A Case Example of CAT with a Person who Experiences Symptoms of Psychosis

Dr Sara Morgan, 2018. A Case Example of CAT with a Person who Experiences Symptoms of Psychosis. Reformulation, Winter, pp.35-38.


Working within a forensic secure service inevitably means working with individuals who experience symptoms of psychosis. These symptoms are often, though not always clearly, linked to offence(s). Subsequently the relationship between the person and their mental health experiences become a focus for clinicians in understanding the patterns that individuals repeat in their relationships and how this links to their risk to themselves and others, both in the present and the future.

Having recently begun working with patients using CAT informed work (under supervision) I was asked to work with Peter (not the patient’s real name). At the time of therapy Peter was a 52 year old single man who had lost both parents over a short period of time. Peter was 44 years old when his father died and 48 years old when his mother died. His only remaining close relative was his sibling. Peter had a successful academic and working life as an engineer until he was diagnosed with schizophrenia aged 30 years old when his first admission to a psychiatric hospital took place. In spite of this diagnosis, further hospital admissions and the care and attention of outpatient and community mental health services, Peter maintained active employment for the next fourteen years. However, Peter was made redundant and had not worked in the five years prior to being admitted to our hospital. Peter came to our service following being arrested by police having allegedly attempted to run over a person he knew in his community. Peter was assessed and deemed, due to both the severity of his illness and risk, to require care and treatment in a medium secure setting.

Main Issues in Treatment

The main issues being considered in Peter’s therapy were around risk, particularly in relation to his mental health and more specifically his connection to ‘Sun Man’ who was a representation of his psychosis. ‘Sun Man’ was a person who Peter believed was real and whom he believed controlled him during the time of his offence; making ‘Sun Man’ responsible for the offence rather than Peter. Therapy also focused on Peter sharing his concerns, feelings and experiences regarding his connection to ‘Sun Man’. The other area considered in therapy was Peter’s relationships with staff and how patterns enacted with staff often reflected early patterns of relating from his childhood.

Reciprocal Role Development and Target Problems Identified

In our initial sessions we discussed Peter’s childhood and early life, particularly focusing on the key relationships with his parents, grandparents and sibling. Peter’s descriptions of his childhood gave us a powerful insight into how emotions such as love and kindness were withheld from him by his father when he was growing up. This withholding led us to consider that Peter’s experiences of how expressions of emotions were not responded to had possibly resulted in him having difficulties in naming feelings and managing his emotions. As the interaction required for emotional containment and processing had not been met by either parent in infancy or childhood this had lead to an experience of a ‘withholding to withheld from’ reciprocal role.

Peter’s descriptions in our work together also resulted in us forming a picture of his childhood that was strict in some areas, and as a result the reciprocal roles of being controlled/ disciplined/ and punished emerged. When feeling controlled in relationships Peter would either comply with his parents (withholding how he felt) or alternately he would defy his parents. The acts of defiance Peter described appeared to be opportunistic and impulsive and served to ensure Peter regained control, if only momentarily. These patterns of complying or defying within relationships in which Peter feels he is being controlled have continued since then and remain apparent in the hospital setting.

Given the very harsh reciprocal roles described above it was not surprising to hear how Peter longs for an ideal place within relationships through being specially cared for. We discussed how certain members of staff occupy the specially caring role at times, and that this role is reciprocal because the staff member is specially caring and Peter feels specially cared for.

Another reciprocal role identified was being criticised/ blamed through discussions when Peter would share how his father would criticise/ control him. There were also a series of sessions in which we discussed Peter feeling angry with his father and this was repeated with me in the transference. On two occasions Peter openly stated that he thought I was angry and projecting his anger on to me. Initially we spoke about Peter feeling angry when he was in the controlled/ punished/ disciplined roles. In this session the anger was palpable between us, however Peter strenuously avoided using the term angry and instead referring to feeling injustice/ humiliated or stressed. I was therefore left wondering if by suppressing his anger this put Peter in a position whereby he believes he is in control of it. Although he did eventually own some of his anger when he felt more contained by myself and the process of our work together and then was able to name and be in touch with his angry feelings towards the end of therapy

We spent quite some time exploring Peter’s relationship with ‘Sun Man’ and he told me how he occasionally connected with Peter and influenced him to commit acts by taking him to a position where Peter was dangerous and powerful. Peter explained how if ‘Sun Man’ connects to him he either exacerbates how he feels (i.e. annoyed becomes angry) or crushes how he feels so that Peter becomes emotionless/withholding feelings; which is a scary place as he feels lonely and disconnected from others, which is his core pain.

