Learning With Young People About Being “In The Middle”

Nick Barnes, 2016. Learning With Young People About Being “In The Middle”. Reformulation, Summer, pp.11-18.


Building on the framework laid down in the first  of three articles about developing a CAT-informed way of working with children, young people and parents through an Adolescent Outreach Team, in this article I explore elements of CAT in clinical practice with young people. As the title suggests, I focus on the idea of helping young people negotiate for themselves to be more “in the middle” – a descriptive phrase that represents the integrated self, the compassionate heart of their Map, a place where positive self to self and self to other Reciprocal Roles and Procedures are placed as Exits on the SDR.  This concept of “in the middle” seems helpful as an accessible means of describing and depicting therapeutic change for many young people who, at times, feel overwhelmed by some of the more formal therapeutic procedures.  

My role, as a Young People’s Psychiatrist, is often to assist a multi-disciplinary team in supporting young people and families through crises – managing risk, coordinating care and offering formulations that are, hopefully, sufficiently meaningful to inform future care planning. As I previously described, it is through CAT that I believe I have found the tools and theory that offer a good enough perspective of scaffolded support that can be both enabling and empowering for young people and/or their parents. So it is through the case material of this second article that I seek to show how this work has evolved – for both the young people and for myself.
“Youz lot is fuckin’ useless!” 

When I was contacted by Amy’s social worker asking if I would be able to offer some therapeutic work and support for this young person, now 18 years, I have to confess I was a little surprised, and perhaps rather suspicious about who was really asking. It had been 4 years since I had last seen her, and the meeting then had not been an easy one. On that occasion we were sat round a kitchen table in a care home, nearly 100 miles from “her” security of the streets of North London – a place where she had felt she could call the shots, playing the game of keeping one step ahead of her social workers, the police, the youth offending service or the staff in her care home. But time had run out, or rather, the patience of the professional network had been exhausted, and the collective opinion of those who tried to work with her was for her next placement to be located out of London. The risk of exploitation, violence, gang involvement and harm to self had become too great to tolerate, and a new placement had been found.

[See Figure 1: Map of Contextual Reformulation below]
But as I sat in that kitchen, with Amy and her new care manager (the 7th in 2 years), I was the embodiment of all that she hated about professionals and services who had robbed her of her “freedom”. Numerous individuals and interventions had been offered to work with and alongside Amy, and all had been rejected and dismissed. And now she was finding herself in a place where she felt she was being rejected and dismissed – and she was angry. “What the fuck do you think you’re doing? How fuckin’ dare you? Piss off – I never want to see you again” was the message, loud and clear, as I sat and soaked up the rage and contempt she held for all the professionals in her network. “Youz lot are fuckin useless!!!”.

For Amy, at that moment in time, her world had come to an end, and I was responsible. I could have offered a rather feeble response – “No, the final decision lay with your social worker” – but that would just be splitting the network and ultimately making things harder for Amy. All those nights out on the streets, hanging out with friends, getting chased by “the feds”, testing, challenging and threatening each other, regardless of risk or consequence, had suddenly been brought to an abrupt halt. And for Amy, that meant there was nothing left to live for. Her fury not only represented her anger at me, and all the others in the wider network, but also it represented her loss. For once again she was being abandoned -  just as she had been when she was a baby when her mother had died. History has a habit of repeating itself –  and it had done so yet again.

Keep It Simple. Stupid

When I first came across CAT, I knew CAT was for me. CAT offered something so much more than just “a therapy” – it was also the wider relational theory and understanding that I found so attractive. Mental health services over the years face ever complex material, and it feels as though one of our roles as mental health professionals is to help provide some sense of clarity and/or understanding not just for those being referred, but also for their families and their networks/communities. 

As a psychiatrist one is being repeatedly expected to explore a diagnostic formulation that whilst being helpful to a network, also still adds to the layers of complexity -  and potentially can reinforce some of the distance between the client, their network and the practitioner. A diagnostic formulation is not always able to offer any greater clarity and understanding about how to address need and manage distress.
CAT presented itself as both a way of understanding the relational development of the self, whilst offering a way of working – with the client, with their family or with the network - that enabled all to see how they could contribute to making things easier.

