Dr Alison Jenaway, 2013. Change your Parenting for the Better - exploring CAT as a parenting intervention. Reformulation, Winter, p.32,33,34,35,36.
Having worked for the last 10 years in a Child and Adolescent Mental health service, but being from an adult psychiatry and psychotherapy background, I have been asked to see several parents with psychological difficulties of their own. This has mostly happened when the clinician seeing the child or the family has identified problems in the parent, which seem to be impacting on the way they respond to their child. Although some of these parents have considerable difficulties, they have often not met criteria for adult mental health service and so it has been difficult to get therapy for them. Also, adult mental health services have much less of a focus on the psychological aspects of their role as a parent, so this tends not to be integrated well into their care. The interventions mostly widely available to CAMH services in our area are manualised programmes, often given in a group format, which emphasise both behaviour management strategies and positive relationship building using play, praise and rewards. The two most widely used in our area are Webster Stratton (2007) incredible years programme and Triple P-positive Parenting Programme. Neither of these programmes focuses particularly on the parent’s own relationship patterns in childhood or as an adult, although these may well come up during the group sessions. The programmes are generally less effective for parents who are difficult to engage or where there are complex difficulties, parental mental health problems or personality disorders and individualised programmes are recommended for these parents. Psychodynamic therapy for parents places much more emphasis on relationship patterns but is less likely to include advice or strategies, and there is little access to psychodynamic therapy for parents within CAMH services, at least in our area. I wonder if Cognitive Analytic Therapy could provide a way of working with parents, which places more emphasis on their own early life experience and ongoing relationship patterns, as a prelude to trying to shape parenting behaviour. This might provide an integration between the two types of therapy for parents and could be more helpful in working with parents with complex difficulties, perhaps in advance of one of these more behavioural programmes. Cognitive Analytic Therapy offers a great way of talking to parents about their own early life experiences and relationship patterns, and then adding in the patterns that are evolving with their own children, which may be causing problems. In this paper I will go over my ideas about the developmental model of reciprocal roles and how they can be used with parents, and then describe a case report of using individual CAT with the aim of improving parenting.
I have found a developmental explanation of reciprocal roles very useful when talking to parents. The model originated from Michael Knight (Jenaway & Rattigan 2011) and I have modified it a little so that it becomes a more direct description of babies and how they develop. It makes it easier to talk about a variety of factors which may have led to problematic roles, rather than such a strong focus on parental interactions, and I think that makes it easier for parents to hear and take in with a curious mind. The model starts with the idea that babies have just two extreme emotional states. At the top of the diagram the baby is warm, fed, comfortable and blissful, all desires are fulfilled. At the bottom the baby is hungry, wet and alone, feeling abandoned and rejected because the carer is not there immediately. If the baby was thinking consciously about the parent then in the top state, the parent would be thought of as perfect and ideal, while in the bottom state, the parent would be thought of as neglecting and abandoning. On the left hand side are the procedures which the baby develops to try and get it’s needs met and get back up to the state of bliss – initially these are quite primitive, mainly crying! Later, other procedures start to emerge, being charming, temper tantrums etc. In a family where temper tantrums get you what you want, these are likely to increase. On the right hand side are the things, which go wrong or interrupt the state of bliss, good things come to an end or are not as wonderful as we thought they would be (Fig 1). If parents can understand these states and the idea of reciprocal roles, then it becomes possible to explain how our job as parents is to help the baby develop a middle ground area, where the baby can be upset at being hungry but still know it is loved and can learn to wait and be patient, and eventually to comfort itself. Also the parents need to guide the infant on how to get it’s needs met by healthy, more appropriate ways other than tantrums and demands. This will include being able to put their needs and feelings into words rather than acting them out, learning to negotiate and compromise. While later on, being able to take care of their own needs rather than having to depend on others so much. Finally, as parents, we need to help our children learn to cope with disappointment without feeling that it is the end of the world. Being able to comfort and soothe themselves and reassure themselves with hopeful thoughts about the future. (Fig 2). Since the parents job is to fill in the middle with a range of less extreme reciprocal roles, this model makes it a bit easier to acknowledge that there are many factors which can interfere with this process, and that some of those are not under the parents control. We could think, at the very least, of factors in the child, such as an illness which makes the child precious and special, factors in the parent, such as their own negative childhood experiences and social factors, such as being left as a single parent with little money. (Fig 3)
I have written in the past about using this kind of contextual reformulation with parents where their child does not want to engage in therapy (Jenaway, 2007). Since this developmental model is a kind of universal human diagram, it can also be used as a kind of template to map out the parent’s reciprocal roles and the strategies they use to try and get their needs met (Jenaway & Rattigan, 2010). Thus it is possible to create two diagrams, which can be looked at side by side. These often turn out to be fairly similar and the building up of healthy relationship roles becomes clearer as the solution to healthier parenting roles, as well as the solution to the difficult patterns the parent is stuck in with themselves or other adults. This joint approach can be used in several ways, for example working with a parent and young person jointly, drawing out the adolescent’s diagram and the parent’s diagram and working with the two diagrams side by side, as you might work with a couple. However, in this article I want to describe an individual CAT therapy with a parent, which was aimed primarily at improving her parenting.
