Maggie Gray and Maria Falzon, 2013. CAT as a bridge between confusion and psychoanalytic thought. Reformulation, Winter, p.26,27,28,29,30,31.
The problem was that ward staff in a busy psychiatric admission ward were angry with patients and arguing with the consultant about whether patients were actually ill or if they were just exhibiting “bad behaviour”. They were also finding it difficult to come to work. In addition patients were staying in the ward for long periods and it seemed impossible to discharge them. There was little money for training and the staff had little understanding of what might be going on and how to manage their unacceptable feelings. Generally staff at all levels felt beleaguered and that there was minimal understanding or support from others.
One of us, Maria Falzon, was a psychiatrist in the area. She has a background in psychoanalytic thought and wanted to encourage staff to make use of their emotional reactions to patients as information and to develop a shared non-pejorative language. Just having time to think about patients would be helpful. She approached me, Maggie Gray, as a friend and colleague from outside the area, working in an out-patient service with experience in working with patients who attract a diagnosis of Borderline Personality Disorder and as a CAT therapist. In addition I am a psychiatric nurse and those we hoped to reach came largely from a nursing background. We were already thinking of bridges – Maria knew some of the hard to help patients, I knew some of the experiences of being a nurse in similar situations but we also had some distance so could maybe allow the development of “the observing eye”.
Maria: We decided to devise and deliver the Hard-to-Help course locally.
Looking back, the kernel for this course was sown in me a long time ago.
Whenever I have worked in a multidisciplinary team in psychiatry I have striven to develop a common language to talk with staff about interpersonal difficulties and our different interpretations of the patient’s behaviour. It has often boiled down to whether the patients are seen as being ill or being manipulative. It seems hard for people to be seen as potentially both. In the hurly burly of everyday practice it is difficult to find the time and space to verbalise these conflicts with the staff.
I remember “inheriting” a long term patient when I first started work as a consultant in general psychiatry. I admitted her in crisis. A couple of older ward nurses told me that they felt deskilled and unhelpful with her. She was perplexing. She worked in a caring profession and was behaving in an histrionic fashion. The nurses could tolerate her behaviour only if they thought she was ill and therefore unable to help herself. However, they weren’t sure if she was ill. I think her similar profession made it harder for the nurses – they didn’t want to identify with the mad bit of her and found it hard to empathise with her; that is, to imagine what was driving her while keeping their own separate mind. That made it harder to nurse her as they suspected she could choose to behave differently. I was caught on the other side of that – finding it hard to not over-identify with her sad and lonely side, and wanting therefore to keep her on the ward to show her how much I appreciated her suffering.
I tried then and strive now to empathise with all aspects of the patient’s presentation while having a dialogue with the staff about the meaning and effect of the same. External psychoanalytic supervision and training has been invaluable to me in maintaining this effort. As I grew in confidence and built relationships at work I became increasingly impelled to pass on my learning as something valuable that could enhance day-to-day frontline practice.
From this was the idea for the Hard-to-Help course born.
We decided to spread the teaching over 6 months starting with a full day which was quite didactic using videos and exercises to start the participants thinking in terms of Reciprocal Roles (RRs), transference and countertransference without eliciting the shame which we speculated would surround the feelings about patients. We also thought that it was necessary for the group to get to know each other and us before asking them to talk about the problems they were having with their work. We then met for half a day per month to allow the new ideas to be assimilated and moved towards a more obvious consultative position. We were keen to get a broad section of experience in the participants so we advertised throughout the service in this way:-
Have you ever wondered why some patients are hard to work with? Or why some bring out the worst in us? We would like to offer an eight session course to think about these issues. We will use psychoanalytic and CAT models in case discussions to understand the feelings and behaviours elicited in both patient and professional.
“There is nothing so practical as a good theory” (Lewin, 1951) and we think we have some good theories. Come along and see if they are helpful to you.
