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Thoughts and Experiences of the Application of Cognitive Analytic Therapy to Clinical Work with Adolescents

Mulhall, J., 2010. Thoughts and Experiences of the Application of Cognitive Analytic Therapy to Clinical Work with Adolescents. Reformulation, Summer, pp.34-36.

Introduction

While little has been written about CAT with adolescents, it has been useful to read the thoughts of Alison Jenaway (2006, 2009), Jenaway & Mortlock (2008) within this publication, and the research of the Melbourne Group, Chanen et al (2008). I was also fortunate to have had the opportunity to discuss this with Tony Ryle, who gave me the encouragement and challenge to put pen to paper.

Background

I practice as a Social Worker within a multi disciplinary Child and Adolescent Mental Health Service (CAMHS), in Colchester, Essex. About four years ago, I was on a generic Mental Health training course, part of which was a half day introduction to CAT. I recognised that this approach could be useful in my work with children, adolescents and their parents. My service was supportive of me bringing a CAT based intervention into our clinic, and funded me to undertake practitioner training at St Thomas’s. I am now fairly close to completing the academic and clinical work. Over the last four years I have undertaken a CAT informed intervention with over a dozen adolescents. During this time, I have become more adept at selection for more formal CAT and have now completed five 16 session CAT interventions with 15 -17 year old females and males (ratio 4:1). Alongside this, I have completed five formal CAT interventions with parents of adolescents, and utilised CAT tools and ideas to inform other forms of individual and group therapy.

Type of patient referred to CAMHS.

The age range is 2-17 years old (soon to rise to 18). Referrals have to come from professionals, mainly G.P’s, schools, community doctors and social care agencies. The social class and circumstances of referrals are extremely broad. They range from children at risk and in need, to, children at the local grammar schools. The majority of children that we see tend to live in their family, with at least one natural parent.

As a multi disciplinary team we have many different ways of understanding and formulating seemingly similar clinical presentations. For example, one might hear, it’s; a family script issue, an attachment issue, a parenting issue, related to the meaning of the child, Reder et al (1993), he has ADHD, she has anxiety and depression, and quite often, a mixture of all of the above.

Appropriateness for CAT and how I have come to assess this

When I started to offer a CAT informed intervention, I was asked to consider a wide range of patients and difficulties. The usual suspects were present; I.e., low mood, anxiety, self harm, and most commonly social isolation/withdrawal and school avoidance. Understandably some colleagues were not entirely sure what CAT was or how it was applied. I used journal club and clinical presentation slots within the team meeting structure to share the approach and discuss how it might be applied in practice.

When I first started, I saw some adolescents who were still in Secondary education. I have come to learn that being in their GCSE year is a significant added difficulty. There are also issues of dependency and autonomy, which will be discussed later in the paper. At the assessment stage, I write to the patient directly with a two page explanation of CAT and direct them towards the ACAT website. Experience has taught me that if they have not engaged with the information, it is usually not advisable to proceed as they are likely to find it difficult to engage with therapy and complete out of session work. Similarly, if they come purely to satisfy another e.g. a parent, again I will not usually proceed. Within the assessment session I try to engage the person both with their difficulty and with CAT by illustrating a reciprocal role or sketching a target problem procedure, like a mini CAT session. We usually decide together whether it would be right for us to proceed. In instances where we don’t, I try not to make it feel like a rejection by writing to them outlining why we agreed not to proceed and detailing what we learned about them, in a thoughtful way. With these criteria in place, fallout has been quite low for an intensive adolescent therapy (2 of 7).

Reformulation experiences

All seven adolescents I have seen for formal CAT have been living at home with at least one natural parent. I have given them various versions of the psychotherapy file, matching the format to their visual aptitudes. Most have reported not finding it particularly useful, and it has often been a challenge to get it back. Perhaps the part paid most attention to is the Different States section. One person in particular found that seeing extreme written descriptions for how they might be feeling enabled her to write the unsayable. She wrote under her heading of “my main bad states”,

(Spak out) intensely angry at myself. Wanting to hurt myself. Intense hatred of myself. Out of control.
Sheer Panic, deer in the headlights, fear of keeping on existing, wanting to disappear or go to sleep and not wake up.
In a hole of despair. Hopeless, lethargic, deep sadness, like it is never going to get better.

Being able to name this and have it witnessed and acknowledged made a hugely noticeable difference to her and her ongoing demeanour.

I find asking adolescents to compile enriched genograms , which put more description to family members and ‘their ways’, highly useful and very engaging for the patient. On the back of this I usually ask them to devise a timeline of the significant events of their life, as home work. I have been amazed at the work put into these timelines and by what has sometimes happened before they were even born or conceived.