Zoe (all names have been changed) was a 40 year old mother of two who was referred to me by the family therapist in the Child and Adolescent mental health team where I work. The patient referred to the team was actually her 10 year old son, Michael, who seemed both unhappy and angry and had become aggressive and violent towards his mother and younger sister at home. He was also having problems at school, getting into fights and using bad language. The family was assessed by the locality team and allocated a parent support worker to help Zoe with her parenting skills, and they were also referred for family therapy. However, the family therapist felt that Zoe’s own psychological problems were so great that she needed some individual therapy before family therapy would be possible and asked me to see her for individual CAT.
At assessment, Zoe was very anxious and confused. She described having been in a same sex relationship for the last 20 years with Samantha. Samantha had been very controlling and, towards the end of the relationship, physically abusive. Samantha had wanted to sleep with men throughout the relationship and had persuaded Zoe to do the same, even though she did not want to. This had led to the two children, Michael and his younger sister Lucy, now 7 years old, who had different fathers. Zoe had not wanted to have the children initially but had been persuaded by Samantha to go ahead and described how she had “fallen in love” with the babies once they were born and very much wanted to be a good parent. While the couple were together, Samantha had been the more affectionate parent, tending to give in to the children’s every demand and leaving Zoe to try and impose some discipline, which was often undermined. Zoe had initially left the family home after the relationship break up but Samantha had been unable to cope with the children and so Zoe had moved back in and Samantha had left. Michael had witnessed Samantha being violent towards Zoe in the past and seemed to have taken over this role of being violent towards Zoe since Samantha had left.
As Zoe described her own childhood experience, it became clear the she had very little idea of what a healthy relationship was. Her own mother had been alcoholic and rarely showed her any affection. In fact, Zoe had often comforted her mother after episodes of domestic violence from her stepfather. Zoe was also sexually abused by a male neighbour who had given her presents and this had left her unable to ask for things or accept gifts or help from others. It made her feel very uncomfortable and as if she would have to comply with the other person’s demands. In her youth she had had a very turbulent time, using alcohol, drugs and self harm to block out her feelings. She had been confused about her sexuality, uncomfortable with the possibility of being gay, and had therefore attempted to live as a man for a while in order to pursue a gender reassignment operation. She had abandoned this as she felt more comfortable about being gay.
Current stresses were her tendency to try to help and rescue others (as she had with her mother) and her inability to say no to anyone that was in need. She described herself as “an armadillo” looking tough and strong on the outside and helping everyone, but quite soft on the inside. We talked about how she had lost touch with what she needed and so was unable to express it or give any priority to her own needs and feelings. This meant she was often under a lot of pressure from competing demands, for example on one occasion she needed to take her son to the dentist at 2pm for a tooth extraction but a friend asked her if she would drive her up to Birmingham to look at a car the friend might want to buy. Zoe was unable to say no and ended up driving like a maniac in order not to be late for the dental appointment with her son. This kind of thing was happening all the time and put a lot of stress on her and her children. Not being able to accept gifts or payment for work that she did for others also caused extra stress and lead to people taking advantage of her, asking her to do more and more for them. She rarely had any time for herself to relax or think about her feelings. Indeed, she began to realise that this was her new way of blocking out feelings, being too busy doing things for others to think about her own emotions. At times, the stress and resentment would build up and she could be explosively angry with people, this would confirm that she must keep her feelings bottled up. We drew these roles and patterns out on a diagram, which follows the developmental template style (fig 4).