In the event we attracted mostly nurses though there were a few occupational therapists and two social workers over the 3 years we ran this training. The first training was overbooked and we started with 20 people. This felt like too many for the on going sessions so we reduced the numbers to a maximum of 12. We learnt as we went along. In the first year I wanted to share all the various things that I had found helpful – Mindfulness, Dialectical Behaviour Therapy and theories around trauma. Both Maria and I wanted to give them articles to read as we both learnt in this way. We found that this was too much to take in so we pared back to concentrating on the problems brought by the participants. It was in this exploration that CAT was so helpful.
Maria The psychoanalytic papers were too theoretical and the language was too different to be useful to the participants. The different techniques Maggie brought became an overload of many different paradigms. I brought a recording of Anton Obholzer (Talking Cure BBC TV 1999) consulting to a school where the headmaster was overburdened and seen as special by his staff. We hoped that some of the participants would identify with him while others would be more critical. We could then have discussed “splitting” within teams. In the event I, the sole medic, was the only one who identified with the headmaster; everyone else saw him as doing too much and only having himself to blame for becoming ill. I also showed a film clip of a doctor with a detached bedside manner. This did not lead to much discussion either; participants seemed accepting of the doctor’s dismissive attitude. Criticism of the doctor and an expectation of a “softer” compassionate manner did not seem possible to consider.
I will now talk about 3 clinical dilemmas brought by the participants. These are composites based on several stories.
The first was brought by a male CPN whom I will call Fred. He had been seeing a female patient for some time, she had moved area and his team was pushing him to discharge her but every time he tried to do so she overdosed and he felt unable to complete the discharge. This is a fairly common dilemma and Fred was able to talk about the RR irritated to demanding. However, he was also sorry for the patient and had sympathy with her feeling of losing all her supports due to the house move. This more positive feeling was the one of which he was ashamed and could therefore not acknowledge with his colleagues. So we put caring and cared for on the diagram we drew and explored the fear of abandonment which was the warded off emotion in the patient but possibly also in Fred in relation to his colleagues.
Seeing these RRs in a very sketchy diagram others were able to agree that they had also been caught in this type of situation. Generally they had been trying to discharge patients without talking to them about what was happening and what both might feel about this. They had definitely felt that acknowledging the positive RR would have made the discharge more difficult. It didn’t seem appropriate to write a letter to the patient as we might do in CAT but we asked Fred to think about what he might say to the patient and what the exits might be from the central dilemma. We didn’t resolve this in one session but Fred was able to talk to the patient about her fear of being abandoned. He also put in place a structured ending which he was able to share with the team in which he worked. Over the next few meetings the situation resolved. Not a complicated exit but not one that could be considered while Fred was trying to not acknowledge his emotions or those of the patient.
This case was an overt expression of something that we had noticed earlier in the various exercises. The shame carried by the staff was not only or even mostly about “hate” of patients but rather about “love” for patients which was seen by many as being “soft”. The idea of having a positive feeling but being able to make decisions which were based on logic and scarce resources seemed alien so positive feelings were not acknowledged.
This was very different to my experience with counsellors in training who seem to only allow the positive feelings and disallow the “hate”. In both situations CAT allowed both positions to be acknowledged and better decisions to be made with the patient/client.
Maria. We noticed that it was easier to hate Hard-to-Help patients that didn’t respond to our efforts.
It seems to me that there is an organisational dynamic and imperative in the NHS about being tough. We have to keep to targets, do the same job with fewer resources, not molly-coddle people, measure outcomes with tick box questionnaires, not let people wait too long or keep them on too long. At the same time we have to be caring and compassionate and provide the highest quality service that saves lives and makes patients better.
More locally I am aware that most of the patients that get referred to secondary care have tough lives where they live hand to mouth on benefits. They often seem anxious, helpless and overwhelmed. There seems little space for playfulness and tenderness in their lives. I think some of this was mirrored in our courses (Searles, 1955). We gradually became aware of the tenderness we felt towards our patients. Just as the patients as parents could not show tenderness to their children and keep their boundaries at the same time, so we seemed reluctant to “come out” as liking our patients. Some of this seemed linked to the fear that clear boundary setting and discharge would then prove impossibly tough and we, the professionals, would become overwhelmed.
