When the therapist is disabled

Crowley, V., Field, B., Lloyd, J., Morrison, P., & Varela, J., 2014. When the therapist is disabled. Reformulation, Summer, pp.6-9.


It is one of those times when you know you are not equipped to offer therapy. You predict a pretty well total failure to communicate. You think to yourself that even if you were to try, you would not know what to say. A lot of your vocabulary would probably be unintelligible and your client would be sitting there not understanding. To make matters worse, you would not understand them either. Their sparse and ill-formed speech is so poorly articulated that you would not know what to say. Should you say that you don’t understand, so they feel embarrassed and frustrated, or should you pretend you understand and then have to deal with mis-attunement? How awful would this be? And you wonder whether therapy would be useful. You reason that if an aim of therapy is for the person to learn new things, how would this person learn anything even if the communication barrier was overcome, given their poor memory, diffi culties in planning actions, inability to do things you can do, and problems evaluating how actions turn out. How would a Reformulation work, when it’s not just that they can’t read, but that they can’t understand complex ideas? Is CAT the right approach anyway? “No”, you decide, the client cannot access this therapy so cannot be offered therapeutic space; maybe this doesn’t matter because they probably don’t notice their problems. There’s a part of you that fears working with people with disabilities might damage you, or at least damage your prospects for climbing up the carer ladder if you were associated with ‘them’. You decide to do nothing and leave it at that, although if you were feeling generous you might decide it would be better to hand it over to those experts, those very special therapists obviously oddly different from most mortals. You admire their skills; skills that you believe evade you. “Must have the patience of a saint,” you think, but then you revise this idea realising that they must fi nd their work very rewarding. But it is unlikely to be ‘real’ CAT. Shame that no one does CAT with this client group in this geographical area, but that is how it is......Underneath it all, you feel relieved that the client has been disposed of safely.

The result is a “does not meet referral criteria/ service remit” response to this type of work and bemusement at those who actually choose to do it. This imaginary scenario seeks to describe how therapists can feel disabled; too unskilled to accept a referral for someone whose level of verbal and cognitive skills is impaired. The point is that the therapist can only hope to take the client to the place where they are themselves. We are taught that feelings are information and so getting a sense of the emotional landscape is a vital fi rst step. When sitting in a room feeling disempowered, de-skilled, and downright stupid, therapy might seem pointless and unproductive and as if the therapist’s self-esteem is being attacked. The therapist may feel very uncomfortable. In this paper we try to understand the barriers and to suggest some responses.

At a recent 2-day CAT Introduction course for people working in learning disability services, Jo Varela and David Wilberforce captured this sense of enforced silence, puzzlement and embarrassment “The exercise starts at 1.50 and ends at 2.20” said David. And that was all. The group sat there looking awkward and as they described afterwards, wondering what on earth was going on, if they were allowed to talk, what the rules were, what were they supposed to do, or what were the trainers about to land them with. Nothing was known. Excruciating! Then, little by little, people started to go into the middle and write down the reciprocal roles that they were experiencing in relation to the silence or lack of understanding in the room. After a while, the monstrous unknown became playful and creative. We understood that intellectual disability is a reciprocal role, and this means we can all be at either end of it and that we can even fi nd meaning when there are no words.

Difference: How LD staff are viewed

We ask, “Are therapists who choose to work in learning disability or other areas of disability not the same as the rest?” Is there an ‘us’ and a ‘them’? Or do we become set apart over time as we enter a dance of exclusion or separateness?

The notion that the therapist working in learning disabilities or other client groups must be fundamentally different in some way or other from those working with neuro-typical clients has a long history to it. What these differences might be remains unarticulated. Most therapists working with people with normal IQ scores are regarded by the public as special in some way to do the job that they do. Maybe all of us hold onto something ‘unspeakable’ in some magical way, but the difference is that the learning disability ‘profession’ has been set up in order to separate out further people with intellectual and social impairments. There is a clear parallel process with how we are viewed by other staff. Thinking about Mike Bender’s seminal paper on ‘The Unoffered Chair’ (1991), there can be a reluctance to see the therapists’ work in learning disabilities as the same as work with people with higher intellectual abilities. Tribalism and tribal thinking invites competition rather than collaboration and reinforces separateness. Others can assume that only behavioural work could be offered, taking the view that ‘why waste your time working with people with a learning disability? you can’t change them’.

Being different is a reciprocal role and many of us in the SPIG have noticed that it is not just that our group is so strong and has such a bond because we are made to feel different by the parent body, but also that many of us do, at times, identify with this difference. Most of us cannot specify what this sense of being outside and different is about, beyond our mission to have both CAT and learning disabilities included. As a group, we all insist that we do not have any ‘special’ qualities and that our work does not require us to do anything ‘special’; we have some adapted tools and we make reasonable adjustments to work within the context of learning disability services. The content of a CAT may be adjusted, but the process remains recognisably the same. The government’s position paper on services for people with learning disabilities, called, ‘Valuing People Now’ places the onus on services (and therapists) to make reasonable adjustments to support access to generic services.

