King, R., 2005. CAT, the Therapeutic Relationship and Working with People with Learning Disability. Reformulation, Spring, pp.10-14.
This article is derived from my dissertation for the IRRAPT CAT Psychotherapy Training. Throughout my career as a psychiatrist, I have felt that the therapeutic relationship is a key factor in promoting healing. When I was doing my CAT training, I was keen to understand this relationship better and to see how it linked with the structure of CAT. The majority of my clinical work at this time was with people with learning disability. I was encouraged to find that, with modification, CAT could be used effectively in this context (e.g. King 2000) and that the work held a particular freshness and vibrancy. I explored my experience of the therapeutic relationship in my CAT work with people with learning disability, with the hope that it would also be relevant in other contexts.
The importance of the therapeutic relationship is acknowledged by CAT theory (Ryle and Kerr 2002, p.100) as it is across a wide range of therapeutic approaches (Clarkson 1995) CAT has a distinctive contribution to make to the study of the therapeutic relationship, the central concept of reciprocal roles bringing fresh understanding to the key role of relationship both in human development and in the process of therapeutic change. (Ryle 1991;Ryle and Kerr 2002)
As a framework for my study I used the model of five different aspects of the therapeutic relationship described by Clarkson (1995): namely; the working alliance; the transference/countertransference relationship; the developmentally-needed or reparative relationship; the person-to-person or real relationship and the transpersonal relationship.
Clarkson (1995) emphasises that these are aspects rather than stages in the relationship. However she describes a gradual development through the different aspects as therapy progresses. This was echoed in my work in which the development of the relationship seemed to evolve naturally, though at times I was aware of guiding or encouraging the process. The working alliance was established at the start and deepened as the therapy progressed. Sometimes it was threatened by transference and countertransference issues, which needed attention. Provision of the developmentally-needed relationship was required from early on. Working with these three aspects of the relationship seemed to allow for a stronger development of the person-to-person relationship in which could be found the transpersonal with all its creative energy. It was my experience that all of these aspects of relationship were grounded in the very ordinary stuff of being human.
In many ways working with people with learning disability is just like working with anyone else. However issues of woundedness, weakness, limitation, difference and vulnerability (alongside the need for appropriate independence and autonomy) are particularly strong. The challenge is to find a way of establishing and maintaining authentic, life enhancing relatedness (Safran 1993) in the face of these issues.
It is increasingly accepted that CAT can be used effectively with people with learning disability. Experience, gathered by a few practitioners working in the field and pooled in a special interest group has been summarised by Ryle and Kerr (2002 p172).
In this article I will consider each aspect of the therapeutic relationship in turn, linking each with the theory and practice of CAT and my experience of working with people with learning disability. The clinical material quoted in this article is derived from six completed CAT therapies, which I have undertaken with people with mild or borderline learning disability
The working alliance has been described as involving the reasonable, rational part of the patient and therapist, allowing them to be part of a shared undertaking. This enables the work to proceed even when difficult transference and countertransference feelings occur by allowing them to be recognised and worked on. (Gelso and Carter 1985) Bordin (1979) proposes three essential aspects of the working alliance, the collaborative setting of goals; the joint agreement on tasks and the development of a human relationship or bond.
Working within each individual patient’s Zone of Proximal Development (Vygotsky 1978) aids the establishment and maintenance of the therapeutic alliance. (Ryle 1991) This concept is of particular importance in work with people with learning disability. One way of addressing the difference in cognitive ability is in modifications of the CAT tools. I found that simplifying the wording of the Psychotherapy File (King 2002); taping the Reformulation and Goodbye Letters and using simplified SDRs incorporating colour and drawings (King 2002) were all helpful.
Other ways of working within the individual’s ZPD are the use of nonverbal techniques in the therapy such as the use of colours to express feelings, (King 2002) the use of buttons to express how patient’s experience themselves and the therapist, (King 2002), and a circle with 16 segments to indicate the passage of time in the therapy (King 2002 p35).
