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Dr Kim Liddiard, 2020. Tyler's Story. Cognitive Analytic Informed Therapy within a Secure Care Setting. Reformulation, Summer, pp.31-34.
CAT is increasingly applied in secure settings for clients who have complex mental health histories and challenges. The strength of CAT as an approach is its flexibility whereby therapists can work with individual clients, provide group therapy and /or work with staff. In this paper I describe a case study of a client whose name has been changed in respect of his confidentiality.
Introduction
Tyler was referred for 24 sessions of Cognitive Analytic informed Therapy (CAT) due to his continued detention in a secure setting with no clear discharge pathway. Tyler presented with emotional dysregulation characterised by self-injury, physical aggression and violence which had resulted in several convictions.
Tyler had a history of poor engagement and withdrew prematurely from a CAT informed therapy a year previously, although received a reformulation letter upon ending. At the time, Tyler experienced the therapy as too exposing and avoided sessions.
Identification of target problems at the beginning of Tyler’s therapy included being unable to manage difficult feelings alongside being controlling in relationships. Tyler also spoke of his desire to leave the current care setting. Whilst Tyler was able to cognitively identify these areas of difficulty, he was not yet psychologically mature enough to think, feel or behave in ways to achieve these goals.
Background Information
Tyler’s childhood was turbulent and unsettled. His biological parents separated shortly after his birth and Tyler was then brought up by his mother and step-father who both struggled with long term substance misuse. Tyler’s mother and step-father were chaotic, emotionally neglectful and violent towards each which Tyler often witnessed during his childhood. In these physical fights between his mother and step-father, Tyler described how both adults would occupy the victim and/or perpetrator role.
Growing up Tyler described being particularly fearful of his step-father and recalled how at age 15 years he finally retaliated and violently attacked him. Following this attack, Tyler reported that his step- father was never violent again. It was at this point that Tyler began to strongly identify with the role of a powerful male.
Despite his parent’s separation, Tyler remained in contact with his biological father until he died when Tyler was 8 years old. Tyler recounted stories of fear and terror when witnessing his father’s violence for which he had a reputation alongside substance misuse.
Outside of his family system, Tyler revealed that he struggled in relationships. As a young child, Tyler disclosed being controlling of his friends and did not like them socialising with others. During adolescence, Tyler spoke of refraining from getting too close to anyone for fear of being rejected. Furthermore, Tyler described himself as a “social drifter” and considered this a helpful way of preventing him from connecting with others in both platonic and romantic relationships.
Development of Reciprocal Roles
Tyler’s early experiences caused him to struggle in his relationships with others, resulting in him either being [Ideally Connected], thus finding himself in intense/dependent relationships, or alternatively assuming a more distant position. Whilst these patterns had developed to prevent Tyler from feeling [Rejected], ultimately they resulted in him often feeling this way. Indeed, [Rejecting] to [Rejected] was quickly identified as Tyler’s core pain which, when triggered, caused him extreme distress.
To avoid feeling vulnerable around others, Tyler had learnt to occupy either a [Controlling] or [Powerful] role. Together, we considered how the [Powerful] role emerged when he symbolically physically attacked his step-father as an adolescent. Reflecting on this key moment allowed Tyler to identify that violence prevented him from feeling vulnerable and [Powerless] in relation to others.
Within his care setting, Tyler opted for a less powerful role which we came to call [Controlling] to [Controlled]. When feeling [Controlled] by staff, either psychologically or physically, Tyler would assume a more [Controlling] position and often rejected others in order to assume ultimate control in his relationships. Whilst this pattern of relating helped Tyler to feel safer in the shorter term, ultimately it resulted in him feeling [Rejected], alone and with unmet needs.
From the care staffs’ lens, Tyler managed his core pain through misusing substances, self-injury and aggression. In his current setting, Tyler communicated his negative affect through his behaviour which enabled him to receive care when he needed it most. In his therapy, we developed a growing awareness of this pattern and came to see it as [Conditionally caring] to [Conditionally cared for].
Stages of Therapy
Tyler’s ambivalence was demonstrated early in the therapy by his prolonged silences, dismissing view of the therapist, and attempts to control sessions. Strong transference and counter-transference reactions between us allowed rapid mapping to occur which detailed the live reciprocal roles uncovered in the room. This process helped Tyler to understand which role he was occupying and what feelings were associated with each one in an open and non-threatening way. In particular, the CAT map enabled Tyler to accept his occupying of the [Controlling] role in therapy and to understand why this happened. As Tyler felt more secure in our alliance, he also developed a greater awareness of when he was assuming other reciprocal roles including the [Powerful] role, which represented the violent part of himself.
During the middle phase of therapy Tyler focused more on the origins of his core pain. Tyler came to understand that his usual responses (i.e. self-injury, substance misuse and violence) were the only ways in which he knew how to demonstrate his emotional pain to others and to receive care. Tyler’s increasing awareness of this pattern allowed him to become curious about gaining support from others in other ways including using words rather than actions.
In the later stages of therapy we examined Tyler’s [Ideally connected] role and whether this was helpful to him or not. Whilst Tyler realised that he longed to be [Ideally connected] to others, he also considered that this was not sustainable and that relationship breakdowns often followed. Tyler identified being [Ideally connected] to his primary nurse and acknowledged that when they were away he felt [Rejected]. This is turn then caused Tyler to reject other staff who offered him support.
