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Meeting with Older People as CAT Practitioners: Attending to Neglect

Sutton, L., Gaskell, A., 2009. Meeting with Older People as CAT Practitioners: Attending to Neglect. Reformulation, Summer, pp.6-13.

Introduction

We are both Clinical Psychologists and CAT practitioners working in secondary mental health services to older adults. Because of this meeting between our clinical psychology specialism and CAT, we wanted to speak to both. To do this, we decided upon submitting a paper jointly to the newsletters of ACAT (the Association of Cognitive Analytic Therapy) and PSIGE (the Psychologist’s Special Interest Group for those working with older people, which is part of the Division of Clinical Psychology of the British Psychological Society).

Because of the IAPTs (Improving Access to Psychological Therapies) Government initiative, PSIGE tabled a conference on 13 November 2007. It involved 4 parallel workshops on different therapies (CBT, CAT, Psychodynamic, and Acceptance and Commitment Therapy) in order to explore them in relation to older adults. The event was repeated on 22 May 2008. We facilitated the one on CAT. This paper is our write-up. It’s organised around the notion of ‘neglect’. We became interested in this for different reasons. Laura’s interest arose in the policy context as she started to think about why it seems so difficult to hold older people and old age in mind when Govt. initiatives – such as IAPT - are rolled out. Alistair’s been curious about how not being thought about is experienced by the person – or, more exactly, when emotional life is disregarded - and how it leads to not being provided for. So the idea of ‘neglect’ raises the possibility that we can start understanding how profound repetitions of neglect and lack of provisions work – socially and within the individual mind.

We start our paper then on the social context, which becomes the wider socio-historical context for older adults. This takes us to the person and their therapy. Questions often arise about ‘How to adapt therapy to older adults’? and ‘What are the differences?’ We’d like to set aside these questions for a moment, to ask another : ‘What is it to meet?’

The social context

Between the first PSIGE day and its repeat, a lot happened in terms of IAPT. One of the things that had happened in Laura’s service was the combining of management of CMHTs with ‘age inclusive’ managers for ‘age inclusive services’. Meantime, the longitudinal studies on clinical and personal recovery from schizophrenia, following the de-institutionalisations of the 1960s and 1970s, had shown that people do better than expected (e.g. Harding et al 1987); the dreaded ‘end state’ of unresponsiveness was not ‘the norm’ after all. In Laura’s service, this led to ‘recovery training’ for all the teams, both younger and older adult. Yet, neither the trainers, nor those who brought them in, thought to critique this research from an old age point of view. This prompted Laura to adopt PSIGE’s naming of the ‘adult-centric’ position (PSIGE 2006) to denote how mental health services can be designed and rolled out from an adult-centric position.

‘Adult-centrism’ is reminiscent of the days when the pronoun ‘he’ was used in a society when men spoke for men and women : ‘adult-centrism’ is really a ‘younger- or middle-aged centrism’, where the powerful midlife of society speaks for all adults. Erikson’s model of development through 8 stages of the lifespan was one of first, and remains one of the few still, to address development in later life and old age (cf Coleman and O’Hanlon 2004). In 1986, Erikson et al wrote :-

“Today we are faced with an unprecedented growth in the number of the so-called elderlies in a technological world in which their overall role remains unclear. There is apparently little historical continuity preserved by their voices and their presence. The fabric of society, the centre, “does not hold” the aged…. From here on, old age must be planned, which means that mature (and, one hopes, well informed) middle-aged adults must become and remain aware of the long life stages ahead. In other words, a life-historical continuity must be guaranteed to the whole human life-cycle, so that middle life can promise a vivid intergenerational interplay and old age can offer what we will describe as an existential integrity”
(Erikson et al 1986, p14)

CAT is unusual amongst the different therapy modalities in its sociological stance (Ryle and Kerr 2002). It’s open to the sociological in the way that the mainstream of clinical psychology – or other therapies – are not. Peter Coleman, Professor of Psychogerontology at Southampton University observes:

“Although vital to lifting our sights to new understandings of what it is to be human, psychology alone can do very little to improve the circumstances of everyday life. Many of the problems older and younger people face are socially and historically conditioned, and therapists need to learn from the perspectives of sociologists, anthropologists, social historians and others working in the field of social sciences and humanities. But too often psychologists have been reluctant to engage in the demanding process of dialogue, understanding and change required, too self obsessed and fearful of what they might become through an excessive contact with society, its history and problems.”
Coleman, foreword to Hepple and Sutton (2004)

In 1995 there was a Whitehall initiative which asked the question, ‘How can the quality of older people’s lives be improved?’ It led to a £3.5 million research programme headed up by Prof Walker, who is the Professor of Social Policy and Social Gerontology at the University of Sheffield. This was a research programme of the highest quality, with the Economic and Social Research Council, embracing quantitative and qualitative research, with the emphasis on empowering the older person’s voice in research, policy and practice. This was the Growing Older Programme (GOP, cf Walker and Hennessy 2004). It has had a significant impact on the European research agenda, leading to the creation of a European forum of population ageing research, and is now a partner in the UN agenda on ageing.

The GOP is inspiring. Walker and Hennessy (2004) introduce the programme, and present 10 of the 24 research projects. What’s inspiring is that each chapter gives the social and research background to its topic, then presents world-class research. For example, it introduces and builds upon the work of the social gerontologist Prof Peter Townsend who wrote in the 1980s :

“If we are to develop better methods of integrating older people into society then above all we need a better sociology of the ageing and the aged …. For many years after the Second World War scientific research into old age was extraordinarily restricted, and only latterly has fundamental enquiry begun to assume a critical and wide-ranging and hence more constructive cohesion. The physical, mental and social features of ageing were seen as natural, or as largely inevitable. Instead of asking what brought abut the modern phenomenon of retirement and accentuated social dependency and the chances of isolation and extreme deprivation in old age … many scientists, scholars and practitioners have asked only how can people adjust to retirement, or how can the burden for relatives or the state be lightened … This emphasis on trying to explain individual ageing within a structure … rather than trying to explain that structure … was shared by most social gerontologists … Elsewhere I have characterised this as ‘acquiescent functionalism’, or the kind of theory of ageing which attributes the causation of problems to the difficulties of individual adjustment to ageing, retirement or physical decrescence, whilst acquiescing in the development of the state, the economy and inequality … From the beginning [however] there were those … who challenged in detail the evidence of occupational and social but also psychological disengagement”
(Townsend 1981, pp5-7)

We are interested to explore the ways in which, and degree to which, such ‘acquiescent functionalism’ is expressed still – in our theories, practice and policy.

On 29th April this year there was a Westminster Briefing in London, entitled “Providing Choice, Dignity, Independence, and Wellbeing for Older People: Implementing New Health and Social Care Strategies Locally”. Paul Cann, the Director of Policy, Help the Aged, chaired the day and highlighted each of the words in the title. He concentrated on the word ‘implementing’ in order to explain that the day was very much concerned with how we are going to implement the government’s strategies. He also highlighted the word ‘wellbeing’, explaining that in his view, it was this that had slipped from the agenda. Over the day however, none of the speakers took this up.

A younger-mid adult centrism overshadows a psychological discourse of ageing whilst in the fields of old age itself there is a parallel absence. For Alistair and me, this inter-generational absence of thinking psychologically when talking about older people is striking. When we presented our workshop in November of last year, one of our participants made the point that it wasn’t so very long ago in our past that PSIGE conferences were largely neuropsychological ones, and didn’t speak to psychological development at all. In 1999 Peter Britton and Bob Woods wrote,

“Theoretical as well as practical developments are important, since the psychology of ageing lacks effective models. Models of adjustment have come and gone, and attempts have been made to extend some of the classical theories of behavioural, cognitive, systemic and psychoanalytic schools to encompass the older person, but very little of this work is based on evidence of studies of older people. Erickson’s theory is among the very few to provide at least some attempt at an integrated model of life-span development, and the more recent compensatory models of Baltes and Baltes [1990] show promise as their potential is explored. The absence of the life-span developmental perspective from mainstream psychology should be acknowledged”.