It is suggested that the tools of CAT all serve to create and maintain the working alliance. (Ryle 1991; Ryle and Kerr 2002 p 101) Joint identification of Target Problems, Reciprocal Roles and Reciprocal Role Procedures facilitates the formation of a strong working alliance early on in therapy. The Reformulation Letter is described as often strengthening the emotional bond between patient and therapist. (Ryle and Kerr 2002 p 76) One patient with learning disability picked out a sentence in her reformulation letter as the “bit that touched my heart”. The prose and diagrammatic reformulations bring understanding, which will help prevent or repair disruptions to the therapeutic alliance.
Working with the transference/countertransference relationship and with the ruptures to the working alliance with which it can be associated, are generally thought to be powerful ways of promoting change in relationship patterns. (Gelso and Carter 1985; Clarkson 1995; Safran 1993; Bennet 1998)
Transference is defined by Gelso and Carter (1985 p170) as “a repetition of past conflicts (usually but not always beginning in early childhood) with significant others such that feelings, behaviours and attitudes belonging rightfully in those early relationships are displaced; in therapy the displacement is on to the therapist. ……Transference entails a misperception or misinterpretation of the therapist, whether positive or negative. The transference relationship is an ‘unreal’ relationship in this sense, and it is a strand of the total relationship.”
Countertransference is described by Clarkson as what the therapist feels towards the patient. It is now generally understood to be a valuable therapeutic tool, which can give insight into the experience and responses of the patient. (Clarkson 1995) Different types of countertransference have been described by Ryle and Kerr (2002 p104) as personal countertransference (what the therapist brings to the encounter) and elicited countertransference (the reaction induced in the therapist by the patient) the latter being either identifying or reciprocating.
Awareness of personal countertransference is particularly important in work with people with learning disability. Relating to those who carry the woundedness and weakness of disability means that we must face our own disability, weakness and wounds, something which we would often prefer to ignore, conceal, deny or thrust on to others. (Symington 1981; De Groef 1999) Powerful feelings may arise in us such as contempt (Symington 1992), guilt and intense compassion (Sinason1992). A variety of responses to these feelings may occur. Disability may be denied, losing connection with what is real. There may be avoidance, distancing or rejection . Alternatively there may be an attempt to provide perfect care to make up for the weakness and pain. We may fall into judging ourselves to be inferior or superior, bringing feelings of worthlessness or contempt. Or we may put unwanted parts of ourselves into those who are different leading to denigration, contempt, rejection, abuse and exclusion. These feelings and responses will tend to undermine or destroy the therapeutic relationship or may even lead to a reluctance to offer therapy at all. (Bender 1993)
Elicited countertransference can be an important clue about the patient’s experience. This is of particular value in work with people with learning disability who may have difficulty in recognising, naming and expressing their feelings. For example in this work I often felt confused and overwhelmed which I understood as an indication of what the patient might have been feeling. Another time my strong feeling of being rejected and contemptible proved to be an invaluable aid in understanding what the patient was feeling. (Both are examples of identifying countertransference).
CAT understands transference and countertransference in terms of Reciprocal Roles (RR) being played out within the therapy. Common RR encountered in work with people with learning disability are Abusing/Abused; Not Being Heard or Understood/Unheard or Not Understood; Rejecting/Rejected; Contemptuous/Contemptible; Neglecting/Deprived; Infantalising/Infantalised; Ideally Caring/Ideally Cared For; Overprotecting/Overprotected; Abandoning/Abandoned. In one case I found myself being uncharacteristically neglectful over an agreed arrangement. Consideration of this confirmed the Reciprocal role of Neglecting/ Deprived as important in for this young woman.
In the special interest group we recognised that polarised responses often occur in people with learning disability. Examples include All-Powerful (often the therapist) / Completely Powerless (often the patient). Living with a sense of weakness and woundedness a person with a learning disability may see “normal” others, including the therapist, as clever and useful and herself as dim and useless. Kim, when choosing a button to represent herself, selected a very small button because she felt that she could not do anything, whilst she chose a very large button for me. It was as if in facing the cognitive difference between us she felt completely worthless and useless. It was good to see that when she repeated the exercise towards the end of therapy she chose buttons of much more equal size. Ideal care is often sought out and reciprocated. It is as if we need to somehow magically make up for the limitation, vulnerability and sense of woundedness, which are faced by patients on a daily basis. CAT helped me to be aware of this and to avoid colluding with it.