CAT allowed me to move away from feeling stuck within the complexity, and offered a window for accessing a shared clarity, focusing on trying to keep things a little more straightforward. This is not to be dismissive of the complexity of our case load. For many of our young people - and Amy is a fine example – their lives are complicated, and often they move in and out of phases of crisis and chaos – as do the services and professionals that then try to support. But CAT allows us to accept the complexity of both need and response as a given, and to then help focus much more on the relationships and our roles. CAT helps us use our understanding of what we are getting drawn into and, to then understand how this may feel for the young person. As Alison Jenaway states in her paper on working with young people – “Keep it Simple. Stupid!” 

Whose map is it anyway?

Even without a formal training, as my interest and exploration with CAT grew, I found myself building on the models offered by the likes of Chanen  and Ougrin , of Potter  and Kerr , of Jenaway  and Hepple , as well as the founding work of Ryle  and Leiman ; all offering ways of focusing on connecting and understanding, and creating opportunities to think relationally about, and even believe in the possibility of change. But as noted in the first article, there was also a need to think about the how, when and where of practice. That, for some, the clinic was perhaps not the most accessible place to work – nor the most appropriate for many young people, whilst appreciating that a shift out of the clinic and into the community needed to be complemented by theory and practice that was both sufficiently flexible and accessible. Subsequently, a gradual understanding of Vygotsky  and Bakhtin  seemed to offer the scaffolding needed to enhance my own learning and development of practice.

Undertaking a training in CAT was therefore less about the “if” and more about the “when” and the course offered both the intellectual reach, alongside the group venture, as well as the self-reflective draw to be both grounding and accessible, as well as enabling and empowering. But the training also guaranteed the need for one’s own therapy and experience of CAT – invaluable in helping me find a way of working more “in the middle”.

I should perhaps explain further what I mean by being “in the middle” – as there is a risk this could be interpreted as more of a “fudge”, rather than about learning and negotiating new ways of being – negotiating with self and others. The work of Jenaway and Rattigan  (although both attribute the original idea to Michael Knight) has explored the use of templates for drawing CAT diagrams, and this is something that I have been drawn to in my practice. This is partly because the developmental map can be used so effectively within parenting work , but also because I find that many young people value the simplicity of the map that shows both the circularity of some of our patterns and procedures, but also helps them visualise where they may test out exits – without feeling overwhelmed with the prospect of locating something that is too far and too unrealistic. For many young people who have been profoundly traumatized, the map can feel quite overwhelming as the visualization of the reciprocal roles can reveal quite a bleak and desperate representation of their lives. The template model doesn’t shy away from this reality, but allows the work to also focus on thinking about what might be possible “in the middle” of the diagram – somewhere between the extremities/polarities of feelings that are represented by the different states on the map. By being “in the middle” the young person is drawn to a space that allows them to experience a more compassionate self, and from there explore the possibility of being able to care for themselves, parent themselves, and even learn to become their own therapist. The use of the template map will vary according to where the young person “is at” – i.e. in their ZPD – but it is often an easier starting point, and allows the drawing of maps from the start – and mapping whilst talking . Some of the maps highlighted in this article use this template model, including the map for myself and my role within my team, in a hope that they offer some clarity of how easy they are to create, but also of how accessible they can be for enabling understanding.

As we work alongside our clients we are repeatedly looking for ways of thinking with them about change, and how this can emerge through understanding. But we are also embedded within services that have been going through profound change themselves. We repeatedly find ourselves being torn between clinical practice and the exhaustive mechanisms put in place for recording risk, care planning, clustering and outcomes - all of which never really feel as though they fit with the needs of our clients. The demands to see more clients, discharge more cases and evidence better outcomes has become insatiable – and often leaves people feeling exhausted and isolated. The overriding feeling of the tap being left on, and yet staff being asked to mop the floor is articulated by so many clinicians, and yet feels so difficult to address. And it is this sense of pressure that generates the risk for splitting and divisions within teams, services, and across networks that can become so toxic if failed to be understood. 

So, within this climate, and supported by embarking on a CAT training, I was becoming increasingly aware of my own patterns and procedures in my own work within the NHS – and really questioning my stance of moving away from the clinic – risking becoming increasingly isolated. Was I simply adding to the splits and tensions by seeking to become the “lone rider” out in the community, leaving colleagues and peers behind with a dismissive wave?