For each adolescent having formal CAT, I have produced the same type of letter I would produce for an adult. These have been well received in the sessions. One patient brought a letter for me to read detailing all the things she wanted to say to her father but never could. This then became a central tool in the rest of the work. Writing a full reformulation letter suits me as a practitioner, but I realise that it won’t suit every patient. I would like to introduce ways of evaluating this more formally with patients in the future.

There can be more anxiety surrounding an adolescent reformulation letter than an adult one. It can often feel as if there are three people in the consulting room, the third being the shadow of an involved parent. Sometimes I fear how the letter could be used by a patient towards their parents. Some patients are brought to sessions by a parent, who is the focal point of a lot of the thinking. The patient then walks out to them and they drive home together. Some talk of feeling disloyal at times and others are wary of taking their letter home. So far, no patient has wanted a letter changed or its existence destroyed. With these tensions in mind, there is added importance to using phrases like: “you said you experienced your mother as...” “you told me you felt...” Generally the reformulation process has taken longer with adolescents, often taking 6-8 sessions to produce the letter. As this eats significantly into the recognition and revision stages of therapy, I now offer a minimum of 20 sessions in formal CAT treatments with adolescents.

SDR

Many adolescents seem to be more visually minded, and like Jenaway (2006 & 2009), I believe the SDR has perhaps the most potential to help the patient. It offers not only another dimension to look at the struggles but also looks forward at ways of exiting the difficulties.

Perhaps the most common theme in my work with adolescents, is them wanting relationships (general and specific) to be better. Anna Freud (1998) suggests the adolescent process of Identity Formation has something to do with struggles in this area, but strongly developed relational patterns must also be at play? I often use a set of relational diagrams produced by Margot Sunderland (1993) to work on this area. This comprises of thirty simple drawings depicting two people and the state of their relationship. As a homework task, I will ask the patient to think about their key relationships and choose a picture to represent how it is and another to show how they would like it to be. If there is not a suitable picture I will ask them to draw their own. This is usually a good opportunity and medium to get them to think about the self to self relationship, Ryle and Kerr (2002). I then encourage them to represent this relationship as well. Naming this helps to give relevance to the CAT model in the patients’ mind. Once this is done, I encourage the patient to think about extending the relational drawings into a shaping exercise. On a sheet of A4 divided into 8 equal sections, the “how the relationship is” drawing is put into the first box and the “how I would like the relationship to be” drawing is put into the eighth box. I then encourage the patient to think about the processes that would need to happen for the first picture to metamorphose into the last. Adolescents (and adults) can engage with this task well, and, it has an obvious focus on exits.

Recognition and Revision

As with adults, this stage of the therapy is usually the most challenging for the adolescent. They are often told that talking about their problems will make them feel better. But within therapy, they come to acknowledge on some level that change requires them to do more than just talk. Some, understandably, have reservations about continuing to address the difficult dynamics after the therapy has finished

Dependency

As mentioned previously, most of my adolescent CAT patients live at home, usually with their primary carer. In many cases family work has been considered or tried and individual therapy substituted as the best way to help the patient in the long term. In all of the formal CAT patients I have seen to date, a “dynamics” issue with a carer is often identified. With adolescents, there is often an extra challenging dimension to the work as they are usually still materially, financially, emotionally, and in terms of decision making, dependant on the primary carer. It can be extremely hard for them to experience much distance or separation for thinking and reflection. I continue to be amazed at their capacity and willingness to explore what goes on between them and their parents. Within the microcosm of the CAT work, I often find myself encouraging the adolescent to be more adult and relationally proactive than their carers. I try hard to demonstrate my empathy towards this position but I often wonder whether it is asking too much. The crux of the matter for me is, how actually autonomous is the young person, to do what they might need to do, to truly help themselves.

Do I offer a Joint Session at some point in the Therapy?

I have offered them, but for the most part patients have not wanted them, or have parents asked for them. I wonder if this has something to do with the patient not wanting their space invaded. I also have a sense of the adolescent not wanting to distress their carer, by sharing some of the reality of their experience. Additionally, some parents may find it easier to keep the difficulties remaining located within the child.

The mum of a 15 year old female I was working with indicated she wanted a joint session. The patient and I thought about the prospect of this, and agreed it might be helpful. In the session, Mum became extremely emotional. She had colossal guilt about the physical and emotional maltreatment her daughter had suffered at the hands of an abusive ex-partner of hers. I am not sure what my patient had expected, but in the session it seemed as though she did not want to relinquish the control she now had with her mum. It had a negative impact on what might have been achieved with the patient on her own, as subsequently, she exercised the ultimate control and did not come back for another session, or reply to my letters. This was regrettable as we had completed 19 of 24 sessions, and some good work. I wouldn’t rule out joint sessions, but I would probably wait until the CAT therapy had concluded.

