Jo Varela, 2016. “Playing” with CAT - Using a CAT Informed Approach with Young Children and their Families. Reformulation, Summer, pp.6-10.
This article uses a case composite to illustrate the therapist’s very early exploration of an adaptation of CAT concepts to be accessible to younger children, in order to work collaboratively with both the child and parent within their ZPD.
It was written with two aims. First, suggesting that CAT can offer an alternative therapeutic model for short term interventions for children. Second, demonstrating that important aspects of the change process (such as co-creation, creativity, formulation and inviting a parent and child to be active and curious participants) are well supported by the CAT model.
Tom was fast approaching his eighth birthday. He was referred to CAMHS by a G.P. who was concerned that Tom was distressed and showing some signs of developmental delay.
An assessment of his cognitive functioning quickly revealed a boy with a number of strengths who was functioning, intellectually, in the normal range. However there were some concerns about his not meeting developmental milestones or developing the expected independence skills for his age.
He and his family were offered three CAMHS sessions to assess to what extent emotional or parenting difficulties might be influencing his presentation.
The presenting problems were described as follows: “Tom became ‘clingy’ with his mother, this was expressed as sleep onset problems, and frequent tantrums and tears. He followed his mother round, frequently felt ill (requiring days off school), had a number of continence ‘accidents’ at school and was ‘forgetful’. He appeared to be fluctuating in his skills and attainment in various areas of independence and development.”
In the first three appointments, these difficulties were conceptualised using an attachment and behavioural framework (anxiety as a result of separation or inconsistency in parenting approaches to behaviour management) and psycho education sessions were offered. Tom’s mother was given parenting advice and strategies to try. When the problem did not resolve itself Tom and his mother were offered eight sessions with the writer using a CAT approach.
Tom came to the first of these further sessions with his mother, who explained that she was both worried about him and frustrated about the impact his difficulties were having on family life. Tom and his mother were invited to tell their family stories about who Tom was and his life growing up. Tom had been adopted as a baby. He and his mother described how lucky and special they felt that they had been chosen to be a family together. It was a lovely re-telling of a story of loss and finding each other. Tom’s adoptive father had left the family three to four years previously. Tom and his mother had ‘been a team’ since this time, tackling adventures together such as the first day at school and getting a dog. Tom’s mother worked full time and had an important job, but Tom was used to his after school care and had stable relationships there. Tom voiced a concern that he was a naughty boy and sometimes a stupid boy. His mother quickly gave assurances that he was not but it seemed to be part of the story about Tom and worth exploring.
Tom was offered two sessions on his own to complete a play-based assessment of his needs. Tom felt more comfortable playing and talking than one-to-one talking. The aims of these sessions were initially to develop a therapeutic relationship and help him express himself through play.
Tom was invited to pick toys that he liked and to play with them. Play using figures and cars enabled Tom to be a co-creator of the therapeutic space and the work with the therapist. During this time, a ‘sculpt’ was suggested by the therapist to help Tom to describe his world.
During the sculpt, the therapist used open prompt questions to elicit ideas about key people, thoughts feelings and behaviours. Arrows were drawn on paper to show the links between the concepts so that the sculpt could be changed flexibly if needed. The session was as follows:
‘Can you see a toy that is a bit like you and the problem’ or ‘how you feel about things at the moment?’ Tom picked a ‘blob’ toy with big, worried eyes and no other facial expression. He looked watchful or wary and described feelings of worry and feeling in trouble.
‘Can you see a toy that is a bit like what other people are doing when you feel like that?’
Tom picked a green ‘monster’ who was ‘a bit stressed, shouty and cross’ but stated that he was not sure why the monster felt like this. He indicated that a number of important adults in his life acted like this sometimes, including his mother and teacher. On further probing he said he felt that the monster might say things such as ‘stupid boy’ or ‘you are so naughty’.
‘Can you show me what happens next?’ Tom indicated that he was sad like Eyeore, so preoccupied with what he had done wrong and how to make it right that he ‘forgot to be grown up’, This was his way of describing ‘accidents’ and problems with attainment at school.
‘Can you see a toy that is a bit like what happens then/how you feel next?’ Tom indicated that he felt like a sad baby and that, as a baby, was comforted by his mother. This felt good.