By 2004 Bob Knight had published the third edition of Psychotherapy with Older Adults. There he explored the ‘loss-deficit paradigm’ that characterises so much of attitudes towards ageing, including within our approaches in psychotherapy and psychology. This is where old age is characterised largely as an event of a series of losses, in which cognitive deficits are mapped out – by us psychologists - in detail. Knight also pointed out the childhood reductionism of many of our theories, that is to say the absence of consideration of what adult development looks like, and the taking of development as only from childhood development.

This led Knight to propose that we need a scientific psychogerontology. He set out an impressively integrative project for us. He looks at cognitive experimental work, for example, showing a study in which if you used old fashioned words in memory experiments you get better recall. He questioned the child-centred developmental psychology, for example of Vygotsky, to argue for a post formal reasoning period. And, questioned, as I mentioned, the childhood reductionism that features in the classical analytic and current cognitive therapies. And of course this led Knight to specify the need for a ‘cohort-specific maturational model for ageing’. We also have the revisions to the CBT model to make it more expansive in order to be able to deal with the socio-historical, and relationship to the body, better (Laidlaw et al 2003), and we have in CAT our critique of ‘ageism’ as not ‘from one to another’ but as reciprocally held and sustained (Hepple and Sutton 2004).

2004 was also the year in which Peter Coleman and Ann O’Hanlon published Ageing and Development. In this book they set out specifically to counter the loss-deficit paradigm. They noted that old age is also about development. They critically review theories and research evidence which demonstrate the existence of psychological development in later life and extreme old age. They place Baltes’ model and research, and the notion of ‘successful ageing’, for us as a relatively well developed theoretical framework for mid-life and early late life : echoing the recovery studies, we might say ‘retirement’ is no longer the expected ‘end stage’ of development.

Coleman and O’Hanlon (2004) explain however that we don’t have such a model for extreme old age; that this is a neglected area. They then ask, “What comes after “successful ageing?”, because socio-gerontologists are becoming concerned about an increasing stigma towards extreme old age. In chapter 6, Coleman and O’Hanlon (2004) ask questions of what a psychology of advanced old age might look like. Finally, we are brought to the research, such as it is, in the psychology of advanced old age itself.

Finally, we want to add in a zeitgeist for the 21st century. It is as if we have moved from the twentieth century disengagement theory of later life, now to an inability to relax, in over-stimulating environments (any wonder we have ADHD?), and a zealous need to be involved and doing actively, risking an over-extension of positive psychology. We wonder what is being played out here? Is the call for positive psychology and successful ageing driven partly through a midlife fear – a fear, of meeting, actually, our own projections of our ‘feared future self’? Coleman notes that “perhaps because one’s age is always changing, fear of the future self is a significant factor in adjustment to ageing” (Coleman 1999). Unless this fear is addressed, old age ‘as it is’ can’t be thought about – and wellbeing in advanced old age ‘slips off the agenda’.

Neglect in Clinical Practice: A CAT Approach

Working psychologically with older people, questions of emotional care and neglect present themselves to us in several ways. We will argue that a CAT framework is useful in understanding the connections between these types of neglect and in negotiating a response which offers something different from a re-enactment of neglect – what we will call offering a “meeting eye.”

Alistair’s interest in the issue of neglect grew out of his experience of beginning to work psychologically with older people. He found himself slightly unexpectedly struggling to reconcile “adult-centric” ideas about therapy with clients for whom the ideas did not quite seem to fit. In particular he saw more often people who did not seem interested in understanding their distress psychologically. They might be referred because a husband or wife or doctor thought it was a good idea rather than coming of their own accord, or they might express their distress physically or in terms purely of psychiatric symptoms rather than emotions. They sometimes expressed the view that there is “no point in talking,” or even that they are “not worth bothering with.” Of course these presentations are not absent from work with younger adults but they seemed to be occurring much more. He began to conceptualise this apparent detachment from emotional needs as a kind of self-neglect.

