Jenaway, A., 2006. CAT with Teenagers and Teenagers Leaving Care. Reformulation, Summer, pp.3-4.
Three years ago I changed jobs from being a general adult psychiatrist to a consultant psychotherapist working with young people leaving care. This involved working with the 16 plus adviser team of Cambridgeshire social services, providing mental health education for the advisers, consultations about the young people that they are trying to support, and seeing some of those young people for therapy when appropriate. The reason for setting up the specialist service was that the 16+ advisers found it very difficult to access standard mental health services for these young people. Some of these reasons are to do with the NHS systems e.g. you have to be referred by a GP, long waits for assessment (by which time the young person may have moved) and the demand that people are seen in a formal clinic setting. Others are internal to the young person e.g. they do not trust those in authority, they have chaotic lifestyles and forget appointments etc. It has been recognised that there is a need for specialist services for children who are looked after for some time and many new services have developed; services for care leavers are less well developed and I had few examples to follow. The initial plan was for any young people who could access mainstream services to continue to do so, while I would act as a kind of back up for those who were unable to engage with mainstream services, for whatever reason. The group that I saw were therefore more likely to have personality difficulties and I had hoped that CAT would provide an ideal therapy for these young people. It has for some of them; however, I had overestimated the ability of most of them to engage with this type of therapy, think about their past, and face up to their difficulties. Of course it is evident to me now that these young people are even less likely to be able to do that than young people who have grown up in their family of origin. Not only have they had more difficult, traumatic experiences, more rejection and more disruption in their lives, but also they have not been able to mature psychologically in a healthy way because of the absence of stable, caring parental figures. I have therefore spent a lot of time thinking about the process of engaging people in CAT.
Not much has been written about engagement in the CAT literature, because it seems so much easier to engage people in CAT than in some other types of therapy; it is so user friendly for most of the people we see. Thinking about engagement led me to think about the reciprocal roles we offer as a therapist for people to engage with and how different therapies might be characterised by different reciprocal roles. In CAT I think of the therapist offering a “good enough” reciprocal role (caring, listening, encouraging realistic expectations and firm boundaries), but I think I have often been guilty of thinking about this as a kind of static position that the therapist takes up and maintains as far as possible regardless of the type of patient. In fact, Winnicott’s original description of the “good enough” mother defines it as a mother who makes an active adaptation to the infant’s needs which gradually lessens according to the infant’s ability to tolerate failure of adaptation (Winnicott, 1971). I have come to see this as necessary when working with teenagers and particularly those leaving care. Some of these young people are so exquisitely sensitive to criticism or the slightest hint of rejection that they have pretty much given up on relationships of any depth. They keep their true feelings suppressed and hidden while appearing to be completely independent with no needs or feelings. For this group, the normal “good enough” role offered by a typical CAT therapist is not good enough. The need to talk about the past in order to reformulate current problems is too shaming and too painful. The tendency in CAT to point out unhelpful procedures in order to promote recognition feels too critical to bear. It feels to me as if the only way to engage them is to offer a reciprocal role which is nearer to a kind of ideal relationship for them in order for them to feel comfortable enough to be able to self reflect at all. For example, one 17 year old placed his hat over the angry, abusive role on his diagram saying “I can’t bear to see that, it’s making me feel too agitated, I can’t think” even though he had clearly described it. Avoiding triggering this kind of young person going into their more negative reciprocal roles can mean that they can bear to stay in the room, and at least start to think about themselves psychologically. After an introductory day with Annie Nehmad on Solution Focused Therapy, I realised that I had found a therapy, which I think offers a more positive, adaptive reciprocal role for the young people that I am trying to work with. In a lot of ways SFT sees the problems people present with in a similar way to us as CAT therapists. People are repeatedly trying to solve their problems with methods, which do not work, and just perpetuate them. People need to try something different. The big difference is that in SFT there is no need to describe, analyse or even recognise the problem in order to solve it. The assumption is that the person is already, even if only occasionally, doing something different, or less unhelpful. The therapist’s task is to help the patient clarify what their preferred future looks like, and then use the resources they already have to get there. In CAT terms all the effort is spent on defining aims and exits, on revision, and none on reformulation and recognition (unless the patient specifically asks for these and feels they would be helpful). This means that the therapist is spending all their time noticing strengths, resourcefulness and times when the patient takes an exit and does something different. Nearly all the feedback to the patient is validating of the problem but positive in its interpretation of the patient, regardless of how severe the problems are. This seems to have the effect of keeping the patient in more positive reciprocal roles and more able to self reflect. The patient is invited to say at the end of each session whether they would like to come and how long they would like between sessions (obviously this has to be negotiated to fit in with what is practical). The reciprocal role offered by the therapist is validating, approving, admiring, with few limits or boundaries. The patient is almost completely in control of how close they get to the therapist or how much they “attach”. In CAT the question is “what is this relationship we have agreed on going to be like?” in SFT the question is “how much of a relationship do you want with me?” This is a much easier question for young people who avoid relationships as much as possible because they find it impossible to trust that they will not be controlled or abused. Through the process of answering the question, a relationship inevitably occurs but at the pace of the young person, not that of the therapist. One young girl refused to see me when she heard that CAT was “usually 16 sessions”, that immediately felt like I was too much in control. Even in more formal CAT, I now agree 10 sessions initially and then jointly agree how many more are needed at session 10 (an idea originally suggested to me by Claire Tanner).
I do draw diagrams with people, usually based on current difficulties as they are often reluctant to tell me anything about their past, but then spend the rest of the time trying to clarify with them the details of where they want to get to and noticing when they take an exit or do something different. Homework tasks would be about noticing the exits, or more positive roles, not the negative procedures. At first I saw this as an engagement process whereby I could tempt people into a therapeutic relationship with me so that I could do “proper” CAT with them later on. However, I have been amazed by the changes young people have been able to make just through this process of diagram, aims and exits, and most of them have not wanted more.
Alison Jenaway Consultant psychiatrist in psychotherapy, Huntingdon
Playing and Reality, D.W.Winnicott (1971)
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