Once Tyler identified this pattern he slowly began to accept support from other staff but only did so with a level of openness that he felt comfortable with. Forming healthier relationships with others, characterised by Tyler sharing information in a way that he felt safe, became another exit for Tyler and allowed him to operate from within the [Conditionally caring] to [Conditionally cared for] role. With Tyler’s permission his CAT map was shared with staff so they too could become aware of reciprocal roles that they may find themselves in when caring for Tyler.
As we approached the end of his therapy, Tyler disclosed feeling [Ideally connected] to me. Whilst Tyler had been encouraged to consider the ending of therapy throughout our working together, he dismissed the need to do so. Tyler’s dismissiveness of me as his therapist was significant and revealed that he was likely operating from within a [Controlling] role to reduce his chances of feeling [Rejected] by me. After the therapy had ended, Tyler suffered from physical ill health and required admission to hospital and I hypothesised that perhaps his symptoms were somatic manifestations of what he was unable to consciously attend to at the point of ending. Put simply, Tyler felt vulnerable and needed medical admission.
Therapeutic Change
During the therapy we both noticed that Tyler was becoming more rational and increasingly aware of his own relationship patterns. Tyler brought his CAT map to life outside of sessions and used this to identify what role he might be in and how he could exit situations more appropriately. Tyler also disclosed achieving more stability in his relationships with others to me.
As well as Tyler’s own reflections on his progress, positive changes were frequently observed by staff. The most significant change was Tyler’s ability not to occupy the [Controlling] role leading to improved engagement and relationships with others. For example, Tyler was less resistant to collaborative working and went on to achieve improved compliance to the care setting’s rules, his medication regime and use of authorised leaves. The combination of his therapy work and improved engagement resulted in Tyler finally being considered suitable for discharge to a community placement. Tyler was pleased with his progress and hopeful about his future life in the community.
At follow up, Tyler had maintained these positive changes and had essentially become his own therapist with the ongoing help of his CAT map. Importantly, therapy gave Tyler the opportunity to tell his own story and, from within a strong therapeutic alliance, he was supported to achieve meaningful change by increasing his awareness of unhelpful reciprocal roles that had kept him detained for so long.
Tyler’s Reflections on Therapy
Tyler and I agreed to share his therapy with a wider audience and I am honoured by his courage to do so.
“At first CAT is very exposing but you must feel raw emotion to learn how to regulate it without the need for demonstrating negative actions. CAT without a doubt has improved my quality of life; I can now regulate my emotions. Sometimes I still refer to my paper CAT map but can also now work my issues out mentally in my head.
I no longer seek to be ideally connected. I prefer to be in good enough relationships and am concentrating on myself and maybe one day I will have a healthy relationship with a female when I am ready.
I have never enjoyed being in the powerful role but as my therapist has pointed out it was almost vital that I assumed this role in the past. Once it was pointed out to me how intimidating it can be to staff and patients I 100% tried to alter it and felt quite proud of myself. I altered this negative role and benefited by having better and open healthy working relationships with staff.
I still have some work to do but all in all I feel quite proud of myself for completing CAT and keeping the work my therapist and I have done fresh by regularly using my map.”
My Reflections on Therapy
Tyler and staff had high expectations for the outcomes of therapy from the very beginning. Early on I experienced Tyler’s strong ambivalence and struggled with this the most. For example, when Tyler became more [Controlling] in the room, I found myself becoming more forceful which contrasts to my usual therapeutic style. To counteract Tyler’s ambivalence, I noticed myself longing to be [Ideally connected] with him to ensure that he completed the therapy. Through supervision I came to notice that my own expectations of the therapy were likely a projection from both Tyler and staff.
Tyler was extremely dynamic in the room and often shifted state which as a therapist I found both exciting and challenging. Supervision once again was helpful, particularly when I found myself [Ideally connected] with Tyler and less able to objectively monitor reciprocal role re-enactments occurring between us. My supervisor and I would often use the CAT map to allow me to gain a greater understanding of my therapeutic relationship with Tyler, an awareness which may not have been achieved had I of chosen to use a different therapeutic approach.
As Tyler came to trust me more, he shared his vulnerabilities with me and I noticed myself feeling maternal towards him. When Tyler began to understand his relationship patterns for the first time with use of his CAT map, I found myself feeling incredibly proud of him. I also noticed myself feeling satisfied when staff commented on his progress in much the same way as when I attend my own children’s parents’ evenings. During his therapy, I have observed Tyler grow as a person and it has brought tears of joy to my eyes when he too reported feeling happier. Perhaps the most joyous outcome to emerge from the therapy however has been Tyler’s ability to overcome his destructive ways of relating to himself and others that have troubled him for many years.
To end, I hope that this case study has encouraged other therapists to overcome their uncertainty about working with clients who have forensic histories. My view is that CAT’s relational approach and structured framework provides a highly effective way of empathically focusing the therapy on the person’s difficulties thus facilitating meaningful change.
Dr Kim Liddiard
Kim.Liddiard@wales.nhs.uk