He also began to wonder if these detached presentations were connected to the experiences of neglect he was hearing in the life-stories of his clients. For people growing up in the 1930s and 1940s, certainly in Britain and most parts of Europe, experiences of childhood emotional neglect seem to be commonplace. These can range from adoption into impersonal institutions, or into families where the adoptee felt rejected or uncared for, through experiences of being one of a large families where the parents were struggling to put food on the table, to losses of mothers or fathers, permanent and temporary, through illness and war, to more subtle forms of emotional neglect in families where the parents were experienced as “cold” or overly critical or harsh. The common factor in these experiences is of repeatedly not having one’s emotional communications received and attended to, by an attuned other. Such experiences are perhaps clearest in childhood but they may also occur in adult life. There may have been times in adult life when, particularly traumatic emotional experiences such as the loss of a child, could not be heard or attended to.

Thirdly Alistair was facing the question of whether the emotional care that he and the services around him were able to offer was adequate. Whether, given the histories of neglect and presentations of self-neglect, not to mention the context of ageism and shortage of money, the care that was being offered was adequately attuned to clients’ emotional experiences. All too often it seemed not. Instead emotional neglect was being re-enacted, often almost unnoticed. There seemed to be a danger of neglect itself being neglected.

Emotional Neglect in Childhood

Rather paradoxically, the place to start in understanding these particular clinical issues of old age may be childhood. In thinking about presentations of detachment the place to start may be attachment. Although there is a danger of uncritically applying ideas from attachment theory, which was of course developed with childhood in mind, to old age, equally it may be neglectful to ignore ideas that may help us to understand the older people that we meet.

The importance of a close and attentive relationship for the emotional development of children has been recognised by psychologists now for over fifty years, and as Bowlby notes by poets and mothers for far longer. Bowlby (1969) uses as an epigraph to a chapter in Volume One of Attachment and Loss a brief poem by George Elliot, used by Elliot again as an epigraph in her novel Middlemarch.

“A child forsaken, waking suddenly,
Whose gaze a’feard on all things round doth rove
And seeth only that it cannot see
The meeting eyes of love”
(Elliot 1872)

Bowlby and his colleagues’ work was at least partly inspired by the dislocation in children’s lives caused by the second world war. Ironically, of course this dislocation was experienced by many of today’s generation of older people There were studies such as Freud and Burlingham (1944) which documented the difficulties experienced by children separated from their parents.

Bowlby and his colleagues conducted studies based on systematic observation of children separated from their parents often for shorter periods, such as those cared for within a residential nursery while a parent was in hospital. They noticed a characteristic progression of child’s emotional state through stages of Protest, Despair and Detachment.

From these observations and his understanding of human and animal development Bowlby developed attachment theory, which at its base is a theory of how human beings are adapted to ensure the care and protection of children through the development of relationships with caregiving adults, most usually their parents. A secure attachment is based upon the care-giving figure’s ability to be adequately “attuned” (a term introduced by Daniel Stern, 1985) to the emotional state of the child and to develop strategies to, for instance, soothe a child when it is distressed. To attunement is added a care-giver’s ability to give meaning to behaviour through dialogue with a child, enabling him or her to develop “reflective functioning” (Fonagy and Target 2000) From a secure attachment, a child has a source of comfort when distressed and from this “secure base” has is able to boldly explore the world and relationships with other children and adults.

In CAT terms this kind of relationship can be modelled as a Reciprocal Role Procedure (Ryle and Kerr 2002) which is something like Attentively Protecting to Safe and Protected. According to attachment theory, the experience of this kind of relationship is internalised into an “internal working model” of attachment, which is thought to have a key role in allowing a child to develop its ability to regulate its own emotions (Fonagy et al. 2002). In CAT, the infant is considered to contribute to the development of ‘role procedures’ for relating to her/his mother/caregivers on the basis of inborn attachment behaviours and sensorimotor intelligence (Ryle 1991). This is before the discrimination of self and other, yet the infant is learning two parts, namely the part which derives from their own response and the part that derives from the other. Through this process of internalisation, that is, ‘learning’, the child can be thought to develop a self-to-self reciprocal role, of self –protective to self-protecting (as the process is a dialogic one, it doesn’t require the positing of internal working models).

