Raymond, C., 2008. Looking at a Therapeutic Relationship In CAT. Reformulation, Winter, pp.26-27.
Mary is a married lady in her thirties with four children. She initially attended the psychiatric services following the birth of her youngest child, who was born with a genetic illness; this resulted in a brief admission to a psychiatric hospital. Mary has a history of low mood, panic attacks and aggressive and suicidal behaviour. She was assessed by her Consultant Psychiatrist and was diagnosed with Borderline Personality Disorder.
Mary had a very difficult and traumatic childhood. She is fourth child in the sibship with older and younger siblings. She experienced her parents as abandoning, abusive and rejecting/neglecting. The only stable nurturing caregiver in her life was her maternal grandmother, who died when Mary was in her early teens. She had been separated from her siblings since birth, was reared by her grandparents, and lived across the road from her family of origin. Although she recalled grandmother as smothering/caring/loving which Mary longed for, she also had memories of her becoming abusive and critical. I experienced Mary as a very confused person and she directed anger toward others on a regular basis.
In the early stages of therapy we quickly named the above Reciprocal Roles (RR’s) as abusive and unhealthy and I found it difficult to engage fully with Mary. It was as if she distanced herself from me, perhaps attempting to elicit the response of rejection from me, as this had been her only experience of relationship with herself and others.
On arrival to each session in the early weeks, many people in the building experienced Mary as overwhelming and loud, but she appeared to be unaware of this. She had been offered other forms of therapy in the past, all of which she attended for short periods of time then discontinued. Following discussion at our multidisciplinary team (MDT), I was asked to offer her time-limited CAT. Mary attended weekly, although in the early stages she resisted and remained distant yet committed.
On completing her genogram and hearing her life story, it became apparent that Mary re-enacted some internalized roles from her own childhood, namely, overprotective/smothering her children while also neglecting/abandoning them. Initially we began with completing the personality sequence questionnaire (PSQ) scoring 38; we then moved on to the state description procedure (SDP).
Together we identified six states. Some Mary chose names for: (B) Victim, was her ‘Lost’ State, (C) Soldiering on State, (E) Rage / Revengeful was her ‘I hate ya’ State, (F) Zombie, (G) Bully, (H) High and (K) Powerful Caretaker, her ‘I’m marvelous’ State. As we talked about the RR’s in each state we quickly recognized that we could condense these into three significant states that shared RRs:
We acknowledged the ‘Victim State’ where Mary felt the world was against her and the ‘Rage State’ where she felt anger for others whom she perceived as a threat. She also entered her ‘Powerful Caretaker State’ where she smothered and controlled others while neglecting her own needs.
At the beginning of therapy we made many different maps, naming the different states Mary entered. We wrote down separate states on paper and tried to map the procedures that joined them together. In each State we named the main RRs relevant for that State and also noted her feelings in each State.
At a later stage in therapy we introduced the OK State to our main map, naming the relationship we had developed while working together. This helped Mary understand how she is in each State and also showed her how she moves from one State to another. We soon became aware that when in her Victim State she experiences a situation that angers her, she either moves to her Rage State, becoming quite controlling/criticizing of others or she enters her Powerful Caretaker State where she oscillates between ‘over-protecting’ and ‘smothered/helpless’.
At the beginning of an early session in therapy Mary arrived in her Rage/Angry State. In my inexperienced early stage of training. I waited until she calmed down before we started therapy. Supervision was both supportive and educational for me; I quickly understood that I needed to name my countertransference in the room in order for Mary to see clearly what was happening in her relationship with me and others around her. I felt intimidated and threatened by her and unconsciously avoided naming.
Naming the abusing/controlling role in the different states enabled me to teach Mary about her negative and abusive patterns of behaviour. We were also able to name how other people experience Mary, particularly her aggressive and critically controlling behaviour where others feel powerless / crushed / overwhelmed and frustrated by her.
It became apparent to me from early on in therapy that Mary’s capacity for self-reflection was extremely limited. I started by showing her the Other to Self relationship, writing out ‘abandoning / neglecting’ to feeling ‘abandoned and neglected’. I explained the concept of internalization and how these roles are brought into adult life, unconsciously and re-enacted in relationship with Self and Others. I felt the tools of CAT would help Mary identify when she ‘avoids’ by discontinuing personal therapy when it becomes difficult.