The imperative is that we are omnipotent – we can take on anybody and “sort” them if we spend enough time with them. In real life it is hard to help everyone and keeping someone in treatment too long can do iatrogenic harm. And it is even harder to say to a patient: “I can see that you are struggling and I am still discharging you".
A ward based staff nurse whom I will call Andrew brought the second case that I will talk about. He was having a particularly nasty time with a male patient who verbally abused him every time he came on duty. This man would follow him up the corridor shouting and swearing and everyone would look at Andrew who felt he had tried everything to resolve this. Andrew was becoming more angry and frustrated every day and what made it worse was that he used to have a good relationship with this patient. Andrew had started to avoid the patient and to dread coming to work. The obvious RR was abusive to abused but Andrew also felt hurt and useless.
Once again, on seeing this on the diagram we started to think if the latter might also be how the patient felt. One of the participants had been at school with the patient and knew some of his history since then. She, Betty, said that he had always liked to be helpful and that the most recent episode had been connected with the ending of a relationship. Once Andrew started to think about it he thought that the patient’s abuse of him might have started around the time that the patient had been discouraged from taking charge of the new patients and showing them around the ward. The more Andrew tried to avoid the patient the worse things became so we thought that that might be an enactment of dismissive to demanding which we added to the diagram. As Andrew talked about his situation he already started to feel less alone with it. He was able to change his attitude to the patient. Importantly for the patient, Andrew was able to ask for his help with simple tasks so the relationship became more positive though it never returned to the rather special one which they had prior to the outbursts.
From a psychoanalytic perspective Maria thought that the patient was making anal attacks on Andrew in an attempt to shock him into paying more attention, any attention being better than being ignored. However we didn’t share this with Andrew as this type of analytic language seemed to be outside the “zone of proximal development” (ZPD) of the training group.
This situation also allowed us to explore the relationship within the staff team. Andrew had expected to be criticised or teased so he didn’t talk to anyone about his situation and one of the other participants said that no one wanted to raise it with him in case he “took it the wrong way”. The general atmosphere of blame and potential failure meant that any feelings of being useless had to be hidden and the kind of strength that was demonstrated was quite brittle and close to fracture. We were able to discuss the idea of both individuals feeding into a RR that then felt unchangeable. During the training we were able to raise the idea with some participants that we brought our own past experiences into the work and Maria and I both used ourselves as examples. Andrew was still feeling abused by the patient and was not sure that he brought anything to the conflict, which was not elicited by the patient and the situation. However, he did feel that he had gained from the discussion and he completed the course.
One of the issues that we did not explore overtly was the fear of “specialness” either in the patient or in the staff. Of course patients had become special in many ways to individual staff members but this led to criticism from other staff and seemed impossible to talk about. We saw this first with the Obholzer video when the head teacher was universally condemned by the group. It seemed to me that it was the acceptance of being special and therefore working too hard which elicited the group’s scorn. Fred couldn’t talk freely about his concern for his patient in case he was seen as having a “special” relationship. With Andrew it was possible that the withdrawing of the “special” relationship on both sides had felt like abandonment and led to the conflict I have described.
I think it is important to repeat how little experience most of our participants had in thinking in this way and using their shameful emotions as information rather than hiding them and criticising themselves. We were impressed that they continued to think with us and to take major risks in exposing their emotions.
This sense of being unable to think while with a patient was highlighted in the third case I want to talk about. This case has been substantially altered as it is less common in some of the detail than those already mentioned though still provided a template for cases seen by others in the group.
David caught our attention by saying that while with his patient ,Eve, he felt as if he had been with a “Dementor” out of Harry Potter. All ability to think had been sucked out of him and all he could do was continue to see Eve for “supportive” sessions which had been going on for several years and which left David feeling useless and despairing.
Eve’s symptom, which she blamed for all the problems in her life, was that she thought her jaw was unusually small and this was preventing her from having the life she deserved.
Maria. This sense of special entitlement was particularly striking.