The developmentally-needed or reparative relationship is defined by Clarkson (1995 p108) as “intentional provision by the psychotherapist of a corrective, reparative or replenishing relationship or action where original parenting was deficient, abusive or over-protective.” She suggests that it is an important ingredient of many therapeutic encounters, sometimes unacknowledged by the therapist, but often remembered by the patient as the most significant part of the relationship. She also suggests three types of injury or deficit, which may require a reparative relationship, all of which are highly relevant to the lives of people with learning disability. They are trauma, (such as abuse); strain or accumulative, repeated less severe traumas (such as are associated with neglect and deprivation and the negative attitudes of society); and extra-familial limitations and catastrophes in which she includes genetic conditions. Missing elements, which may be provided in the reparative relationship are identified by Clarkson (1995 p235) as containment, witness and care. (Casement 1991) suggests that where there has been neglect, careful attention and responsiveness are needed; where there has been smothering, respect and space are required.
In CAT terms the provision of this aspect of relationship could be thought of as the deliberate use of positive Reciprocal Roles to make up for deficient or absent experience in the patient’s earlier life. Dunn (2002), in considering exits and healthy relating in terms of “Thriving, Reparative Reciprocal Roles”, writes “Patients do not find it difficult to articulate the reparative experiences they need and long for.” And “It is also worth considering that a therapist should be able to provide a more clearly defined and reparative experience in the room to the patient that directly addresses their pathological map by moving from a neutral role post reformulation to enact overtly and consciously the implied reparative roles.” The concept of working within the patient’s zone of proximal personality development (Ryle and Kerr 2002) would also seem to link in with the idea of a developmentally-needed relationship. In addition the structure of CAT could be understood as providing a reparative, holding environment for both patient and therapist.
I found this aspect of the therapeutic relationship to be particularly important in work with people with learning disability. What was needed varied from patient to patient and also with different stages in therapy with the same patient. Early on in therapy I was often aware that I took a very explicit encouraging, accepting and nurturing role, taking responsibility for keeping harmony between us and allowing a degree of dependency. Reassurance was often a strong need at this point. I allowed Barbara to hold my hand when she talked about the time when she had been swamped by feelings of anger and hopelessness when she was first told as a child that she had a learning disability and that nothing could be done to help her. As well as reassurance she needed responsiveness from me to allow her to re-live that terrible moment in a different emotional climate. She needed patient encouragement and support whilst she found her own strength. As therapy progressed it was important to give her more space to try out her new-found strength and to become more emotionally independent.
In working with people with learning disability it is important to guard against getting stuck in this relationship, playing out the RR of Infantalising/Infantalised, with the risk of fostering dependency and stuckness. Early on in therapy Claire sought repeated reassurance from me, but moved on when she could say that she felt anxious about being with people who were not “backward” (see below), and we were able to establish a more adult-to-adult relationship.
Gelso and Carter (1985) write “ the real relationship exists in all therapies, and it does so alongside of and intermingled with the ‘unreal’ relationship. In a real relationship, one’s perceptions and interpretations of another’s behaviour are appropriate and realistic, the feelings are genuine, and the behaviour is congruent.” Miller (2000) writes “We have a responsibility to be a complete, responsive, caring other for the patient, and to understand that the patient will develop and mature not only from our skill as therapists….but also from our humanity.”
Whatever the length of the therapy, the person-to-person relationship tends to emerge and deepen as the therapy progresses and the transference relationship lessens. (Clarkson 1995; McCormick 2000) It is suggested in the literature that the person-to-person relationship involves a certain amount of self-disclosure by the therapist. (Gelso and Carter 1985; McCormick 2000; Thorne 2000) Care and skill are needed to judge the timing and degree of self-disclosure and it must always be undertaken in the service of the therapy and not for the therapist. (McCormick 2000; Clarkson 1995) Clarkson makes the point that it may be difficult to move from the developmentally-needed relationship to the person-to-person relationship and when it happens it may “herald a new phase in the relationship.”
