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When Happy is not the Only Feeling: Implications for Accessing Psychological Therapy

Lloyd, J., 2009. When Happy is not the Only Feeling: Implications for Accessing Psychological Therapy. Reformulation, Winter, pp.24-25.

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“How do you feel when everyone’s left and you are on your own?” I asked Babette (a pseudonym). She had been telling me how she desperately searches for people to care for her and deals with their leaving by going out, determined to find new caring replacements. “Happy” she replied, whilst continuing to describe remediating actions that implied she was anything but happy. Is this inability to name feelings learning disability? It was incongruent with her general language level. She has a mild learning disability, and as such she is able to speak well and she can also read and write enough to get by. So her inability to give a more accurate label had little to do with intellectual disability. I wondered if either she had learnt to describe all feelings as happy or she had a deficit where she had not been able to put feelings into words.

CAT practice does not require that a person is psychologically minded before they start a CAT. Instead, CAT asks why isn’t the person psychologically minded? Taking Vygotsky’s famous statement, “What a child can do with a more competent person today, they can do by themselves tomorrow” to outline the Zone of Proximal Development, Ryle (2002), inverts this to, “What a child does not do or say with the adult today, she will not do or say on her own tomorrow” (p43). Are the feelings produced by loneliness so painful that she has cut them off, making them impossible for her to name, pushing them psychologically out of mind? If the relational damage occurs before the mental age of around 7, when children start the gradual process of developing verbal, and more abstract concepts, then working at the level of an abstract verbal discussion would be outside the ZPD of the time when the trauma happened. This means we need to work at a very early stage.

So the question here is what has limited Babette to labelling all her difficult feelings around abandonment as ‘happy’? CAT’s Reciprocal Roles suggest an interplay between her sense of herself and how others treat her. These effect her emotional intelligence, her ability to share and communicate intimately, her understanding of society and her ability to deal with difficult situations.

Badenoch (2008) describes, in very readable prose, how trauma damages certain areas in the brain particularly early on in life when then brain is highly malleable, creating an over sensitive neural net, fully wired up and ever alert, ready to react to any subsequent whiff of trauma. As the brain’s resources are concentrated on overwhelming emotion, little capacity is left for cognitive processing. Introducing empathic soothing to these trauma circuits helps to reduce over-firing, freeing up cognitive capacity, facilitating processing. Because our brains retain some degree of plasticity, empathic therapeutic relationships work at this neurological level. These relationships help by re-wiring to some extent. A traumatised person cannot do this on their own; it happens within helpful relationships.

However, some people find it hard to stay alongside the unhappiness felt by the people they are caring for. On one occasion, I had been working to teach someone else, with Down’s Syndrome and severe compulsive stealing, to name the 5 big emotions; happy, sad, fear, anger and disgust, (Ekman & Davidson 1994), using a set of line drawings that I had made into a little notebook for her. I was wondering if there were a link between unhappy feelings and her irresistible urge to steal. She was particularly taken by the drawing showing ‘disgust’ and this had developed into a discussion about situations that made her feel disgusted. At the end of our time together, she went to find her support worker to show her the little notebook. Flicking through the pages, her support worker immediately commented, “But happy is the only one you need to know”. If only life were like that!!

Where does this common notion about how sadness and anger should not be named in learning disabilities come from? Maybe we all dream of smiling faces shining with the good care we are successfully giving? This has a constructive and positive side in that it encourages carers to think about what makes their clients happy. However, this monopolised feeling label that staff allow has limits that are only too obvious in situations such as Babette’s. If she stands any chance of finding a better procedure, then she needs to be able to recognise how she is feeling when people she wants are not there.

Perhaps carers feel that unless they can keep the people they are looking after are happy, then they have failed as carers. This leads to a type of controlling care and may take on insistent proportions because there is so much that cannot be ‘controlled’ or remedied; the pervasiveness of disability, exclusion by society, poor services, poverty (both of clients and of support worker staff who are often paid at little above the minimum wage), a lack of enhancing opportunities in life, and seeing people who are often positioned at the bottom of the social hierarchy, to name just a few painful and uncontrollable factors. This reduces the options other people have in the way they relate to her, affecting their use of feelings, their ability to be intimate, their portrayal of society and the range of options they have at their disposal to deal with situations.

If the roadblock to this level of reflection occurs in the space between people, is it an overly heroic use of resources to prove therapy is possible? Therapy on its own, that did not open up with carers about what inhibits people from naming difficult feelings when they are trying to help and protect a vulnerable person, would be very heroic. By heroic, I am describing a person who fights on against all odds, taking a stand against the prevailing system. It is likely to result in such a hero being eaten up for breakfast by carers, who would be unfairly positioned by the hero as dragons (Georgiades & Phillimore). Sensitive time is needed with the carers exploring and describing the possible RRP that unwittingly perpetuates her reduced access to names for feelings.

As Babette was unable to get any further with naming a correct emotion, despite my inquiry, I gave her some dolls, as scaffolding to support her expression. These were 8 dolls covering three generations and I said that one of them looked a little bit like her. Babette, who is 57 years old, immediately selected the cute little girl doll, demonstrating her sense of herself from a child’s position (which is how many adults experience themselves, although few sophisticated adults would actually pick out a child doll). As we got the dolls to role play being abandoned, she crumpled up her doll into a ball. We then thought about what the little girl doll was feeling and although she gave it the label ‘happy’ again, she began to see that this is not the case. By drawing a crumpled little person seeing a big person leave them, we could map out the procedure and develop further her SDR. She was very honest about describing how she needs to show people that she can’t stand on her ‘own two feet’ (her words). At the subsequent session, therapeutic options pointed to working together to find her word for the crumpled little doll and thinking about how a ‘Big Babette’ might look after ‘Little Babette’. As she crumpled up Little Babette again, she started to name ‘sad’ and to describe experiences that made her angry. This became her Target Problem Procedure and the exits were the list she developed of how Big Babette could look after Little Babette. She started to use the pictorial SDR to describe events that had occurred, illustrating various points on the map. Using the dolls took her back to an earlier stage and being able to recognise and start to describe through the dolls, meant that she could then do it directly with the therapist and then with a pictorial diagram as a transitional object.

With thanks to Val Crowley.

References

Badenock, B. (2008). Being a brain-wise therapist: A practical Guide to Interpersonal Neurobiology. London: Norton.
Ekman, P., & Davidson, R. (1994). The Nature of Emotion; Fundamental Questions. Oxford: OUP
Georgiades, N., & Phillimore, L. (1975). ‘The myth of the hero-innovator and alternative strategies for organizational change’. In Behaviour Modification with the Severely Retarded, CC Kiernan and FP Woodford (Eds). London Elsevier Publishing Company.
Ryle, A. and Kerr, I. (2002). Introducing C A T: Principles and Practice. Chichester: Wiley.

Full Reference

Lloyd, J., 2009. When Happy is not the Only Feeling: Implications for Accessing Psychological Therapy. Reformulation, Winter, pp.24-25.

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When Happy is not the Only Feeling: Implications for Accessing Psychological Therapy
Lloyd, J., 2009. When Happy is not the Only Feeling: Implications for Accessing Psychological Therapy. Reformulation, Winter, pp.24-25.