Cognitive Analytic Therapy for People with Intellectual Disabilities and their Carers

Phil Clayton, Julie Lloyd

• Publisher: Jessica Kingsley Publishers
• Year: 2013
• Print ISBN: 9781849054096
• eBook ISBN: 9780857008046
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

With a variety of case examples and contributions from experienced clinicians, this book introduces Cognitive Analytic Therapy (CAT) in practical, user-friendly language, and for the first time guides readers on how to use it with people with intellectual disabilities.

CAT is increasingly recognised as an effective approach for working with people with intellectual disabilities. It focuses on observing and describing typical patterns of how the client relates to others, how they behave in relationships and how they see themselves. By considering how these patterns first developed and how they can be revised in a more constructive direction, CAT can encourage change to occur as the result of healthier relationships. The contributors describe in straightforward terms how CAT may be used with people with intellectual disabilities, and provide CAT tools adapted specifically for this client group. CAT and autism, CAT with people with intellectual disabilities in forensic settings and CAT with survivors of domestic abuse who have intellectual disabilities are also explored in detail.

This is essential reading for any clinician wishing to use CAT with people with intellectual disabilities, including psychiatrists, psychologists, psychotherapists, social workers and support workers, as well as professionals across forensic services.

Part 1

Overview of Cognitive Analytic Therapy and People with Intellectual Disabilities

Chapter 1

Introduction

Julie Lloyd and Steve Potter

How encouraging that you have opened this book, despite the label ‘intellectual disabilities’! Labels like this are so powerful; you may already be tempted to close the book, thinking it is not for you. Finding a voice – starting a conversation – is really difficult, especially where one of you is thought to have the words, but the other is not always recognised as having a means of communication. Having a language puts us into a powerful place. In this book, we search to give people with intellectual disabilities, and those working with them, a voice. However, this book is not just about intellectual disability work; not having the ability to express emotions is a much more common problem than having a cognitive impairment. Many people do not have words for emotions and for reflecting on what early life brought them. Other people, particularly those with personality disorders, struggle with thinking about and seeing the bigger picture in a joined-up way.

This book is about creative uses of Cognitive Analytic Therapy (CAT) and offers ideas about ways of working with people whose life stories, problems and help seem complex. Using inventive ways to work with our relationship with the world and ourselves, this book describes how we can develop helpful and practical conversations together. In it we celebrate how we do this, in particular how CAT helps us to work together safely, carefully and constructively.

Most people in intellectual disability services describe their work in terms of their client group rather than their particular brand of therapy. This suggests that what matters are the people we work with, not the school of therapy. So why CAT? It is popular and useful precisely because it offers an understanding about human relationships, both with others and how we relate to ourselves. This means that, as a therapy, CAT not only offers skills development and explicit learning, but also gives people an experience of healthier relationships, both within therapy and indirectly through working with staff teams. This chapter introduces CAT, and concludes with a brief summary of the contents of the rest of the book.

What is CAT?

CAT’s relational approach

CAT involves working with our relationships with ourselves, with others and with the world around us. The agent of change is not merely cognitive, behavioural or experiential; it is relational. Holding a relational stance means weaving flexibly between possible meanings, conversations and silences. It means trying to attune to the people we are with – sometimes standing back, sometimes getting more involved, sometimes focusing on a detail and sometimes seeing the bigger picture. It means being able to navigate the relationship in the room at that moment, including our own relationships with ourselves. At heart, we are social beings and where people are not adept at being sociable, we sense this limitation and can react in helpful or unhelpful ways. Whilst valuing talking and negotiating, CAT’s relational understanding includes holding onto times when there are no words and meaning is communicated in other ways. In intellectual disability work we know many of our clients have little voice; the attraction of a CAT approach includes our encounter with silence and wordlessness. Intelligence is not placed as the property (however limited) of an individual. In CAT, it is the intelligence between us that we can jointly notice and sustain; hence its utility in services for people with intellectual disabilities.

How did CAT develop?

CAT developed in the NHS as a way of working with people who were hard to help. Tony Ryle, who was originally a GP, brought a medical and compassionate commitment to careful description and evaluation of how psychological help might work effectively. He saw that there was far more need for psychological help and psychological thinking than specialist services could cover. He was keen to provide a clearer language that clients could use to make use of some of the rich ideas from psychoanalysis. He put these ideas in a more cognitive language thereby creating the cognitively analytic approach of CAT. He was particularly interested in combining ideas from Personal Construct Theory (Kelly 1955) and Object Relations (one branch of the British tradition of psychoanalytic thinking Greenberg and Mitchell 1983). He wrote a series of papers in the 1970s based on various research projects he conducted, out of which he developed concepts for describing important relationships in people’s lives and the beliefs and actions that people take in or internalise and replay in their interaction with themselves and the world. By the 1980s, a group of people working in the NHS started to explore how these psychological ideas could be used in an efficient and fair way, particularly to meet the needs of hard-pressed psychological and counselling services that had limited resources. Gradually, the group brought in further ideas from outside British practice at that time, as, with the inspiration and help of a Finnish psychologist, Mikael Leiman, they discovered ideas from Eastern Europe about activity theory (which relates to skills development) and dialogism (which relates to the social and psychological context to our communications). Dialogic ideas further enriched the group’s understanding of how the internal version of early relationships shaped our present day behaviour.