She had a pattern of going outside the area in which she lived and had her treatment. Far away from home she would do “special” activities like opera, joining clubs and presenting herself as knowledgeable. This inevitably went wrong. People either didn’t see her in the way she expected or she would gamble and lose large amounts of money. This led to self-harm and overdoses, attendance at the psychiatric service in the other area and requests from these services for even more therapy. David felt obliged to offer more appointments during which Eve just complained that her jaw was too small and this was why she couldn’t get on in life. She had actually had an operation to enlarge the jaw but felt that this had made things worse and so needed even more support.
Several of us had actually met Eve and had offered various group based interventions which she turned down as she felt “better” than other patients – more intelligent, more deserving. Maria had tried to show Eve how she used the symptom of the small jaw as a way to hold intimacy at bay. Eve appeared to listen but then went to David and told him how angry she was that Dr Falzon did not understand the depth of her distress.
We started by trying to map out the obvious RRs. David’s initial comments about Eve as Dementor to him being Empty of all thought and despairing. When we found out more about Eve’s childhood we discovered that Dad had left when she was quite young and Eve was left with her mother who appeared to pay scant attention to her. Eve still lived with her mother and would self harm in the house in a way that her mother would find it difficult to ignore but it was never talked about. She didn’t know why her father had left.
We speculated that this was the initial destructive relationship and that Eve never had a third party to provide the triangulated relationship which allows thought about emotions and relationships( Britton 1998). In addition her mother had actively discouraged questions. Eve sought an ideal relationship with David and others, which had to be demonstrated in order to feel real. The concrete need to alter her jaw was also part of this need. Attempts by the professionals to think rather than act felt as if the relationship was being withdrawn. So we had 2 more RRs - Admiring to admired which could not last so Eve resorted to Demanding care from a Coerced carer.
We were aware that David was also being coerced by psychiatrists in other areas and we speculated that they might also find it difficult to think and not to act in the face of Eve’s escalating self harming behaviour.
We free associated and together produced a map. We did not know how accurate it was but the interaction involved in drawing the map allowed us to reflect on these issues. This was freeing to the whole group. We thought there might be 2 exits – one was to move in to a therapeutic relationship and try to help Eve think rather than just act out. David felt that he had already tried this and others had offered therapy and been turned down. The second was to move out of the relationship. We were concerned that Eve, in order to coerce care, would continue to escalate her behaviour if there was any chance of being in a “special” relationship with an individual. This might have led to a completed suicide. David was able to set a long termination date and work towards an ending and Maria and David together responded to demands from external psychiatrists by explaining why they would not offer more therapy. Thus they were able to think rather than act. To date, some years later, Eve is still alive and appears no worse than she was in the unending supportive relationship. The patient was not “cured” but David could reflect again and “the therapist has to survive” (Coltart, 1993) to work and play.
There seem to be two aspects to this survival. One is that we cannot help all the patients that we meet and so we need to resist being pulled into heroic measures, which risk the therapist being damaged by the destructive enactments of the hurt and defended patient. After all without surviving we cannot help anyone. The other is that we need to have ways to recreate our own interest in life and learning so that we can continue to find ways to engage patients in finding a life worth living. Nina Coltart says it so much better!!
I chose these three cases as they seemed good examples of the common issues that came up in all the courses. However the metaphors and symbols in the third case did engage us and perhaps show how having interesting symptoms or ways of talking about one’s distress might conspire to making a “special” patient with all that entails.
Maria: Most of the patients we thought about would not have been able to use formal therapy. Instead we helped the participants to reflect on the dynamics of their thoughts, feelings and behaviours and those of the patients. That led to them having a different attitude and understanding, which in turn led to them having more flexibility of thought and freedom to behave differently. We used RRs as a shortcut and an easy language to learn. Putting feelings into words and into the diagrams legitimized the emotions and made them useful rather than a distraction. Even if the patient, like Eve, couldn’t think differently the frontline staff could re-find their thinking as they saw their patients through the lens of a new theoretical paradigm.