Difference: How clients are viewed

People with disabilities can seem different from us. In addition to differences of age, gender, social class, ethnicity, education, life style and life experiences that occur in most therapy dyads, there is also an additional one of intellect, which further serves to reinforce perceived inequalities in the therapy dyad. Furthermore, many people with learning disabilities appear physically different; perhaps too tall or too short, but also their faces particularly, may look ‘different’ as a result of chromosomal changes. When looking at each other, these differences may, at fi rst sight, mask the individual, so what is seen is the syndrome and not how they are feeling. Does the client view themselves as different? Julie Lloyd, one of the authors of this paper, after discussion with Irene Elia, who facilitated a workshop at a CAT Conference about using mirrors to explore how we see ourselves, offered people with Down’s Syndrome a mirror and asked them what their refl ections were saying to them. Responses ranged from a confi dent exclamation about the handsome man on view, to a distressed man who threw the mirror across the room and cried. For therapists new to working with someone with a learning disability, can they take the risk of being in the room with that disability without increasing shame?

Other clients with disabilities make the therapist face the ‘horrors’ and indignities of how we may reach an old age with dementia, lose our sense of self and relationships through brain injury or the fear of unpredictability and loss of self and abilities in ‘madness’. When a baby is born, normally parents rejoice and the mother usually looks at the baby with love. We know that our sense of self is gained through the gleam in the mother’s eye; what is it like for those clients who appreciate that gleam in their case expresses that it would have been better if they had died, been aborted or had never been born?

Cognitive Impairment

If having a cognitive disability impairs the ability to use a describable observing eye and make thoughtthrough changes, some therapists may wonder how therapeutic change occurs. The person may not be able to tell you about their new procedures. Jean Knox (2011)’s research into change in therapy, points to the relationship being the most facilitative factor, rather than thinking. Learning theory (Bandura 1977) shows us that learning is often associational; it is the felt experience of a therapeutically helpful relationship that makes the difference. The point about the Zone of Proximal Development (Vygotsky 1978) is, fi rst of all, to task ourselves with entering that zone at the point where the client is met at their level. If experiencing limits to speech, memory and self-agency is the zone, then our experience of this is our starting point. Our task is to learn how our clients manage these limitations and to use their skills as our zone. The power of non-verbal communication is not to be underestimated and also provides a medium for exploration within the therapy.

Dialogic relationship

The therapist may wonder how they would go about developing a therapeutic relationship with someone with marked cognitive, communication and attentional defi cits. This is similar to concerns about how to develop a therapeutic relationship when working with people with personality and attachment disorders. Therapists may be aware of how they themselves are no different from so many people in society; at a loss to know how to form a social relationship, even if they wanted to. In the CAT Learning Disability Special Interest Group’, (the ironic side to our title i.e., us being positioned as ‘special’ does not escape us), we have been wondering what stops so many therapists from having a go at working with people where communication is a barrier, such as in learning disabilities, or psychosis, early dementia and so on. The other end of this ‘disabled therapist’ reciprocal role is how we are positioned as ‘special’ when the viewer cannot imagine what we get out of doing work like this, so instructs us that our work (in some mysterious way) ‘must be very rewarding’ (presumably as we look a reasonably happy and not masochistic bunch). The implication is that because they feel they can’t do it, we must be qualitatively different. How far our work is ‘real’ CAT becomes disputed. By extension, people can reject what we say, assuming our work has little to do with people who are not disabled. It is as if ‘disability’ automatically excludes anyone who does not recognise their own disabilities!!! In this way, the work we do in the Learning Disability special interest group can become a part of the excluding reciprocal role. This excluding reciprocal role is embedded within what it is to be disabled; by ‘disabled’ we mean lacking the ability to join in and connect with. Like all reciprocal roles, it runs two ways.

Sometimes people do not want to form a connection because they fi nd the perceived differences between themselves and someone with a cognitive or other disability aversive. Our clinical work sadly means we sometimes hear accounts of hate crimes perpetrated by members of the public, although more commonly we hear accounts of social isolation and rejection. Perhaps the impulsive rejection reaction occurs at a Darwinian ‘survival of the fi ttest’ level; impulsively felt instincts to push away someone who is obviously different and fearfully seen as inferior, in case any impairment is catching or reminds us of what may happen in our own lives; disabled by association.

It is through our empathy and ethical cognitive awareness that we give ourselves permission to take the fi rst step and try to enter the world of the person that sits in the room with us, whatever the differences between us. As we seek to discover what it is like to see the world through their eyes, we suspend our own sense of ourselves temporarily seeking their experience, even though this can only be at an ‘as if’ level. To start a dialogue, we then need to return to ourselves and to “dance” (Potter, 2013) to and fro between our awareness of ourselves and our awareness of their awareness. As we fl it between the two, the empathic setting aside of ourselves to be aware of their awareness and the thoughtful move away from them back to our skills and experience, so the dialogue may start. We do not yet know the genre for this dialogue; what objects of reference we will use to develop what symbols that express our conversation, but we do know that reciprocal roles are not dependent on language or IQ. Although some reciprocal roles may be more commonly experienced by people with disabilities, we have no evidence that any specifi c roles are automatically excluded simply because of disability.