Peter has spoken about working hard to keep his emotions “neutral” over the years as it would seem that changes or extremes of emotion are fearful places to be where incidents can happen that appear to be beyond his control. It seems that when Peter is experiencing symptoms of psychosis and connected to ‘Sun Man’ the influence from ‘Sun Man’ to the extremes of emotions are more frequent and most dangerous. It is moving from a powerless role in which he experiences symptoms of psychosis and is connected to ‘Sun Man’ that Peter then shifts into a powerful role where there are feelings of anger and there are risks to others. It is within this powerful role that incidents such as the index offence have happened. Peter found this pattern the most difficult to discuss as it meant recognising that there was a part of him that could become angry and that he was partly responsible for the actions in which there was risk of harm to others. Conversely, when Peter is unwell but unconnected to ‘Sun Man’ is when he feels desperate and in a powerless role. It is at this point that Peter is most at risk to himself as he has taken overdoses within this role in the past as here he feels the desperation of his core pain.

Changes in Mental Health and Behaviour

It was agreed that part of the task of therapy was to help Peter to begin to accept that his connection with ‘Sun Man’ can be dangerous, and also to help him to experience and manage difficult feelings which Peter appears to have had little help with when he was a child. Following our CAT informed work Peter was able to recognise that when ‘Sun Man’ connects with him when he was experiencing symptoms of psychosis and in the powerless role he was more at risk of behaving in ways that put others at risk, such was the pattern in which the index offence occurred. Peter was also able to recognise and share this information about ‘Sun Man’ connecting with him whilst also recognising that he was well medicated at the current time and was not experiencing symptoms of psychosis as he had been in the past; therefore feeling more contained psychologically.

One of Peter’s exits we defined was to talk to staff when the threats from ‘Sun Man’ arose which he was doing. Peter demonstrated that he was able to do this in the moment with staff and was no longer waiting to speak to specific staff about his connection to ‘Sun Man’. This had been a previous pattern in which he would only relate to particular staff that he deemed he had a specially caring relationship with. The exit allowed his to report his symptoms without fear of criticism or being blamed or judged.

Peter reported in his follow up sessions that when he does talk to staff about his connecting to ‘Sun Man’ the threat reduces or goes away for a period of time, and as a result Peter reported feeling less threatened by the connection and more able to move forward with a new exit which creates less anxiety and therefore lessens his risk to others.

Changes in Intimate or Personal Relationships

There were changes within the pattern of withholding feelings and concerns following therapy as Peter demonstrated that he can exit this pattern by starting to talk to staff more about when ‘Sun Man’ was connecting and what that feels like. This appeared to be creating a healthier relationship between Peter and ‘Sun Man’ as he was still connecting with Peter but Peter was not in the withholding role as he had been in the previous pattern with staff. This new exit allowed Peter to feel more in control and less fearful of his psychosis. In addition, staff on the ward had reported that Peter had been more engaged with both them and with other patients; spending more time in the communal areas socialising. They had also noticed that Peter was more spontaneous in his conversations with others and appeared more willing to say what he thought without having to think for long periods of time about the answer he wanted to give, which seemed to fit more with the controlling role.

There was a real sense that he was being less guarded in what he was saying. It was as if having had the conversation about his psychosis and ‘Sun Man’ that he did not feel he had to withhold this from staff in order to progress through the system. In fact, his more open dialogue reduced his risk considerably as in speaking his experience he had not only taken control but had accepted that his psychosis was a part of himself that could be controlled in a self to self reciprocal role with support from an external source i.e. the staff.