Perhaps the most important learning that came out of these trainings was to develop an interest in the emotions and reactions elicited by working with the patients who are Hard-to-Help. We worked with an Observing Eye and an attitude of being interested in all the emotions. The diagrams drawn as people talked about their situations helped us to think by putting the thoughts outside us and on the page. I guess we were “Mapping the Moment”(Potter, 2010). During the second course several of the participants came to a brief introductory course on CAT. Since the courses have finished Maria has continued an interest in Mentalising with some of the staff. Once this kind of thinking is started it is hard to “put the genie back in the bottle” and an interest both in one’s own internal world and that of the patients continues.
Maria. Participants have continued to change and develop their practice in a more self-aware way. It’s a pleasure to continue working with them. We discuss psychoanalytic papers; we formulate from the countertransference/transference and the parallel process; we role play; we support and challenge each other. It’s fun, stimulating and hard work.
It was very striking that by the end of the courses everyone, including me, wanted to get more CAT training, not more psychoanalytic training. I think this was partly due to Maggie being the more experienced trainer at the time, but also because CAT has a more accessible language. We were trying to find ways of looking at projection, projective identification and parallel process. Reciprocal role procedures are easier to understand and more playful to arrive at than interpretations. I think that the “doing” bit of RRs helps capture the entirety of the experience. For example, describing the attack by Andrew’s patient as an anal attack is metaphorical but the roles that Andrew and his patient were falling into were more concrete and easier to grasp.
Before I finish I just want to say a bit about our further experience. Maria and I have written this training up with a much more psychodynamic feel with Maria as the primary author. That article was not accepted for that particular publication though we have now sent a substantially changed version to a journal. The feedback we received was that we talked too much about what we did rather than on our thoughts about the changes in the participants. In addition the combination of CAT and psychoanalytic ideas was not what the editors were looking for. I had the feeling that it was seen as not legitimate.
I was disappointed and Maria has challenged me to think about whether this Narcissistic injury is driving my comments. However, I do think that it is worth considering this rejection leaving aside my initial reaction.
CAT is different to psychoanalytic therapy in the way we work together as well as how we think. We had thought that this was the interest. It was in the dialogue between Maria and I as well as between the participants and ourselves that the most interesting work developed. Neither of us gave up our separate positions but we respect each other’s work and we hope that demonstrated something to the participants. Surely this is a model for therapy – we don’t want to pull patients into total agreement or to have a total separation but rather to create a transitional space in which we can both play with the ideas and allow growth of a third position from which the patient can continue to think about their own situation after they leave therapy.
Maria. Or if, like Eve, the patient doesn’t think differently the clinician can feel less burdened by having a formulation that explains why the patient is so hard to help.
Given my further training in group supervision I wonder if we could have done more with the frame to enable the hard-to-help participants to feel safer. But I do think that psychoanalytic thought is subversive and too disturbing for some. It is a common experience with all trainings that only a few people take it up and run with it in the long term.
We built a bridge between confusion and analytic thought. Maggie and I modelled being a therapeutic couple in which the holding maternal function and the doing paternal function was shared between psychoanalysis and CAT respectively. We helped to show how we could supervise, reaching the Oedipal third position with regard to observing ourselves in relation to our patients. Objectively, we could measure our success concretely as several participants were able to discharge long- term patients, thanks to their rediscovered ability to be both empathic and tough.
Perhaps the struggle to make the former paper analytic lost some of the power of the difference and perhaps this article will lose some of the analytic thought, which underpins CAT and our training. To quote Jason Hepple ( 2012) who was quoting Tony Ryle:- CAT is “the attempt to restate object relations ideas in a cognitive language and to generate an approach compatible with observational studies of early development”
We are aware that it is hard to talk about loving and hating our patients. As we have struggled together to write these two articles we have each been in the position of challenging the other to consider the use of emotive language when caught by a particularly strong reaction that each of us has had. However it seems to me to be important to acknowledge the power of these emotions. How do we expect to help frontline staff cope with extreme and shameful emotion if we can’t acknowledge it in ourselves?
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