CAT, the Therapeutic Relationship and Working with People with Learning Disability
complexity of the relationship matrix in all psychotherapies or approaches to psychological counselling. the reparative/developmentally-needed relationship . any specific psychological counseling paradigm itself that is the quintessence of Clarkson states that there are five types of relationships potentially present in relationship, (c) the developmentally needed/reparative relationship, (d) the. “The developmentally needed or reparative relationship is an intentional provision by the psychotherapist of a corrective, reparative.
Overall, there are really useful principles of therapeutic practice within Rogers approach that speak to me in my growing and deepening work with clients in psychological coaching Clarkson 5 relationship Model I have become interested in Petruska Clarkson due to her body of work on human relationships, including the 5 relationship model.
I like the metaphor Clarkson uses in relation to a piano, that some aspects are played more frequently or loudly than others, but they are always potentially there. This first stage is very much about building a shared understanding and a foundation, so if the relationship falters, both parties can return to the contract and try to repair the therapeutic alliance.
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As I understand it the working alliance is the basis of the client—therapist relationship that enables both the client and the therapist to work together and would include such things as the contract, the presenting issues and maybe a realisation of both people that in other circumstances they may not be kindred spirits, or even necessarily like each other. There are some synergies here with Coaching practice with a contracting process, and examination of presenting versus underlying issues; it leads to my sense that Coaching has beg, stole and borrowed from therapeutic theory!
Most of us have at some time or another met a person for the first time and found ourselves either strongly attracted or repelled by them. Given time the client begins to trust their own judgment and the need to use the therapist as an emotional support lessens, at this point therapy usually comes to an end. Counselling and psychotherapy relies to a great extent on building a human connection with clients, where a deep level of trust is established, this transcends any modality, this is seen to a great extent in the work of Carl Rogers.
Rogers describes the core conditions of empathy, congruence and unconditional positive regard, as the foundations of building an interpersonal alliance between two people. The person-to-person relationship is the core or real emotional connection — as opposed to a professional relationship with say your doctor or dentist.
Research by Affleck has shown that it is significant to the client that there be a real relationship from within which environment the therapists can use whatever modality of therapy she or he is trained in.
It was my experience that all of these aspects of relationship were grounded in the very ordinary stuff of being human. In many ways working with people with learning disability is just like working with anyone else.
However issues of woundedness, weakness, limitation, difference and vulnerability alongside the need for appropriate independence and autonomy are particularly strong. The challenge is to find a way of establishing and maintaining authentic, life enhancing relatedness Safran in the face of these issues. It is increasingly accepted that CAT can be used effectively with people with learning disability.
Experience, gathered by a few practitioners working in the field and pooled in a special interest group has been summarised by Ryle and Kerr p In this article I will consider each aspect of the therapeutic relationship in turn, linking each with the theory and practice of CAT and my experience of working with people with learning disability.
The clinical material quoted in this article is derived from six completed CAT therapies, which I have undertaken with people with mild or borderline learning disability The Working Alliance The working alliance has been described as involving the reasonable, rational part of the patient and therapist, allowing them to be part of a shared undertaking.
This enables the work to proceed even when difficult transference and countertransference feelings occur by allowing them to be recognised and worked on.
Gelso and Carter Bordin proposes three essential aspects of the working alliance, the collaborative setting of goals; the joint agreement on tasks and the development of a human relationship or bond. Ryle This concept is of particular importance in work with people with learning disability.
One way of addressing the difference in cognitive ability is in modifications of the CAT tools. I found that simplifying the wording of the Psychotherapy File King ; taping the Reformulation and Goodbye Letters and using simplified SDRs incorporating colour and drawings King were all helpful. It is suggested that the tools of CAT all serve to create and maintain the working alliance.
Ryle ; Ryle and Kerr p Joint identification of Target Problems, Reciprocal Roles and Reciprocal Role Procedures facilitates the formation of a strong working alliance early on in therapy. The Reformulation Letter is described as often strengthening the emotional bond between patient and therapist. The prose and diagrammatic reformulations bring understanding, which will help prevent or repair disruptions to the therapeutic alliance.