An SDR was drawn as Tom talked. Tom was not sure what happened next in the ‘circle’ (his word for the SDR), but he felt that somehow he did something wrong and was in trouble again. Discussing this further, Tom was able to indicate that sometimes the ‘shouty monster’ was inside his head and that he would think things like ‘I am a stupid boy’.
Using play and a simple sculpt, Tom was able to describe how he saw himself, his relationships and his understanding of the links between his feelings, thoughts, behaviours and relationships. A simple SDR or ‘problem circle’ was created using jointly mediated signs through the use of the toys (see figure 1 below). Tom was interested in his work and spent some time tracing the ‘problem’ circle round, thinking hard about the gaps and the bits that did not make sense to him. The therapist adopted a curious and interested stance, noted his words and phrases and took a picture of the work for next time.
In the next session Tom wanted to re-create the sculpt. He and the therapist took out the picture and the toys and ‘went round the circle’ (SDR) again. Tom wanted to show his mother, who was in the waiting room. Tom showed her the toys and indicated that it was important how they were laid out in the circle, stating ‘this is how it works!’ but then became quiet. The therapist commented on how excited Tom was to show his mother and how difficult it seemed to talk about what ‘the circle meant’. The therapist wondered out loud whether Tom was worried if his mother might be upset or angry or might not understand how important it was for him (and pointed to the ‘blob toy’ on the map). His mother gave assurances of her interest, curiosity and positive regard. Tom was able to use his own words to describe the circle. The therapist then mapped out the sculpt in a traditional SDR with them both using words. The aim of this was to make it more accessible to his mother yet show Tom that it was the same material (see figure 2 below).
Tom and his mother agreed that maybe his mother should have an extra meeting with the therapist in order to use ‘the circle’ to find some ways of helping him.
The therapist met Tom’s mother on her own for the next session which followed very shortly after. They used the picture of the sculpt, Tom’s words and the written diagrammatic reformulation. A number of points struck Tom’s mother: the gaps in Tom’s understanding of the full picture, his ‘egocentric’ focus on his being the locus of cause (and blame) in the patterns described, and how abrupt - and to him, inexplicable - his experiences were of change in his circle. Also of note was Tom’s understanding of the emotional and relational underpinning of his loss of skill. Tom’s mother was quick to see how she could support him with an age-appropriate re-formulation and exits. She also was able to use the diagram to describe some of her internal processes that contributed to Tom’s experiences. She described her emotional and relational response to seeing her ‘little boy’ struggle and how this invited nurture (mother to baby). She experienced this as a warm, happy place but was able to describe how the ‘abrupt’ (for Tom) rupture related to her stresses of being a single parent with a tough job. She described how thoughts would overwhelm her, such as ‘I will not cope if he continues to be this needy’ and ‘I have got so much on at the moment, I am never going to get all the washing done. What if he does not have enough clothes for school? It must stop, It can’t go on.’ (see figure 3 below)
Tom’s mother was able to use these insights to create exits of her own such as holding these fears, seeing the reformulation as a solution and to manage her stresses differently so that she could be more containing and predictable for Tom. We used the diagram to suggest exits that could support Tom, namely to recognise that he was feeling upset or worried and use pictures of Eyeore (or words) to give to an adult to indicate that he needed support. We talked about the concept of the ‘worry/stress monster’ to help him externalise his feelings in a non-blaming way. In consultation with Tom, his mother decided to share with his teacher the understanding that Tom ‘forgot to be grown up when he was stressed’. Tom’s mother also responded to the idea of daily, nurturing ‘baby’ time with co-created rituals to begin and end the time each day so both could enjoy nurture independently of ‘inappropriate’ care-eliciting behaviour.
The sixth and seventh sessions were spent with Tom and his mother to reinforce the shared reformulation created by Tom and to share two initial exits, namely how Tom could indicate that he needed help with his worry/stress monster (following his new-found understanding that the trigger was worry) and how his mother could fill in the gaps appropriately. She playfully shared that she also ‘forgot to look after her own ‘stress monster’ and that maybe it was something they could both work on. Tom quite liked the idea that they both had the same pesky monster to beat and offered to help his mother notice her stress monster.
