King, R., 2000. CAT and Learning Disability. Reformulation, ACAT News Spring, p.x.
Increasingly over the past 20 years reports have been made of the effective use of a variety of psychotherapeutic methods with people with learning disabilities, for example Psychodynamic Therapy (Symington 1981) and Cognitive Behavioural Therapy (Kroese, Dagnan and Loumidis 1997)
This presentation is about my experience of a CAT therapy with a 37 year old woman with Down’s Syndrome and mild (bordering on moderate) learning disability.
Modifications made to the CAT model included the involvement of the client’s nurse for explanation, repetition and support; the use of a modified psychotherapy file (copies on request); the use of concrete imagery; the use of tapes as well as written letters and the use of drawings on the SDR. These are described more fully in the text.
Assessment was made at her home with her community nurse. She showed me her paintings and craft work.
Sixteen weekly sessions of 50 minutes.
Dependency issues around learning disability and her history, made it very important to find a way of being absolutely clear about the length of the therapy in a concrete way. I drew a circle with 16 segments and she shaded in one segment at the beginning of each session. She filled in a modified psychotherapy file with the help of her nurse. From the start she showed commitment, openness and enthusiasm.
TARGET PROBLEMS were identified as follows:-
Thinking about her mother she said "my mum was wonderful. She used to calm me down if I got upset. I was always alright with my mum".
She talked about the sadness of her mother’s death when she was 19, then settling down with her father and then how horrible it was when he got married again. There was jealousy between her and her stepmother she got very angry with her and tried to hit her. Her father had to protect her.
She remembered her father needing to go to stay in hospital because he had Alzheimer’s Disease and how difficult it was living with her step mother who hurt her. Then she had to move and she was very angry and frightened. When her father died she was very upset, she felt guilty. She could see at this point that when things go wrong she tends to blame herself.
It was sometimes a struggle to keep the conversation going. I wondered whether she was able to follow all that we were talking about. It was vital to find a way of communicating which held meaning for us both. In session 4 I suggested that she might like to do a drawing. She chose to draw some of the happy memories she had of being with her mother. Her drawings were detailed, full of action and emotion and seemed to low out of her. They became a regular feature of our sessions. She drew a picture of the time when her father came home late for Christmas lunch, drunk, and there was a row. She wanted to stick up for her mum, but was told to go to her room and keep quiet. She also drew happy, playful times and sad times when she was quiet, sad and angry. In the patter she drew a solid wall-like structure separating her from everyone else. The sessions began to flow more easily. She said the pictures helped her to understand. This seemed crucial – we had found a way by which we could both understand and hold the important issues in her life and begin to make sense of them.
She volunteered that she tends to say "yes, yes, yes" to staff at her home so that they are happy. This helps her to be happy. But sometimes she says "yes" when she wants to say "no" which leaves her feeling upset and angry. Another pattern was emerging.
Reformulation came in session 7 after a break for Christmas. It was clear that she had missed our time together. This emphasised the importance of working on the ending. The reformulation letter was read, given as a letter and as a tape. It included TPs, history and two TPPs (see below)as well as something about our relationship. She was pleased to have it and seemed to understand it. She was able to challenge some points which we changed.
I worked out an SDR with reciprocal roles and the two TPPs. The challenge was to find a way of representing the diagrams diagrammatically which made sense to us both. We ended up with separate diagrams for each pattern which had both pictures and writing. I wrote out the diagram with spaces for pictures which she drew. This took a long time. The drawings and the ideas contained in them were very much her own which was essential if the work was to be truly collaborative. She began to recognise when the patterns were happening in her life. Using her ideas we were also able to define exits which I wrote and she drew on her diagrams.
PATTERN 1 was
We identified the following exits: think of mum’s love for me and the power she has given me (she drew a picture of her mother with very long arms encircling her, a heart and write gold with a yellow pen); listen to tape of reformulation (she drew a tape and tape recorder; talk about how I feel; say to myself "I don’t have to put up a brick wall, I can fly my flag and be happy" (she drew herself holding a big flag).
PATTERN 2 was
The exit was speaking up for herself and both parties having an equal say.
We shared our work with her nurse in session 12 to enable the nurse to provide the repetition which would help her retain the work. This seemed to be a comfortable and helpful thing to do. When she described the segmented circle as a "kind of clock" – not words I had used – I knew that she had grasped the time-limited nature of the therapy. As time went on she was able to talk about some of the difficult things about her relationship with her mother, such as her mother’s protectiveness. This seemed very important because it took her perception of the relationship away from the ideal into something more realistic. She talked about wishing she had known about the patterns sooner. She was able to voice her fears that she would "go back to her old ways" when therapy ended.
The goodbye letter and tape were given on session 14. She gave me a happy busy picture of her life now, a picture of use together and a picture of her "flying her flag" (shown below)
Session 15 was another joint session with her nurse. Session 16 was our last together. She filled in the last segment on the clock and brushed away a tear. She talked about her sadness and then said "but all good things come to an end". She drew a picture of herself with drums, guitar and an office – her dream. She hoped she would be able to move on to a home where she had more independence. I felt she had really faced the ending and the feelings it brought and was able and ready to move forward.
Much of the progress made in therapy had been maintained with only one difficult spell which had been resolved by looking at the drawings of the patterns with her nurse. Improvement was noted in all target problems. Her nurse said she was more confident and assertive, more interested in life with a clearer idea of what she wanted.
Questionnaires (including problems and complaints, inventory of personal problems, social questionnaire and Beck mood inventory) were filled in with her nurse before therapy and at three month follow up. Results indicated an improvement on all scores.
The experience of working with this case has convinced me that it is possible to work effectively with adults with a learning disability using the CAT model in modified form. Clearly much more work is needed to address such questions as the indications for the use of CAT in this client group, assessment of the client’s ability to use the approach (and possible need for preparative work on identifying and describing feelings), the optimum length of a therapy and the most helpful modifications.
Thanks to Sue Kuhn, CAT Therapist, for supervising this work.
Symington, N (1981) "The psychotherapy of a subnormal patient" Br J of Med Psychology, 54, 187-199
Kroese, BS, Dagnan D, Loumidis K. (Eds) 1997) Cognitive Behaviour Therapy for people with learning disabilities. Routledge.
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