To me CAT’s emphasis on an equal, collaborative relationship between patient and therapist helps to pave the way for the development of the person-to-person relationship.
Perhaps what people with learning disability most long for and need is the experience of the person-to-person relationship in which two adults meet as equals. Much can get in the way of this, but my experience was that when we were truly able to make authentic connection as human beings of equal value, then change, growth and transformation could occur. I found that this aspect of therapy tended to grow as the therapy progressed and that it could be encouraged by limited self-disclosure which allowed the patient to have a sense of the person behind the therapist. In my practice this was initially extremely limited, for example to a personal comment about a shared experience such as the weather or noise outside the room. I found that too early or too much self-disclosure was either ignored or caused tension within the relationship. However appropriate self-disclosure could be transforming. Michael saw himself and others as being either all good, loved and accepted or all bad, blamed and rejected. When he made the “mistake” of absconding, we were also able to reflect about a “mistake” I had made when I had not taken enough notice of him saying that he did not want to talk about his father, with the consequence that he had been reluctant to come to one of the therapy sessions. Then we were able to share the reality that, as human beings, we both made mistakes and when we did, if we recognised them and tried to make amends for any hurt we had caused, then it was not the end of the relationship, rather it allowed a deepening and strengthening of the bond between us. This marked a turning point in the therapy and also in his relationships outside. Another example was when I arrived very late for one of my sessions with Claire. As well as accepting my apology she was able to say that she felt angry with me. I was no longer the idealised, nurturing mother. I became another human being who sometimes got it wrong. This allowed us to move forwards with that experience of equality and humanity woven into our work.
In work with people with learning disability the person-to-person relationship necessarily includes the difference in intellectual capacity. I found that in most CAT therapies with people with learning disability there came a point when this difference needed to be openly acknowledged by us both. For this to be able to happen it seemed necessary for the patient to develop confidence in herself, the therapist and the therapeutic relationship and to be able to say directly that she was having difficulty in understanding the work. This was often preceded by a sense of stuckness. As a therapist I needed to be alert to the patient’s often veiled comments about the difficulties she was having, so that I could encourage her to give voice to what she was experiencing. Bringing the difficulty out in the open allowed us to see how the difference was a problem for us both. At this point we moved from the developmentally-needed relationship to the person-to-person relationship. We could begin to accept the difference between us and understand that it was our joint responsibility to find a way of expressing the work, which held meaning for us both. In this way we were acknowledging the difference, but valuing and respecting each other as human beings of equal value. When this happened it marked a turning point in the therapy, allowing the work to flow again and bringing a new creativity. With Claire this point came when she was able to say that she felt anxious about being with “people who were not backward.” We were able to see how this might apply to our work and she was able to acknowledge that sometimes she found it hard to understand me and that she sometimes said that she understood, when she did not, in order to please me. We could see how this was an enactment of one of her Target Problem Procedures. I was then able to say that I felt that this made a problem for us both and that I had a responsibility to be clearer and that I needed her to tell me when I was not being clear enough. This opened up the therapy. It was as if we were saying to each other “we are different but that’s OK, we can each be ourselves as we really are, we can work with that and stay connected.”
Humour also had a role in promoting the person-to-person relationship. With Michael we used buttons in each session to help him express his feelings and experience. Each time at the beginning of the session when he opened the tin of buttons he would comment “what no biscuits then.” It was a moment we both enjoyed.
It is necessary to remember that this sort of relationship has a seductive potential. Clarkson (1995 p160) writes “If having moved into true person-to-person relationship one stays too long, then it actually becomes abusive – a replacement for intimate relationship for both the psychotherapist and the client.” The time-limited structure of CAT helped us to keep our feet on the ground, allowing us to enter a person-to-person relationship but always mindful of the ending.
Clarkson (1995 p181) describes the transpersonal relationship as “the timeless facet of the psychotherapeutic relationship, which is impossible to describe, but refers to the spiritual dimension of the healing relationship.” She suggests a relationship “analagous to that of the marital pair” with its potential for space and fruitfulness, writing about the “sacred space.”