Figure 1: Secure Attachment in a CAT Framework

When a child experiences emotional neglect, however, when an attuned relationship is not possible, either through the physical unavailability of a parental figure or inability or unwillingness to attend to the child’s as opposed to the parent’s emotional state the child does not develop a secure attachment / RRP. A great deal of work has gone into understanding different “styles” or strategies of insecure attachment, which are essentially ways of adapting to the lack of an attuned parental figure. (eg: Ainsworth et al. 1978) “Organised insecure” strategies include ambivalent attachment in which a child amplifies its distress signals in an attempt to evoke care from a poorly attuned parental figure, and avoidant attachment in which the child minimises its emotional reactions in an attempt to evoke approval and protection from a parent with a dismissive parenting style. Again these responses can be modelled fairly simply in CAT terms – as the development of a Conditional to Striving Reciprocal Role in the case of avoidant attachment (the child learns that he / she only receives care and protection if he/ she denies emotional need) or the development of a controlling to clinging reciprocal role in the case of ambivalent attachment. (The child learns that he or she only receives care or protection if he / she amplifies emotional needs.) It is notable that implicit in the avoidant strategy is the development of a controlling / restricting self-to-self reciprocal role – that is that the child is not able simply to express needs but must control or restrict the expression of need in order to achieve care.

Figure 2: Adaptation in conditions of partial neglect
a: avoidant attachment

Figure 3: Adaptation in conditions of partial neglect
b: ambivalent attachment

Disorganised attachment styles occur when care is below a level of consistency which allows an organised strategy, or when a caregiver is a source of anxiety as well as a figure to be turned to in distress. Children in such relationships are unable to find a consistent strategy to evoke care and protection from adults and so are forced to rely on their own inadequate resources to regulate their emotions. David Howe (2006) has observed that they usually do this by adopting a form of controlling behaviour. such as parentified behaviour, passiveness or aggressive attempts to dominate. These strategies too, can be simply modelled using Reciprocal Roles. (figure 4) It is worth noting that although the self- controlling reciprocal role that may be adopted is similar to that in an avoidant strategy, there may be more dissociation from emotional experience which may have implications for therapeutic intervention.

So in many instances the child is forced to respond to the partial or substantial deficit in emotional care by adopting a controlling self-to self Reciprocal Role. There are individual differences in the way in which the controlling strategy works, if it is through denying needs and presenting a front of apparent not-needing, then this can be seen as a form of self-neglect (perpetuating the neglect which has been experienced.) The extent of the neglect may affect the amount of anxiety which underlies the strategy; the more neglect the child has experienced, the more anxiety he or she may feel and the more rigid the strategy is likely to be. Equally, other experiences positive and negative will affect the formation of reciprocal roles, and perhaps the rigidity of the roles. If there are attentive relationships outside the home they may facilitate the development of healthier reciprocal roles, whilst abuse and trauma on top of neglect will lead to further layers of complication and dysfunction.

Recent work in developmental psychobiology has shown that the experience of neglect can have a physical effect on the development of the endocrine system. (Fries et al. 2008) Imaging studies have shown with the effect of neglectful experiences on areas in the frontal lobes which are linked to the regulation of emotions and social relationships. (De Bellis 2005) Thus the experience of neglect can have a very physical effect on a person’s ability to care for both others and him or her self.

Ironically too, children who have experienced violence or emotional neglect also find it harder to construct coherent narratives of their experiences. (Osofsky 1993) Without an attentive other it may be hard to attend to one’s own experiences sufficiently to make sense of them. So the experience of neglect becomes hidden and neglected, making it easier for it not to be noticed by those around them.

Although the organisation of reciprocal roles described can be used to model the effects of childhood neglect, it is also notable that traumatic events creating high levels of distress in adult life, particularly trauma which is unattended and unprocessed can lead to a similar organisation of reciprocal roles. This can be seen for instance in the experience of losing a baby, which for the current generation of older people was often an unattended tragedy, unrecognised and unspoken.