Reciprocal Role Enactments in Therapy

The pattern of being in the controlled position within relationships was enacted within our therapeutic relationship when I asked Peter to take responsibility for attending the sessions himself without prompting from myself or other staff. Initially there was defiance and a sense of regaining control by Peter asking staff to prompt him or arriving late to the session. When I raised this role being enacted between us Peter became somewhat angry that I was suggesting that attending therapy was his responsibility and that being late and asking staff to prompt him was actually a way of both defying and controlling me. This enactment was in the early days of therapy prior to the reformulation letter when we were discussing feelings of anger which up until then Peter had kept hidden from staff for fear of it being judged and him ending up in the controlled and punished role. Peter does not agree that these were acts of defiance or control. Instead he insists they were ways of him ensuring he attended the sessions and was on time for them. From these key-sessions we discussed how there had been times within our relationship when we had experienced being in the specially caring to specially cared for role. Our relationship seemed to repeat other relationships Peter had experienced in his life that would change between Peter being in the specially cared for role or the disciplined/ controlled/ punished role such as with his parents and old friends. One of the exits we identified for this striving to be specially cared for was accepting good enough care, which he seemed to be able to do more with staff members on a day-to-day basis.

Over the 24 weeks of our CAT informed work there was a change in Peter’s engagement in the therapy as he was more open and willing to talk, and also accepted some of the difficult questions I asked him. There was a real sense of working together on Peter’s CAT map and on the problems he faced; particularly in relation to ‘Sun Man’. I was impressed with Peter’s request to share the map and the letters with the clinical team, and particularly impressed that he wanted to be an active part of that. It was as if through the process of our work together that Peter could risk being seen and sharing information, even about his psychosis, and that this could be contained and understood without blame, judgement or punishment; roles he had feared from childhood.

Reflections on CAT with a Person who Experiences Symptoms of Psychosis

Having used CAT informed work with Peter it has become apparent that the relational nature of the therapy serves a containing and ‘meaning making’ function in connection with a person’s lived experience of psychosis. Peter’s relationship with ‘Sun Man’ was both meaningful and functional within the context of his experiences and relationships with others. Often experiences of psychosis such as these are seen as disconnected entities or experiences that need to be managed, reduced or eliminated, often with medication alone. However, by making sense of Peter’s experiences and relationships through mapping his relationship with ‘Sun Man’ and others, we (both the clinical team and I) have developed a greater understanding of Peter as person, particularly in relation to his psychosis.

We (Peter, I and the clinical team) have also developed a better understanding of Peter’s mental health and risk. This therapeutic work has served to provide a language which we can all use and has opened a full and frank dialogue around mental health and risk, which before would have been more difficult due to the disconnection in understanding and meaning between all parts of Peter or the variety of roles which he presented to the clinical team. Prior to this work we were not able to understand the meaning of Peter’s need to be in control or why he contemptuously dismissed some of the staff whilst taking care and understanding with others, and how this is linked to his reciprocal role repertoire. We took his guardedness as a symptom either of psychosis or withholding information.

As such this work has opened up a much clearer, understandable and relational element to knowing and understanding Peter and how his psychosis both affects him and how his presentation is linked with his aggression and index offence.

Reflections from Peter

Over the 26 weeks there was oral communicating which is not my strong point, while other communication (written) is something I am more familiar with from employment. Initially I was a little sceptical however the psychologist Dr. Label helped. The CAT map is helpful and I believe various psychologists think so; it helps me direct my thoughts along ‘safe’ avenues using mindfulness. However I was a bit disappointed that the team did not put more weight on it. This was subsequently clarified by my psychologist saying that this form of therapy is fairly new.

I should like to emphasise one of the points in the last paragraph, being that some staff treat patients and others care for them, this points reciprocity. The reflections paragraphs were particularly insightful.

Dr Sara Morgan

Clinical Psychologist

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Full Reference

Dr Sara Morgan, 2018. A Case Example of CAT with a Person who Experiences Symptoms of Psychosis. Reformulation, Winter, pp.35-38.

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