They both wondered whether this could be the missing gap on the diagram and whether the breakdown in care had nothing to do with him. Tom now took the picture of his ‘circle’ home with him (complete with exits) and he and his mother used it as a structure to debrief about his day.
A final session was spent retelling the now familiar story of the presenting problems, the story of the circle and the exits they had created together. Tom and his mother reported hope for the future, confidence that they understood the problem, some successes and some self-generated suggestions for further things to try. Tom was invited to pick some toys to represent how he felt about this new relationship with his mother, and his feelings about stopping sessions. He chose Kung-Fu Panda and Batman, who seemed to think they ‘could probably deal with it OK’ (figure 4 below).
I am a CAT therapist and clinical psychologist with experience of working with people with intellectual disabilities, children and young people. At present, the evidence for CAT for children is sparse. It feels as though the first steps in developing an evidence base are firstly to describe how the model is used, and secondly how it can be adapted to be more accessible, for this population. I hope that this article contributes to these initial steps, and generates further discussion about ‘what works’ in CAT for children. I would welcome comments and questions.
Dr Jo Varela
Consultant Clinical Psychologist
Sheffield Children’s Hospital
A ‘sculpt’ is a creative technique that can aid exploration of perspectives and formulation of an issue within a therapeutic process (Duhl and Kantor, 1973). It is a projective tool with which to explore aspects of self and can be used independently of a theoretical model for interpretation. In CAT, it can be used as a tool for reformulation, but also as a way of exploring possibilities in the revision of problem procedures and reciprocal roles.
To create a sculpt, a client is invited to choose from a set of objects which they then use to articulate and explore an issue. The objects may be toys, coins, ornaments, picture cards (specially designed cards such as the saga cards http://www.oh-cards-na.com/card-decks/saga/ or ‘top trumps’), buttons or beads. Variety within the objects is useful, but not always necessary.
The sculpt may be introduced to the client in a similar way to the Six-Part Story Method (see Reformulation Winter 2015), essentially as a creative way to represent and explore an issue that may be difficult to describe in words. It may be important to describe the type of objects that will be introduced, or to offer a choice if approaching a sculpt with adults, so that they do not feel infantalised if, for instance, toys are used.
The client is invited to choose an object to represent, for example, themselves and then further objects to represent other people who are important to them. The client arranges the objects in front of them however they want. The sculpt may be more or less structured by the therapist as needed, but once created by the client, is explored by the therapist using open questions and prompts to elicit meaning.
Developing shared Meaning
Client descriptions of the salient attributes of the objects they choose and each object’s spatial position in relation to the other objects is noted and ascribed personal meaning by the client. For example, a toy lion may be used because the client feels it has a sad expression, or expresses fear, threat, protectiveness or maternal instinct. A thimble may be chosen as it is the smallest object, because of its colour or shine, or to represent practicality, mending, patching up or homeliness. A coin may represent wealth, security, loss or status. Proximity and positioning are discussed as an aid to understanding relationships within the sculpt. In Cognitive Analytic Therapy, interpretations may be offered by the therapist but are likely to be discussed and agreed with the client.
Uses of a sculpt
Examples of uses of a sculpt include exploring the client’s relationships with others or their own relationship to their ‘problem’, expressing parts of themselves and how they relate, examining power dynamics, helping a client define their goals in therapy, or representing an important pattern or narrative.
As described in the above article, a sculpt can be used to elicit problem procedures and to create an SDR. The sculpt technique is particularly useful when the SDR is initially tentative and fluid. Patterns can be explored and changed with experience. Once better understood and affirmed as a valid representation, the sculpt can be made more concrete. A photograph may be taken, and labels and descriptors written down for clarity or connecting arrows added.
The technique can also be used in CAT as an additional tool for eliciting change, defining the task of therapy, and exploring possibilities of revision or test exits in a safe and contained therapeutic space. The client may be invited to change the sculpt to discover what needs to change in their relationships to meet a goal, what might be an easier-to-manage first step, or to explore the consequences of change if the dynamics of the sculpt (and by extension, the dynamics in their life) are changed.
Duhl, F. S., Kantor, D., & Duhl, B. S. (1973). Learning Space and action in family therapy: A primer of sculpting. In D. Bloch (Ed.), Techniques of family psychotherapy: A primer. New York: Grune & Stratton.
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