One big advantage is that many people who have a substantial level of learning disability show a reduced amount of self-censorship in relationships; what you see is what you get. We then realise that this greater transparency makes it easier for us to learn what it is to be human.

CAT’s reciprocal roles offer a useful tool to describe these self-to-self relationships that develop from how people perceive they are seen by the world. We can use pictures (such as line drawings of relationships in the book ‘Draw on your Emotions’, buttons and pebbles, Play Doh, 6 Part Stories, cut and stick images and drawing stick people to describe reciprocal roles. We draw out idealised, normal and dreaded positions using the same roles as for anyone else. Reciprocal Roles are not built on IQ; they are created by social context. As therapists, we are disabled with any client group with whom we don’t creatively fi nd the tools to work with.

Like other therapists working with complex clients, we also work with the staff team interactions with clients, with a view to enhancing the client’s opportunities to learn through experiencing more useful reciprocal / relational roles. The African saying, “It takes a whole village to bring up one child”, neatly describes CAT’s radical social approach to working with people with complex problems.

Language

This brings us to the topic of speech. Language is not the same as speech; language is also drawing, (hence the usefulness of CAT mapping), selecting pictures from a small pile, and lots of other creative tools. We think that this is where the, “It must be very rewarding” comment is true; the ‘Blue Peter’ approach to developing and using creative materials is great fun. A lot of us consider ourselves unskilled, clumsy artists; but here is the therapeutically horizontal or levelling moment; if we are clumsy at drawing then we are less likely to outshine or overwhelm our clients; we model being ok with our ‘disabilities’. Our lack of artistic sophistication becomes a relational bond. The same could be said of not always knowing what to say to the client and modelling the importance of conveying this. Therapists who are used to working in learning disability services may feel quite overwhelmed when working with the vast amounts of verbal material coming from someone with a university education.

How services are organised

We wonder why intellect and age are treated as something so different that different and separate services have to be set up for them. And why is it that if, for example, someone has a learning disability and a problem with alcoholism, they would be referred to a learning disability service where few staff have specialist knowledge of substance abuse, rather than a drug and alcohol service? Could services be set up along other lines? What is this disability idea all about? Is CAT too disabled or handicapped a therapy to be useful or genuinely CAT? We claim, as our many published articles in Reformulation show and as shown in our book published in December (Lloyd & Clayton 2013), that CAT is very able. In response to those who question whether the work we do is ‘really’ CAT, we are curious about how such a view defi nes ‘real’ CAT. Are our clients too disabled to benefit? Whether working directly in face-toface therapy and / or working with staff teams, using creative dialogue, we fi nd our intelligence and ability relationally. In our experience, this work is not ‘rocket science’ and does not require ‘special’ skills delivered by ‘special therapists’, just an open-minded, fl exible stance, which can be offered by any therapist with an informed, refl exive and relational stance. The LD SPIG welcomes inquiries from CAT therapists who would like access to some of the tools as well as support to say ‘yes’ to opportunities to work with people with learning disabilities (either directly, or with staff teams or as a supervisor). We seek to challenge public perceptions that people with disabilities at worse have no value to society or at best are passive recipients of what society decides to give them. CAT is part of this challenging journey.

References Bandura, A. (1977) Self effi cacy-towards a unifying theory of behavioural change. Psychological Review, 84, 191-215.

Bender, M. (1993). The unoffered chair: the history of therapeutic disdain towards people with a learning diffi culty. Clin Psychol Forum: 54: 7-12.

Knox, J. (2011). Self-Agency in Psychotherapy: Attachment Autonomy and Intimacy. London: Norton.

Lloyd, J. and Clayton, P. (2013). “Cognitive Analytic Therapy for people with intellectual disabilities and carers”. Pub London, Jessica Kingsley.

Potter, S. (2013) Chapter Six in ‘Cognitive Analytic Therapy for people with Intellectual Disabilities and their Carers’. Edited by Julie Lloyd and Phil Clayton, pub London: Jessica Kingsley.

Sunderland, M and Engleheart, P. (1997). “Draw on your Emotions”, Speechmark Publishing.

Vygotsky, L.S. (1978) Mind in Society; The Development of Higher Psychological Processes. Cambridge, MA: Harvard University Press.

Val Crowley, Clinical Psychologist and CAT Psychotherapist; Bryony Field Clinical Psychologist in a Community Learning Disability Team, and CAT trainee; Julie Lloyd, Clinical Psychologist in a community learning disability team, CAT Practitioner and supervisor, Perry Morrison Clinical Psychologist and CAT Practitioner in a Forensic Learning Disability Service, and Jo Varela, CAT Practitioner and Clinical Psychologist. For discussion, please email Julie.Lloyd4@ntlworld. com who will forward any emails to all authors.

Full Reference

Crowley, V., Field, B., Lloyd, J., Morrison, P., & Varela, J., 2014. When the therapist is disabled. Reformulation, Summer, pp.6-9.

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