In order to explain the concept of alternating from the active to the passive roles I wrote an example down on paper of the listening and being listened to roles, and it seemed Mary understood this. We quickly named this as part of the OK State that was developing between us. This enabled us to move on to naming and understanding other roles that had been enacted by Mary.
Mary recalled having to live with her family of origin following the death of the grandmother and feeling rejected/not accepted by anyone. She described her parents as abusive and her father as an alcoholic. She had felt angry that she had to live in a place where she didn’t feel welcome. I recall her telling me that she had memories of her siblings making her feel unwanted and unloved. Within a year she had met her husband, John, and had wanted to get married immediately to get away from her family. This was discouraged by her parents, but by the time Mary was19 years old she married. Soon after, she and her husband began their family.
Throughout therapy I consciously tried to work within Mary’s zone of proximal development (ZPD). We clearly mapped out the two main abusive roles, overprotecting and neglecting, on either side of the page. Then with arrows from each, I joined the roles with the word ‘confused’. At that stage I noticed Mary’s eyes open wide, & she said it made sense; she understood what I was referring to.
I was aware also that I needed to make therapy a safe place for Mary, containing and validating without her experiencing me as judging or criticizing her. The maps were very useful for me to refer to when I noticed Mary shift from one state to another. In the early stages Mary recognized her different states but had no understanding of her movements between them.
Following the Reformulation stage of therapy, while working through the process, Mary prepared a ‘no send’ letter to her mother. Mary found it extremely helpful and containing. She felt it encouraged her to express her anger in an appropriate manner without harming or abusing self or others.
I felt it was important to focus on the healthy aspects of her personality by encouraging and empowering her, until she felt confident to do this for herself. Mary began to learn to self soothe. Trust between us built up in the room and enabled us to write exits on her maps, moving to the OK place and making this State larger each week. We named the RRs of trusting / respecting / relaxing / realistically caring and feeling safe / comforted while being honest with one another.
Soon Mary became more independent and less demanding of her husband. It seemed she didn’t need rescuing as often and was largely able to cope in difficult and stressful circumstances by listening to her new internalized voice, which was similar to the one I had used with her in sessions.
In session 19, Mary arrived verbally abusive in her Angry/Rage State, threatening in behaviour and insisting that CAT was ‘stupid’ and that she had only come to tell me she would not be continuing therapy. I remained calm, with our maps on the table I immediately explained, in a low voice, how I experienced her in the room. I told Mary that I was confused and felt dismissed / threatened by her and that I didn’t understand why she felt so angry towards me. Referring to the different States and to the triggers, Mary soon understood how she shifted from one to the other. I felt Mary was experiencing her new way of being, developed in CAT, as frightening. She was insecure and it was as if she anticipated her own failure. Although she felt more relaxed and calm most of the time, her family found the changes in her personality difficult to accept, perhaps waiting for her to return to her abusive pattern. They too dismissed therapy and this precipitated Mary’s feelings of insecurity and anger that made her act out in our session.
The rupture that was needed in therapy had occurred, was identified on the map, and then was repaired. We also named how, working together we had moved to an OK place. Although Mary hadn’t planned to stay for the session, nor did she take her jacket off, she calmed down considerably, stayed for the entire time, and left at the end of the session relaxed and reassured. She returned the following week apologising for her behaviour, saying she shouldn’t have ‘projected’ her anger onto me; she had been quite reflective during the previous week. This was a turning point, a new beginning for Mary. She spoke in a calm, low tone of voice and acknowledged her loud presence as a cover up for her insecurities and fears.
The trust built enormously from that point on and it enabled us to prepare for the ending of therapy. I ended by asking Mary to complete the PSQ once again with a score in the twenties. During our follow-up sessions Mary appeared to continue to develop her OK State telling me that her relationship with her family was better and she appeared to be a calmer, less stressed person. It seems she had a better understanding of state shifts, saying she keeps her procedural maps with her at all times in case she needs to refer to them.
I have gained written authorization from this client with whom I did Cognitive Analytic Therapy, in order to present this condensed version of our work together. I have also received authority from my line manager and her Consultant Psychiatrist. The names have been changed to protect the identity of the individual and her family.
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