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When Therapy Feels Like A Roller Coaster Ride: A CAT Perspective

Dr Diane Agoro, 2017. When Therapy Feels Like A Roller Coaster Ride: A CAT Perspective. Reformulation, Winter, pp.19-21.

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Introduction

In my final year as a Psychologist in Clinical Training I chose to do my placement under the supervision of a CAT practitioner. I was drawn to the integrative nature of CAT and its particular focus on reciprocal roles. Throughout my various placements, reflections on the therapeutic process have always been a focal point, whether it has been considered from a psychoanalytic or a more systemic perspective. However, using CAT and the concept of reciprocal roles has enabled me to formulate a clearer sequence of steps to describe the therapeutic process. This article is therefore an initial attempt at sequencing a therapeutic process that I have observed at times, not only during this placement, but also during my previous placements. The sequence does not describe a specific client, but instead is a generalisation of what I think might be occurring for some clients.

The idea for writing this article was prompted by a fleeting comment I made during supervision. Whilst discussing a client I mentioned that the most recent therapy session was their ‘good week’ and that the following week would be their ‘bad week’. This alternation of ‘good week’ versus ‘bad week’ had occurred several times throughout therapy, to the extent that I came to expect it. Although I had noticed a similar process in my therapeutic work with other clients, I was unsure as to why it occurred.

Negative Therapeutic Reaction (NTR)

As this process had happened several times, I began to wonder whether there was a term for it and whether other therapists had observed it. I was particularly interested in the therapist and client factors which might contribute to the process. In my search I was directed to literature about the Negative Therapeutic Reaction (NTR). NTR was first coined by Freud (1923) who observed that on making accurate interpretations about a client, the client would then regress and experience worsening ‘symptoms’. Tindle (2006) describes four steps involved in this process:

1. The therapist communicates or makes some form of verbal intervention

2. The client experiences this as accurate or helpful

3. The client experiences relief

4. The client then experiences a worsening in their symptoms.

Tindle (2006) suggests that this process can range from occurring within a few seconds to over an extended period of time. It can also occur within or between therapy sessions.

NTR does not seem to fully capture my observations as it focuses on deterioration after therapy appears to be progressing well, rather than a constant shift between deterioration and progression. However, it emphasises the importance of the therapeutic relationship and the countertransference that the therapist brings to the session (Tindle, 2006).

This led me to consider whether I could use reciprocal roles to map out my observations of the therapeutic process. It also reminded me of the importance of countertransference. In particular, using CAT encouraged me to think more about my role in the process and how I might also be contributing to this pattern. I now wonder whether on previous occasions I have focused too much on what it was about the client that meant that we experienced sessions in this way and neglected to think about my own role. It is possible that this is what prevented me (and the client) from being able to comprehend what was happening in our sessions.

The therapeutic cycle

From these thoughts, I have developed a possible CAT map (see figure 1), which might explain how the client and myself have found ourselves in this cycle of alternating between progression (‘good’ sessions) and regression (‘bad’ sessions).

Pre therapy

Prior to therapy, both the client and the therapist have needs to fulfil. As a therapist I am driven to help others, perhaps with an unrealistic perfectionist ideal. This is not unusual for therapists and can often lead to experiences of burnout and a sense of failure (D’Souza, Egan & Rees, 2011).

Early adversities such as trauma, abuse and neglect may contribute to mental health problems (Read & Bentall, 2012) and I have often noticed that many of my clients have a persistent fear of being abandoned by others. Thus it seems that the therapist’s desire to help and the client’s need to feel secure might complement each other.

Progression (the ‘good’ session)

As a result the therapist enters therapy and assumes the position ‘striving to help’. The client reciprocates by being ‘vulnerable and dependent’. The therapist experiences this relationship in a positive way and an increase in enthusiasm might lead them to adopt a role in which they are ‘optimistic and affirming’. The client also receives this positively, satisfied that their needs are being met. Thus the client moves into the role of feeling ‘praised and cared for’. This is what seems to be the ‘good’ session.