Zoe was moved by the reformulation letter and managed to write back to me. We did some relaxation together and she started to notice when people were taking advantage of her good nature, although she was unable to stop this pattern. We talked a lot about what a healthy relationship would look like, between partners, between parent and child and with one’s inner child self. We drew a developmental diagram for Michael and had this alongside Zoe’s own diagram so that we could follow the shifting states they both got into and to emphasise how important it was for her to stay “in the middle” (fig 5). On that diagram “tears and tantrums get you what you want” was something that Michael had written on his Facebook page.
The unhealthy reciprocal roles in the family can be clearly seen in this excerpt from a tape of the 6th session where Zoe is talking about how upset she is when Michael is violent towards Lucy:
“He keeps fighting with Lucy, and I cannot stand boys hitting girls, because of my mum. That is one of my worst pet hates ever, and I will knock his block off, and I will, when he is 18 and I see him hit her. I’m gonna whack him, and that sounds so nasty, but I’ve told him time and time again. He gets her in a headlock and strangles her, and stuff like that - “leave her alone”- and I have to walk away ‘cos I know that I will rage into some crazy lunatic, and then it’s like - ‘did I knock you out Michael?’ You know what I mean? It’s scary”
Zoe identified a role model for good enough relating which was her maternal grandmother. She was still alive and still a good source of support, someone who would urge Zoe to think about what she needed and not keep giving in to others. We also did some EMDR sessions on Zoe’s traumatic early life, although she found these sessions very disturbing and did not want to continue beyond two sessions, I think they were helpful as they brought home to her how awful things had been for her as a child and that she did need to start looking after herself.
Zoe gradually began to start to make a little time for herself in her week. She started to say no to people’s requests when they would cause a lot of stress, she even began to accept money and gifts from others without feeling so uncomfortable. As things became a bit less hectic, she became more able to stay calm and stay “in the middle” with Michael when he was having a tantrum. She also described being able to let the children get closer to her and being able to be more affectionate towards them without fearing that she might abuse them in some way.
By the end of the therapy, Michael’s behaviour was much improved both at home and at school and he was discharged from our service without needing any more family therapy sessions. In this taped excerpt from session 16, she describes the new relationship between her children, illustrating a significant change in the reciprocal roles in the family:
“I had a word with Michael about hitting Lucy ‘cos it worried me about her getting into an abusive relationship, obviously like my mum. I didn’t want that happening. So, I sat down and explained ‘ it’s not good, blah, blah, blah’, and I said ‘you’re upsetting her, you know. What if she gets into a relationship when she’s older and the boyfriend beats her up and she just thinks it’s normal because she’s used to you doing it.’ I said, ‘next time you hit her and you see her cry, just look at her little face when she looks up to you as much as she does and loves you with all her heart’, and he’s not hit her. Apart from last weekend when he got a bit handy, but that’s the first time in God knows how long, they’re getting on well good.”
I think Zoe would have found it very difficult to maintain the positive parenting advice and continue to implement it without have worked on her own psychological issues. CAT therapy gave her a chance to think about how much she had suffered as a child and to start to identify how to take better care of herself. This allowed her to be a calmer and more affectionate parent. CAT allows a genuine felt sense of what a healthy relationship should be, learning it “in the heart” rather than the educational advice of parenting strategies which can seem to be learnt just “in the head”. Zoe herself felt that all three interventions had been helpful in different ways and she described them as a “triangle” of care.
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Jenaway, A., 2007. Using Cognitive Analytic Therapy with parents: some theory and a case report. Reformulation, Winter, pp.12-15.
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