[See Figure 2: Reflective Practice below]
We all seek to have an impact through our work – we all wish to feel validated by our work – and so it is important that we all find ways of ensuring we can be “working in the middle” as much as we seek to support the people we work with of finding ways of “being in the middle”. The use of mapping and understanding of reciprocal roles helps us outline the relational antecedents of emotional distress – but also spells out to the clinician when we might be getting caught up in the procedures; when we might be rescuing, or withholding, striving to offer the perfect care, or dismissing the efforts of others. And this is so crucial when we explore working with young people – and why I believe they value the model offered by CAT.

“I think I might be Bipolar”

In this current climate of transformation of CAMH Services it has been very interesting to note the implementation of the CYP-IAPT framework  on how services are being re-designed and developed. The aspirations of a participatory agenda – with children, young people and parents being involved in all aspects of service delivery and design – is hugely admirable, if not a little over-ambitious. But the prospect of offering a therapeutic intervention that is collaborative with the young person would hardly sound “transformational” to most CAT practitioners. But what is also noticeable is the possible emergence of a paradigm shift within this transformation as one hears increasingly the call for practitioners to move away from a diagnostic formulation of distress, and for there to be a greater focus on overall need . And it is here that I believe CAT has its real and genuine appeal for young people. 

We are possibly living in a time when young people have been given the greatest amount of responsibility, and yet the least amount of authority, and through this we have generated a huge disconnect that we are only just starting to appreciate and recognize. But if we are to address this concern, then the offer that young people need through therapy requires an acknowledgement of “agency” which CAT can enable. 

Through my clinical practice I am very aware that there is a large cohort of young people who transition through their adolescent years with a profound degree of turmoil and distress that can, at times, be classified within a variety of diagnostic frameworks.  There can be self-harm, traits of eating disorders, depressive episodes, anxiety, times of panic and social anxiety, obsessive features, insecurities and uncertainties about identity and self – the list could go on. At any one moment, you could find enough evidence to classify a young person’s distress to fit within the criteria of DSM V. But how helpful this can be is often up for negotiation. For some young people, and their families, this approach is important and valuable, but I have found a considerable number of young people who would much rather work through an understanding of their distress, rather than seeking a label.

A good example is Polly, who was referred to me fearful that she might be “bipolar”. Polly was initially a young person who was difficult to engage and required a number of exploratory appointments in community settings and at home, before she was eventually able to agree to meet and to properly explore what was going on. I also think, on the surface of what she was describing, she had good grounds to wonder if she might be “Bipolar” as she spoke about significant mood swings and shifts in her behavior that potentially could “tick all the boxes”. But as she gradually began to explore worries and concerns, her fears and her preoccupations, it became increasingly clear that this diagnostic perspective was not necessarily going to be that helpful.

Having lost her father at the age of 5 years, for Polly her role and her duty within the family, ever since, had been “to look after her mother”. This had been the mantra of the extended family – and was clearly offered with the aim of being supportive. But for Polly, it endorsed her need to “strive to be the perfect carer” for her mother, and gradually reinforced her view that her own needs were not important – that no one needed to, or perhaps should, care for her. Polly aimed for perfection in all that she did, but also slowly developed a way of shutting off when things became overwhelming for her. This became an established pattern so that when I met with her in her mid-teenage years, she could only hold 2 places in her mind. She would oscillate between a place where she was 100% in the clear, and functional, or a place that she felt was “fuzzy” and had no sense of clarity or substance. And this was where we were able to begin a therapeutic relationship.

Once it had been possible to gain Polly’s trust – we agreed to explore a CAT model of therapy that might be able to map out this polarization between being “in the clear” or in the “fuzziness”. We explored what might exist within each pole; finding reciprocal roles that existed within each pole or across both.

But it was the opportunity to spell out, through maps and reformulation, that she had the capacity, and even the permission, to move between these 2 poles that allowed for the biggest shift in understanding and appreciation of self for Polly. Holding to the principle of “Keep it Simple Stupid” and allowing for Polly and myself to slowly draw out what was going on – within herself, between herself and others, and within the therapeutic space – it was possible to provide a framework for understanding her distress that was helpful, meaningful and eventually enabling. Seeking a place “in the middle” became accessible to Polly as she learnt to better look after herself, to explore what it meant to sooth and care for herself, to find time to parent herself, and eventually to think about how to become her own therapist.

