wife.

The work felt more like therapy for the couple. I was able to start the SDR in the room and could see that they shared RR’s – admiring/admired, supportive/supported and critical bullying/struggling failure. Getting into the last RR triggered an extreme fear in both of them. Each felt that the other was the critical bully and that they were the struggling failure. It had become so intense that giving in to the other even on small issues felt as if they would totally lose their identity and be overwhelmed by the personality of the other. They avoided talking about anything that led to this position and if they did arrive there both just froze and held on to their own argument in a quite unhelpful way. Once they understood this, and they both contributed to developing the understanding in the sessions, they were able to fully appreciate each other’s position. The intense fear declined although there was still a problem in finding a way of living together. The more positive RR’s helped them find ways of being happier together though the nature of their separate life choices made compromise difficult.

I still have not written them a letter. I’m not sure that it would add anything to the reformulation which was done verbally and in the diagram as we progressed. Looking back I think I was pleased to feel as if I was working with the couple in a helpful way and I didn’t want to take the risk of interrupting this.

The workshop question about this case was why I had added Procedural loops to the SDR. My answer at the time was that it had not occurred to me to do it any other way. The person asking the question commented that she used RRs with couples but not a full diagram. I have been thinking about this and I think it was helpful to have procedures that Giles and Linda could work on changing. They both made behavioural changes and these followed cognitive challenges to the assumptions contained in the procedures. Without the TPP’s in the diagram it might have been harder to see clear exits. Perhaps I misunderstood my interlocutor but this question helped me think about something that I had done by habit.

This started me thinking about the way that we may get into routines with diagrams and it is not until these are questioned that we become aware of how habitual we have become. However, it is also the case that someone else might well have created a totally different therapy around different themes. The dialogic nature of this work makes it difficult to think of it as being right or wrong. Perhaps we can only say that the therapy has been helpful or unhelpful and I think that with these couples it was helpful. The problems have been less intrusive. Linda has suggested to other couples that they come to see me. All the couples used the language and the diagrams we created together. Alex and Louise might have continued to avoid his severe depression but without treatment for this there was little hope of the situation resolving.

The next step is the dialogue with you. I have some apprehension in inviting this dialogue but hope that if I trust the process we can create a positive interaction which will lead to growth around the issues raised by doing CAT with couples.

( I have changed the names and some of the details of these cases )

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Full Reference

Gray, M., 2006. Musings on Doing CAT with Couples. Reformulation, Winter, pp.29-31.

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