In between sessions

Despite the progress, this satisfying therapeutic relationship cannot be maintained outside of therapy, as the enactment is compensatory. Once the client leaves the session they are reminded that they are still alone and that the enactment was only temporary. This sudden realisation may leave the client feeling abandoned and resentful, particularly as it may remind them of previous experiences. Unbeknown to the therapist who is likely feeling upbeat about a positive therapy session, they become another person who is unavailable to the client.

Regression (the ‘bad’ week)

The client thus attends the following session reporting that they had had a bad week. This comes as a shock to the therapist who is still feeling positive from the previous session. This disappointment is noticed by the client leaving the therapist feeling ‘exhausted and despondent’ in relation to the client feeling ‘helpless’. Often these sessions seem to involve talking about risk and making a crisis plan. In this session, neither the client’s nor the therapist’s needs are being met. In addition, the therapist’s narrow focus on risk means that the underlying reasons behind the regression are not being mapped.

In between sessions

The client leaves the session and continues to have feelings of abandonment, neglect and trauma. The therapist leaves the session feeling deflated, but the drive to help others and to ‘solve’ the problem is reignited, particularly after a discussion of the session in supervision. Thus both the therapist and client revert back to their pre-therapy needs and the cycle begins again.

Further thoughts and reflections

Whilst developing and reflecting on this map I have come to the realisation that I perhaps drive the process more than the client, or at least more than I realise. Some argue that a client might not want to improve because they fear losing their relationship with the therapist (Murdin, 2010). However, throughout the process, the client’s feelings of abandonment are always present and discussed in therapy. I thus have to consider whether it is my response to the client’s feelings of abandonment which determine how the enactment develops.

I have made observations about how the atmosphere within the room changes with each session and encouraged the client to reflect on this difference. However, I have neglected to own my responses and how they might also contribute to the process. I acknowledge that I do feel disappointed when the client, having previously had a good session, recalls that they have had a bad week. Although I do not voice this disappointment, it is likely that it is communicated by my nonverbal cues and tone of voice. As a therapist who is driven by an unrealistic perfectionistic ideal to succeed, this disappointment may lead me to project feelings of inadequacy. The client may then identify with this inadequacy leaving them feeling helpless.

Interestingly, the therapy sessions I can recall in which I remember this process happening are all cases where the client completed therapy and both myself and the client concluded that the therapy seemed helpful. As therapy progressed the cycle of enactments seemed to diminish and instead there seemed to be a slow but steady improvement each week. In retrospect, it is difficult to establish why this steady progress occurs; however, my initial thoughts are that as the therapeutic relationship develops, the enactment and reciprocation is more readily discussed and contained. As I begin to anticipate it, it is likely that my disappointment diminishes and I am more helpful within the sessions. This then enables the client and me to use the enactment between us to help the client progress in therapy. For example, the interim between sessions may be used as an exit to help the client manage their feelings of abandonment.

As I have formulated this sequence after I have observed this process, I have not had an opportunity to feed this back with a client and to hear their perspective. Thus, it is likely that there is room for further development in my practice, particularly in regards to understanding what happens in between sessions. In addition, I would be interested to know if other therapists have experienced this phenomenon and whether they can relate to the observations in this article.

References

 

D’Souza, F., Egan, S.J. & Rees, C.S. (2011). The relationship between perfectionism, stress and burnout in clinical psychologists. Behavior Change, 28(1), 17-28.

Freud, S. (1923). The Ego and the Id. The essentials of psychoanalysis. London: Hogarth, 1986.

Murdin, L. (2010). Understanding transference the power of patterns in the therapeutic relationship. Palgrave MacMillan: New York.

Read, J. & Bentall, R.P. (2012). Negative childhood experiences and mental health: Theoretical, clinical and primary implications. The British Journal of Psychiatry, 206(2), 89-91.

Tindle, K. (2006). Negative Therapeutic Reaction. British Journal of Psychotherapy, (23)1, 99-116.

Article written by Dr Diane Agoro, a clinical psychologist who currently works in an Older Peoples’ Service.

Full Reference

Dr Diane Agoro, 2017. When Therapy Feels Like A Roller Coaster Ride: A CAT Perspective. Reformulation, Winter, pp.19-21.

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