The kind of restrictive / self-depriving organisation of RRPs (figures 2/4) in the current generation of older people would also have been reinforced by the cultural context of the 1930s-1950s, particularly in Britain and other countries in Western Europe. During a period of economic and military turmoil, the cultural values were of communal struggle not attending to individual distress. Older people often remember injunctions to “not make a fuss,” “don’t be a cry-baby,” “don’t feel sorry for yourself,” or countless variations. Public policy tended not to be informed by or attentive to emotional need, As an example, the organisation of the evacuation of children from London and other major cities, during the second world war, was not carried out in a way which would have reduced the emotional damage to refugees, for instance by evacuating children with parents. This evacuation has been shown to have had a long-term disruptive effect on evacuees attachments and well-being. (McKee 2005) Distress for these children was not attended to and the cultural message that was given to them was that it was not important for it to be attended to. This seems to have been repeated for many experiences of neglect both large and small.

The Effects of Neglect in Older Age

In adult life this kind of restrictive organisation of reciprocal roles can be relatively functional. While the focus of life is on work or on caring for others, difficulties in recognising and attending to emotional needs may not be too disabling. However Old Age (and perhaps particularly advanced old age) is a time when life events may mean that issues of care and emotional need come to the fore once again. The experiences of loss of role in retirement, the loss of partners and friends through bereavement, loss of capability through ill health and cognitive losses, and the prospect of dying, are all things which may evoke feelings of emotional need and distress. Old ways of managing need may break down, and it is often at this point that someone may come into contact with older peoples mental health services.

A person in this kind of situation could be seen as being, in CAT terms in a dilemma. Emotional need, without adequate internal resources to manage it may be experienced as shaming and terrifying, so there may be a strong urge to re-establish old ways of coping, in CAT terms through a restrictive RRP. However this leaves the needy feelings unattended and particularly with a progressive problem may become increasingly hard to manage.

Figure 5: A potential dilemma of Old Age

Again the social and cultural context surrounding Old Age may intensify the difficulty in facing emotional needs at this point. The culture of ageist neglect of the emotional needs of older people, is likely only to intensify feelings of shame and fear regarding emotional needs, and make it harder to move away from responses which are no longer functioning. For instance there is almost no consideration given in research or practice to the emotional experience common to older people of moving out of home into a care home. In this context it is not surprising if an older person should feel that they should detach from this experience.

Coming for psychological help at this point there may be a great deal of ambivalence. It may not be a person’s own idea to seek psychological help, they may be following the advice or responding to pressure from a family member or doctor. There may be a view, implicitly or explicitly expressed that it is “not worth bothering with.” (understanding the problem.) A therapist may feel his or her efforts to understand a problem and empathise with a client are being rejected, and there is a temptation, particularly in hard-pressed health services to shrug one’s shoulders and conclude that the client does not want help or is not “psychologically minded,” or is otherwise unsuited to our services. However this merely perpetuates the chain of neglect.

This situation can be conceptualised as a dilemma for the therapist to either to retain an interest in trying to understand the problem and so risk becoming unwelcomely intrusive, or to withdraw and risk perpetuating the neglecting pattern.

Figure 7: A Therapeutic Dilemma

Offering a “Meeting Eye”

CAT has a potential to offer a way out of this dilemma, by offering an understanding of the problem which is collaboratively developed and so not intrusive, and attends to rather than neglects emotional needs. Following George Elliot (above) we have termed this offering a “meeting eye.”

At its core this involves finding a way to offer an understanding which is within the client’s zone of proximal development, that is simple enough to be understood and processed by the client and yet does not over-simplify or assume that things are too difficult for them to understand, and so neglect that part of a client that might yet be open to understanding.

One aspect of this is a reformulation letter which offers an understanding of how difficulties in managing intense emotions may have developed in response to gaps in parenting. This may be difficult to piece together given the likelihood that a person who has adopted a restrictive strategy with regard to emotions is unlikely to have a well-developed narrative about their childhood experiences. It may also need to be carefully constructed to avoid unwarranted blame of parents, and which is also mindful of the cultural value of “not making a fuss” It may be useful to explicitly stress that what we are concerned with is witnessing or understanding what a person experienced rather than complaining about it.