CAT does not explicitly acknowledge this aspect of relationship. However by encouraging the development of the real relationship CAT could be understood as opening up the possibility of the transpersonal. (Clarkson 1995; McCormick 2000 p46)
In my work with people who have learning disability I found that in recognising, facing, accepting and appropriately communicating our limitations, woundedness and vulnerability, in person-to-person relationship, we were brought to a part of ourselves where we could meet together, as adults of equal value, at a deeply significant level and experience a creativity which was bigger and beyond ourselves. With it there came a sense of freeing bonds that had tied us both, allowing for spontaneity, movement and change. Often this was expressed in the diagrammatic representation of the work as the patient brought this alive with their use of colour and drawings. (For examples see King 2002). I understand this to be the transpersonal aspect of relationship.
In all the complete CAT therapies which I undertook with people with learning disability there was an issue around the patient not making themselves heard, e.g. through the placation trap or through bottling up of feelings. In therapy, as exits from these procedures were found, the patient’s voice gradually became stronger. In listening to the patient’s new found voice, valuing it and bearing witness to the story that was told, (whilst at the same time remaining faithful to my own truth), I found that a more authentic connectedness based in real, lived experience developed between us. This seemed to be powerfully therapeutic.
It was interesting to see how Claire’s perception of me developed. At the beginning of therapy she selected a large brown button for herself as a reflection of her sad mood. For me she chose a similar sized pale blue button, which for her was a happy, good colour. It was as if in her mind she held all the bad, difficult feelings and, by contrast, I held all the good, happy feelings.(King 2002, illustration 6, p78) Towards the end of therapy, using colours, we found that she could hold lots of different feelings towards me and that these feelings could be mixed. (King 2002, illustration12, p85) She seemed more aware of the complexity of our relationship, seeing each of us more as whole people.
Dependency is a big issue in work with people with learning disability. I found that the segmented ‘clock’ (King 2002, p35 and Appendix 4, p101), which we used, was invaluable in being clear in a concrete way about the time that was available to us. Towards the end of therapy, as patients coloured in the segment at the beginning of the session, they would often comment about the fact that there were not many sessions left, which opened the way for discussion of feelings around ending. All were able to express something of what they felt. A sense of disappointment, sadness and anger were often voiced as well as a sense of hope and improvement in their lives. Claire, Barbara and Kim all wrote goodbye letters to me. Each was able to express their feelings with depth, directness and complexity. Michael reflected on his feelings in the room using buttons, Sally drew several pictures and Elizabeth made a card. I felt very close to all these patients and it was hard to say goodbye, knowing how many struggles lay ahead. And yet it felt necessary and important to hand back to them to hold for themselves, perhaps with the help of carers, all that we had learnt in our work together.
All five aspects of the therapeutic relationship described by Clarkson (1995) were recognisable in my work with people with learning disability. It became clear that the development and use of the therapeutic relationship was closely interlinked with the structure and techniques of CAT. Together they made up a whole.
The study has emphasised to me the importance of finding human connection in my work, being genuinely myself, relating with authenticity and integrity. I believe that it is this person-to-person relationship, and the creative potential of the transpersonal held within it, which ultimately bring growth, change and healing to both patient and therapist. But in order for this to occur it is necessary to overcome personal countertransference to disability, establish and maintain a working alliance, address issues arising out of the transference/countertransference relationship and provide for developmental deficits in the reparative relationship. I have found this to apply, not only to my work in learning disability, but also in my current work in addiction psychiatry and my work as a CAT psychotherapist in a general mental health setting.
As individuals, as psychotherapists and as a society, it is healthier to learn to connect with people with learning disability and the pain that they bear for us, and the gifts that they bring us, than it is to distance ourselves or destroy. In wishing to conceal or get rid of disability we deny or destroy an essential part of our humanity. Living in a society which places such a high premium on achievements, possessions and the perfect looks of the adverts, it may be hard to be in touch with the imperfections which are part and parcel of the human condition. Connecting with disability brings us more in touch with the whole of ourselves, allowing us, if we will, to accept the strengths and weaknesses of our full humanity.
Consultant in Psychiatry of Learning Disability (retired). Currently clinical assistant with Salisbury Alcohol and Drug Advisory Service and CAT Therapist”.
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