I used to not like you, but now I realise you’re ok

So returning to Amy, with whom I began this article, I have to confess that my curiosity was raised when the social worker called to sound me out about therapy. Was there something about having been “rejected” and “dismissed” so vehemently 4 years previously that made me desperately need to have one further opportunity to be “appreciated” or “valued”? The social worker had informed me that Amy had asked to meet with me as I was one of the few people who knew her from before, and therefore would understand how far she had moved on from where she was – that perhaps she wasn’t just repeating her history, and that she was now in a better place.

One thing that was very different - she was now a mother. Hence the request for “therapy” was not necessarily hers, but rather, may have been a request of the system – a system that would need to decide whether she was able to keep her child. Hence there were multiple agendas behind that one simple phone call from the social worker – agendas belonging to Amy, to the social services as well as myself. But what Amy was looking for from me was a professional that she could trust. She knew all too well how our last encounter had played out 4 years previously, but she also knew that I had tried (and failed) to offer “support” at that time. My offer at that time was meaningless to her. But now Amy was in a different place – she was on her own, with her baby and within a system that, perhaps not surprisingly given some of her past history, was not even sure they could trust her to be a “good enough” parent.

But by the time Amy came to the sessions, I could see and hear changes, but also recognize some of the patterns of the past. And yet I also knew that her request should be accepted. The fight and feistiness has not been lost – but there was a part of her that knew things needed to be different -  she just wasn’t sure how this could be achieved. More than her fighting the system to keep her baby – it was clear that she was also struggling to understand who she was, and why she repeatedly found herself in a place where she felt people were taking advantage of her. 

We started with her “history” as she felt this was what was being used against her by social services. She was clear that she had come to me, as I knew that history, but she was also keen for me to be able to see what was different. I am sure I can hear alarm bells going off for some readers – as many of us know that (unspoken) expectation for our work to form the basis of reports for court. With this clearly in mind, I outlined my own approach – I would be happy to work with Amy, but only on the condition that our work was not to be used in court. If there was to be any evidence provided for the courts, then this needed to be requested independently – with an expert witness meeting with Amy before and after her therapy. This may have got my work out of the court arena, but it had set up a rigorous evaluation and measure of outcome – no pressure!
But I needn’t have worried. Amy wanted to do some “therapy”. Still unsure what this really meant she signing up to attend 16 sessions on a weekly basis – despite the need for childcare. Tackling her “history” we looked at many of the patterns and procedures that I knew from before; starting with the original risk assessment that I had been asked to complete for the network which had contributed to her care placement out of London. She was keen to work with me on this at the start, surprised by how much had been gathered together to help understand what was going on for her 4 years previously, especially when she was so unwilling to offer much to professionals at the time. But this focus also allowed us to move through a series of steps in the first few sessions – moving from what others wanted for her and gradually working towards what she wanted for herself and ultimately, for herself and her baby.

It was clear that the old patterns and procedures– of attacking but ending up feeling attacked, of rejecting but then feeling rejected – were still as strong as ever in her relationships with others, and one could easily imagine the concern of her social worker. How long would it take for these procedures to become established within her relationship with her child? Her social worker wanted Amy to have some “anger management”. But Amy remained uncertain that this was her core problem. She recognised that her anger really only came to the fore in settings such as the large network meetings where she felt she was being scrutinized and questioned, blamed and criticized. She felt her focus needed to be more on what caused her to erupt, and why she repeatedly felt others were just “taking the piss”. Slowly, through a reformulation letter staggered and mapped through a number of sessions, we began to create an environment that was not abandoning we were able to start reflecting on the sense of abandonment she felt in relation to her mother, and how the rest of her family had been unable to ever fill that void, leaving her unable to trust others or herself.

3. Amy’s map in therapy – thinking about her relationship with herself and her relationship with her baby, with a clear appreciation of how hard it is to get to the middle.

Amy’s case allowed a chance to reflect on the history, but it also allowed for the work to consider her presentation at different stages in her life, alongside my own understanding of CAT. The template map that formed much of the work for the therapy with Amy bore great similarity to the original map developed through contextual reformulation with the network 4 years previously. The language had changed, and the ownership was very different, but the procedures were similar and hugely helpful when asking Amy to reflect on how much had changed, and how much she needed to work on.

I am not suggesting this work offered some enormously self-revelatory moment and Amy left therapy a changed woman, with a perfect understanding of her needs and the needs of her child. But I think she left therapy with an understanding of the importance of trusting relationships and of how this will guide her to find ways of better negotiating to be “in the middle” for herself and for her child.