Another element is an understanding of present day issues around emotional need and the ways that a person has developed to manage these issues. This may include thinking about the “voices” with which a person addresses themselves when experiencing emotions, and the development of an internal voice which is more congruent with an attentively protecting reciprocal role. The ideas of Paul Gilbert about the development of self-compassion are relevant to this. (eg: Gilbert and Proctor 2006)

There may also need to be ongoing attention to the therapeutic relationship to notice enactments of neglecting to neglected reciprocal roles are not re-enacted. These might be subtle things like a therapist neglecting to be on time or neglecting to put enough effort into a diagram or reformulation letter knowing that the client’s reciprocal roles are such that they will not complain. One client would repeatedly suggest to Alistair that if he was too busy he could cancel his appointments. With another client he found himself being repeatedly a few minutes late in leaving for her home visits.

It is important too, to be realistic about what individual therapy can achieve, particularly within current resource constraints. It may be important to be able to offer longer-term contracts, particularly in situations where a person has experienced severe emotional neglect. Because with this kind of presentation so much of a person’s emotional distress can be hidden, the results may also not be immediately obvious in terms of symptoms although being able to be a little more understanding of and tolerant of one’s distress can feel like a huge relief and can make the business of accepting care so much easier.

Offering a “Meeting Eye” as a Service

The re-enactment of neglecting to neglected RRPs is not confined to therapeutic relationships. It is important to ask how much the services that we work for are able to attend to people’s emotional needs or how much they are neglected, either through not noticing older people’s emotional needs (and hence not referring them or accepting them) or by over-medicalising them, seeing them purely as symptoms of an illness or neurological damage rather than as something to be understood. Reluctance to respond to overtures of help may also be responded to with further rejection rather than attempts to understand.

Personality disorder and alcohol abuse are among the factors associated with a risk of suicide in old age, but less so than for younger adults (Dennis 2008). Rather, ‘personality traits’ convey the greater risk, in obsessionality, neuroticism and lower score for ‘openness of experience’ (Dennis 2008). One wonders whether these processes of neglecting emotions, in favour of striving, and closing down to wider narrative, have contributed; and that the current service and social repetitions are contributing still.

Developments in the services in which we work often seem to work against the need to offer a meeting eye to the emotional needs of older people. Whether it is through the uncritical adoption of adult-centric thinking in IAPTS or the silent cuts in community and day-services or the concentration on quantity rather than quality of contacts, attending to older people’s feelings does not seem to be considered. There may be an important role for CAT-informed professionals to help services to attend to emotional needs, for instance through promoting life-history work and services which allow the time and space to ask how people are feeling and so at least offer the possibility of promoting compassionate and attentive reciprocal roles.

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PSIGE (2006, June) Discussion paper : PSIGE in relation to the Division of Clinical Psychology, www.psige.org
Ryle, A. (1991) Object relations theory and activity theory : a proposed link by way of the procedural sequence model. British Journal of Medical Psychology, 64, 307-16
Ryle A. and Kerr I. (2002) Introducing Cognitive Analytic Therapy: Principles and Practice. London: Wiley Blackwell
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Full Reference

Sutton, L., Gaskell, A., 2009. Meeting with Older People as CAT Practitioners: Attending to Neglect. Reformulation, Summer, pp.6-13.

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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.

Meeting with Older People as CAT Practitioners: Attending to Neglect
Laura Sutton and Alistair Gaskell, 2016. Meeting with Older People as CAT Practitioners: Attending to Neglect. Reformulation, Summer, pp.22-28.

CAT in Later Life: Becoming a Historian of the Self
Sutton, L., 1999. CAT in Later Life: Becoming a Historian of the Self. Reformulation, ACAT News Summer, p.x.

Developing a Language for the Psychotherapy of Later Life
Hepple, J., 2003. Developing a Language for the Psychotherapy of Later Life. Reformulation, Autumn, pp.10-12.

Borderline Traits and Dissociated States in Later Life
Hepple, J., 2001. Borderline Traits and Dissociated States in Later Life. Reformulation, ACAT News Autumn, p.x.

Attachment, The Body and Trauma
Diamond, N., 2005. Attachment, The Body and Trauma. Reformulation, Autumn, pp.25-26.

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