Final Thoughts

I was advised that there are three main things to consider when attempting to evaluate innovative practice;

Do patients (adolescents) accept a CAT approach? From my experiences so far, I think they do. I have been amazed by the levels of enthusiasm, commitment and willingness to explore complicated feelings and psychological processes. However, there is an onus on those who practice in this field to share experiences to ensure that CAT can become increasingly helpful, accessible and delivered in innovative and acceptable ways.
Do they get helped by CAT? Anecdotally, I would say most patients certainly seemed to get some benefit at the time of therapy, and probably for a period afterwards. I feel that issues of dependency will understandably and undoubtedly impact on the longer term effectiveness of the therapy. It may even become a bigger factor given that sociologically speaking, younger people are tending to become increasingly dependent on their parents for longer periods of their lives. Ideally in the future I would like to set up a comprehensive system of evaluation over a longer period.
What have I learned from these experiences? That CAT can be a helpful and valid therapeutic input for this hard to engage client group. I would like to see both CAT informed and formal CAT interventions become a mainstream treatment option for adolescents (and parents) within CAMHS, and the therapeutic world generally. I have plans to work towards this aim in my location. It would be good to hear from (and join forces with) others with similar ideas who may be working towards similar aims in their areas.

Acknowledgement

I wish to thank Tony Ryle and Geoff Barford for their helpful comments.

John is 43, and commenced his professional career in the field of Aquired Brain Injury Rehabilitation, in 1994. He went on to train as a Social Worker, graduating from Suffolk College in 2000. Following this, John spent 4 years in front line Child Protection work, before moving into the field of Child and Adolescent Mental Health. He has since gained an MA in Advanced Social Work Practice, studying at the University of East Anglia. John has a keen interest in Attatchment Theory. You can correspond with him at john.mulhall@nepft.nhs.uk

References

Chanen, A., Jackson, H., McCutcheon, L., Jovev, M., Dudgeon, P., Yuen, H., Germand, D., Nistico, H., McDougall, E., Weinstein, C., Clarkson, V., & McGorry, P. (2008). Early Intervention for Adolescents with Borderline Personality Disorder using Cognitive Analytic Therapy: Randomised Controlled Trial. The British Journal of Psychiatry. 193. 477-484.
Freud, A Adolescence and Psychoanalysis. The Story and the History. London: Karnac Books.
Jenaway, A (2006) CAT with Teenagers Leaving Care. Reformulation: Theory and Practice in Cognitive Analytic Therapy. Issue 26 Summer 2006.
Jenaway, A (2009) K.I.S.S (Keep It Simple Stupid) - Reflections on Using CAT with Adolescents and a Case Example. Reformulation: Theory and Practice in Cognitive Analytic Therapy. Issue 33 Winter 2009.
Jenaway, A & Matlock, D. (2008) Service Innovation: Offering CAT in a Child and Adolescent Mental Health Service. Reformulation: Theory and Practice In Cognitive Analytic Therapy. Issue 30, Summer 2008.
Reder, P, Duncan, S, & Gray, M (1993) Chapter 5 - The Meaning of the Child. In Beyond Blame: Child Abuse Tragedies Revisited. Routledge.
Ryle, A & Kerr, I (2002) Introducing Cognitive Analytic Therapy. Principles and Practice. Chichester: Wiley.
Sunderland, M & Engleheart, P (1993) Draw on your Emotions. Milton Keynes: Speechmark Publishing Ltd.

Full Reference

Mulhall, J., 2010. Thoughts and Experiences of the Application of Cognitive Analytic Therapy to Clinical Work with Adolescents. Reformulation, Summer, pp.34-36.

Search the Bibliography

Type in your search terms. If you want to search for results that match ALL of your keywords you can list them with commas between them; e.g., "borderline,adolescent", which will bring back results that have BOTH keywords mentioned in the title or author data.

Service Innovation
Jenaway, A., Mortlock, D., 2008. Service Innovation. Reformulation, Summer, pp.31-32.

K.I.S.S. (Keep It Simple. Stupid) - Reflections on Using CAT with Adolescents and a Couple of Case Examples
Jenaway, A., 2009. K.I.S.S. (Keep It Simple. Stupid) - Reflections on Using CAT with Adolescents and a Couple of Case Examples. Reformulation, Winter, pp.13-16.

The CAT Articles Review
Knight, A., 2009. The CAT Articles Review. Reformulation, Summer, p.32.

Clarifying an ethical dilemma with CAT in work with children and adolescents
Marie-Anne Bernardy-Arbuz, 2013. Clarifying an ethical dilemma with CAT in work with children and adolescents. Reformulation, Summer, p.28,29,30,31.

Cognitive Analytic Therapy (CAT) and (Open) Groups with Adolescents within an Inpatient Psychiatric Setting: Initial Thoughts and Experiences
John Mulhall, 2013. Cognitive Analytic Therapy (CAT) and (Open) Groups with Adolescents within an Inpatient Psychiatric Setting: Initial Thoughts and Experiences. Reformulation, Winter, p.37,38,39.

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