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Case histories

Karen's story

This is a case history written by Liz McCormick - it draws on different clients' stories as a way of explaining how CAT works. All the clients gave Liz permission to use their stories in her self help book 'Change for the Better'.

Karen was recommended for Cognitive Analytic Therapy after a number of admissions for overdosing on Paracetamol – a potentially life-threatening action.

Her family background was unsettled. She had been fostered at age four, and then adopted by a couple who split up when she was eight and she was ‘parcelled around’ to family and friends. Two ‘uncles’ had sexually abused her, she had been made to ‘keep quiet’ by being offered food. Her experiences of rejection and abuse had left her feeling worthless and unlovable as if no-one wanted her or loved her. She had never had the opportunity to develop a language for feelings and did not know how to say ‘no’.

Karen learnt to cope and survive with her confused and unhappy feelings in different ways. From about the age of 12 she developed an eating disorder, one of her patterns was to starve herself – that way she felt in control and this gave her temporary relief, but then her need for food would lead her to binge and she would feel overfull and disgusted with herself and vomit. In the end neither way helped as she still felt lonely and at the mercy of difficult feelings.

By the time she began secondary school all her peer group seemed to be pairing off and it reinforced her feelings that she was worthless, as if no one really wanted her. All she could identify with were stories from romantic novels or an idealised longing for ‘perfect care’. In reaching her mid teens this longing for love and care developed into a pattern of making intense and immediate relationships with men. Whenever she met anyone new she ‘fell immediately in love’ idealising how things might be and how this new person might offer her ‘perfect care’. Her desire for closeness made her appear overwhelmingly demanding and the relationships would end explosively after just a few weeks when she would be intensely angry at what she experienced as betrayal and rejection, and would reinforce her feelings that no-one cared for her and she would make an attempt on her life. She had had five admissions in two years for overdosing.

We worked on developing the diagram below and this helped her to see and understand the pattern of responses in relationships that led to her overdoses. She started to understand how these patterns had emerged from her early experiences and learning and she began self monitoring and finding experiences that she could rate as ‘good enough’ through therapy rather than continuing to seek ‘perfect care’ that only existed in romantic novels. She also began to untangle what she was feeling, learning a language of emotions and recognising the patterns of her emotions involved in bingeing and starving. She started a feelings diary, slowly being able to describe what she was feeling when she wanted to binge or starve. Just these few self help skills helped her to feel more stable and in control.

During the middle phase of her therapy she began to see how her idealisation of relationships had become a substitute for her grief at her early losses and how it had prevented her from being able to recognise ‘good enough’ and that if she said ‘no’ it did not mean that she would have nothing (when she felt as if she was rubbish and would always be alone). Her sadness and anger at everything that had happened in her life sometimes felt overwhelming for her but the regular sessions helped her to express what she was really feeling rather than expressing this through overdosing or bingeing and vomiting.

Life began to stabilise for Karen and she began the work of receiving ‘good enough’ care for herself and found that when she began to say how she felt, that it did not result in rejection that she feared.

Making sense of Karen's map

• Karen’s map describes one of the patterns that she and the therapist worked out between them. Start at the purple circle:
• Karen’s experiences when she was growing up left her with raw emotions and feelings she could not make sense of, and which were overwhelming
• She needed to get away from feeling like this about herself, and like anyone else, wanted to have a relationship but
• Part of her had learned to behave in particular ways and to expect others to do likewise (in CAT we call these ‘reciprocal roles’), so relationships would nearly always take the same course

• Karen would become too demanding and the other person would pull away and end the relationship, or Karen would do anything to keep the relationship going and suffer abuse rather than be alone
• This would leave Karen overwhelmed with anger, grief and betrayal and the only way to cope with these unbearable feelings was to block them out by overdosing but this again left her back in silent despair
• The light purple squares show some of the changes that Karen slowly made to find ways out of these patterns (‘exits’ in CAT language). They look deceptively simple, but summarise important changes that were hard to make and meant many different things to Karen.

 Some clients have written accounts of their experiences of CAT and have very kindly agreed for them to appear on the website.  See:

• CAT or Can You Make a Mad Man Sane
• CAT and borderline personality disorder
• A suitable case for treatment: CAT and diabetes

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