Amy wrote a very touching “Good bye letter” at the end of the 16 sessions – made all the more moving as she had never written a letter to anyone before in her life. But I think the summary of where her relationship was with me perhaps showed how far she had come – and how much she had got what we were doing in the sessions. The letter was one of thanks and gratitude – which was very gratefully received – but went on to reflect on my work with her 4 years previously, and where we today. Put very simply; “I never used to like you, but now I realise you’re ok”, but as she said this to me, was she saying this to herself?

Perhaps I took on this work with Amy as I needed to be admired and valued by her – that I wanted to be appreciated and validated after feeling so useless 4 years ago. And perhaps she wanted me to like and value her. But I think through her Goodbye letter at the end of her CAT Therapy that she found a way of showing that the therapeutic relationship had led to change because it had truly been able to be somewhere “in the middle”.

References

Barnes, N. 2015 Reformulation, Issue 45; Reaching Out – A Journey Within and Alongside CAT

Jenaway, A., 2009. K.I.S.S. (Keep It Simple. Stupid) - Reflections on Using CAT with Adolescents and a Couple of Case Examples. Reformulation, Winter, pp.13-16.

Chanen, A.M., McCutcheon, L.K., Germano, D., Nistico, H., Jackson, H.J. and McGorry, P.D. (2009). The HYPE Clinic: an early intervention service for borderline personality disorder.Journal of Psychiatric Practice, 15 No. 3, pp 163-72

Ougrin, D., Ng, A.V. and Low, J. (2008). Therapeutic assessment based on cognitive-analytic therapy for young people presenting with self-harm: pilot study. Psychiatric Bulletin, 32, pp 423-426

Potter, S., 2010. Words With Arrows The Benefits of Mapping Whilst Talking. Reformulation, Summer, pp.37-45.

Caruso R., Biancosino B., Borghi C., Marmai L., Kerr I.B. and Grass L. (2013). Working With the ‘Difficult’ Patient: The Use of a Contextual Cognitive-Analytic Therapy Based Training in Improving Team Function in a Routine Psychiatry Service Setting. Community Mental Health Journal, 49, pp 722-727.

Jenaway, A. (2006). CAT with Teenagers Leaving Care. Reformulation, 26, pp 3 - 4

Hepple, J. (2006). The Witness and the Judge : Cognitive Analytic Therapy in later life : The case of Maureen. Reformulation, 27, pp 23 -28

Sheard, T., Evans, J., Cash, D., Hicks, J., King, A., Morgan, N., Nereli, B., Porter, I., Rees, H., Sandford, J., Slinn, R., Sunder, K. and Ryle, A. (2000). A CAT-derived one to three session intervention for repeated deliberate self-harm: A description of the model and initial experience of trainee psychiatrist in using it. British Journal of Medical Psychology, 73, pp 179-196

Leiman, M. (1992). The Concept of Sign in the Work of Vygotsky, Winnicott and Bakhtin: Further integration of object relations theory and activity theory. British Journal of Medical Psychology, 65, pp 209-221.

Vygotsky – Newman F., Holzman L. (2013) Lev Vygotsky (Classic Edition): Revolutionary Scientist. Psychology Press & Routledge Classic Editions.

Pollard, R., 2003. Book Review: ‘Language for those who have nothing. Mikhail Bakhtin and the Landscape of Psychiatry’ Peter Good (2001). Reformulation, Summer, pp.40-43.

Jenaway, Dr. A. and Rattigan, N., 2011. Using a template to draw diagrams in Cognitive Analytic Therapy. Reformulation, Summer, pp.46-48.

Jenaway, Dr. A. 2013. Change your Parenting for the Better - exploring CAT as a parenting intervention. Reformulation, Winter, p.32 - 36

Potter, S., 2010. Words With Arrows (see above)

CANHS Transformation and CYP-IAPT - http://www.youngminds.org.uk/training_services/vik/children_young_peoples_iapt

Fonagy, Professor P. Quote from presentation at conference “Future in Mind – One Year On” – The Kia Oval, London. March 2016.

Both young people referenced in this report have read the material related to themselves and have given their consent for this to be published. Their names have been changed to maintain confidentiality. Since reading this account of her work Amy has since agreed to work with me on a training programme for social workers to help develop their understanding of the mental health needs of young people who are in the care of the local authority.

Full Reference

Nick Barnes, 2016. Learning With Young People About Being “In The Middle”. Reformulation, Summer, pp.11-18.

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