Reciprocal roles

‘Reciprocal roles’ describes a core concept in CAT, naming the psychological and social, inner and outer sense of ourselves and others. Reciprocal roles are the psychological equivalent of genes because they are the building blocks of our social, mental and emotional lives. ‘Reciprocal’ describes the interchange between ‘doing to’ and ‘done to’ and the coping response. We have a number of different relationships and at various times hold a range of views about ourselves. For example, if I am with someone who is being kind to me in ways that I welcome and accept then the reciprocal role might be described as ‘giving kindness in relation to receiving kindness’. Later, I might be involved in a different reciprocal role with someone else or with myself at a different time. For example, I might subsequently be with someone who is very bossy. In response to their bossiness one person might tend to be a placatory ‘good girl ’ or tend to be resentfully compliant, and another person might appear to go along with them but be covertly defiant. A third person might make a stand and be overtly rebellious. Whatever position I get into, I am responding to them; we are in a reciprocal role. Reciprocal roles have two faces: one facing inward and giving voice to a way of relating to ourselves, and one facing outward and giving voice to a way of relating to others, or to things (including ideas) and the world around us. Reciprocal roles summarise the forces behind familiar, automatic and habitual ways we cope with the actions that have an impact on us.

All of us tend to get into certain relational roles more often than others. The options I choose and how I experience the impact of their roles on me is influenced by how I have learnt, from what life has brought me, to respond to people in those roles, such as kind or bossy people. I will likely be particularly influenced by the pattern I developed in my early life from how my parents and I related (either by continuing that style or by specifically reacting against them). Although the origins of any particular reciprocal roles lie with people we have known, in CAT the continuation of these roles is emphasised by describing the role and not naming the person we are like. For example, we talk about a nurturing or a hostile role, rather than ‘being like my mother’. This is because a role rarely starts and stops with a specific person we have known, but like a ripple in a pond, spreads wider because we take it in as a relationship with ourselves even when the initial person is no longer around. We then play it out, drawing others into responding to the role relationships with which we are familiar and that have become part of our nature.

Playing one role always implies a partnership between two roles where one is being cast or controlled by the other. One is more parental or powerful (we mostly call it the top end of the reciprocal role) and the other is more childlike and less powerful (we mostly call it the bottom end of the reciprocal role). We learn to participate in these role relationships by knowing the actions, voices and intentions of both ends and tend to pull or push for reciprocation from one end or another within ourselves and between ourselves and others. Using behavioural insights, we describe the top end of the reciprocal role as the stimulus, and from psychodynamic insights, especially object relations theory, it is sometimes called the ‘parentally derived’ top end role. It is the ‘doing to’ or active point. It often involves words ending in ‘ing’.

At the receiving end is the bottom pole. This is the response, the child derived role or the impact position. It is the ‘done to’ place. This often involves words ending in ‘ed’. Many of us may find that people will try to move from the bottom end to the top end, either for themselves or they experience others moving from one end to another. The issue is often: either I am bossy or am being bossed around. Reciprocal roles capture what often becomes our essential character and social style. Ryle and Kerr (2002, p.220) describe a reciprocal role as a ‘stable pattern of interaction originating in relationships with caretakers in early life, determining current patterns of relationships with others and self-management’.

We have said that reciprocal roles are simultaneously internally and externally facing. Take the ‘bossy’ example; a person may end up ordering him or herself around all the time, so there is a part of them that is in the top end. Of course, treating him or herself like this may invite them to put things off endlessly as a secretly defiant way (bottom end of the role) to deal with such a bossy part of their self! Their lack of progress then proves to their ‘top end’ that this only goes to show why they need to be bossed around. This is an example of a self-to-self reciprocal role. Roles start off as other-to-self (how my parents treated me), and in the process of repetition and learning become self-to-self (how I treat myself) and self-to-other (how I treat others) in a self-perpetuating circuit. If we cannot get out of the dance of being at one end of the reciprocal role or another we may shift to another set of roles from our familiar repertoire.

Tony Ryle, who first coined the term ‘reciprocal roles’, describes how they are useful as a shortcut that lets us work out (usually without thinking about it), what is going on and what position we are taking up in response. We get a feel for what is going on and select how we are going to react. We deduce reciprocal roles from stories of childhood, current relationships and our interactions with individuals, and use these role descriptions as a tool that allows or assists us to predict relational patterns. Roles are strong because we are kept in them whilst we are unaware of their operation. Tony Ryle wrote (Ryle and Kerr 2002, p.112): ‘By learning to link the wide range of acts and experiences to these broad patterns, the patient can reflect upon th...

Table of contents

• Cover
• of related interest
• Title Page
• Copyright
• Dedication
• Contents
• Foreword
• Acknowledgements
• Part 1 Overview of Cognitive Analytic Therapy and People with Intellectual Disabilities
• Part 2 Using Cognitive Analytic Therapy in the Community
• Part 3 Using Cognitive Analytic Therapy in Forensic Settings
• Afterword
• Appendix 1 The Psychotherapy File I
• Appendix 2 The Psychotherapy File Ii
• Appendix 3 The Psychotherapy File Adapted for People with Intellectual Disabilities
• Appendix 4 Adapted Personality Structure Questionnaire
• Appendix 5 ‘1:1 Cat Care Plan’ with Nursing Staff
• Appendix 6 The Helper’S Dance List: A List of Typical Interactions that can affect the Helping Relationship
• Appendix 7 Sequential Diagrammatic Reformulation
• Appendix 8 Reformulation Letter
• Appendix 9 Goodbye Letter
• Appendix 10 Sequential Diagrammatic Reformulation
• Appendix 11 Sequential Diagrammatic Reformulation with Exits
• Appendix 12 Reformulation Letter
• Appendix 13 Sequential Diagrammatic Reformulation
• Notes
• Glossary
• The Editors
• The Contributors
• References
• Subject Index
• Author Index