It is now generally understood to be a valuable therapeutic tool, which can give insight into the experience and responses of the patient. Clarkson Different types of countertransference have been described by Ryle and Kerr p as personal countertransference what the therapist brings to the encounter and elicited countertransference the reaction induced in the therapist by the patient the latter being either identifying or reciprocating.
Awareness of personal countertransference is particularly important in work with people with learning disability. Relating to those who carry the woundedness and weakness of disability means that we must face our own disability, weakness and wounds, something which we would often prefer to ignore, conceal, deny or thrust on to others.
Symington ; De Groef Powerful feelings may arise in us such as contempt Symingtonguilt and intense compassion Sinason A variety of responses to these feelings may occur.
Disability may be denied, losing connection with what is real. There may be avoidance, distancing or rejection. Alternatively there may be an attempt to provide perfect care to make up for the weakness and pain.
We may fall into judging ourselves to be inferior or superior, bringing feelings of worthlessness or contempt. Or we may put unwanted parts of ourselves into those who are different leading to denigration, contempt, rejection, abuse and exclusion.
These feelings and responses will tend to undermine or destroy the therapeutic relationship or may even lead to a reluctance to offer therapy at all. This is of particular value in work with people with learning disability who may have difficulty in recognising, naming and expressing their feelings.
For example in this work I often felt confused and overwhelmed which I understood as an indication of what the patient might have been feeling.
Another time my strong feeling of being rejected and contemptible proved to be an invaluable aid in understanding what the patient was feeling.
Both are examples of identifying countertransference.
Petruska Clarkson – 5 Relationship Model
CAT understands transference and countertransference in terms of Reciprocal Roles RR being played out within the therapy. In one case I found myself being uncharacteristically neglectful over an agreed arrangement.
In the special interest group we recognised that polarised responses often occur in people with learning disability. Kim, when choosing a button to represent herself, selected a very small button because she felt that she could not do anything, whilst she chose a very large button for me. It was as if in facing the cognitive difference between us she felt completely worthless and useless.
It was good to see that when she repeated the exercise towards the end of therapy she chose buttons of much more equal size. Ideal care is often sought out and reciprocated. It is as if we need to somehow magically make up for the limitation, vulnerability and sense of woundedness, which are faced by patients on a daily basis.
CAT helped me to be aware of this and to avoid colluding with it. She also suggests three types of injury or deficit, which may require a reparative relationship, all of which are highly relevant to the lives of people with learning disability.
They are trauma, such as abuse ; strain or accumulative, repeated less severe traumas such as are associated with neglect and deprivation and the negative attitudes of society ; and extra-familial limitations and catastrophes in which she includes genetic conditions.
Missing elements, which may be provided in the reparative relationship are identified by Clarkson p as containment, witness and care. Casement suggests that where there has been neglect, careful attention and responsiveness are needed; where there has been smothering, respect and space are required.
In addition the structure of CAT could be understood as providing a reparative, holding environment for both patient and therapist.
I found this aspect of the therapeutic relationship to be particularly important in work with people with learning disability. The Therapist shared with her Supervisor how she began the session gently, giving the client time to get comfortable in the room, establishing eye contact and getting a feel for the pace that would be appropriate for the client.Building the Therapeutic Alliance
The Therapist said that she expressed her goodwill towards the client by how she listened; how she was seeking to understand fully; how she was respecting and acknowledging the experience and the insight of the client and expressing her empathy through, as Rogers said: The Therapist explained to the Supervisor that her instinct was to avoid too many questions at this early stage but, having welcomed Fleur she did ask: The Therapist said she was listening and summarising, contracting, setting mutually agreed goals, sharing the responsibility for treatment and ensuring, as best she could: She said to the Therapist: I think that the client is being well cared for the in relationship and the question you are asking is, does she feel well cared for?
The Therapist was reassured that the Supervisor was following closely as she was keen to have the benefit of her insight and an external view. The Therapist went on to say that it was at this point she asked her second question: So much so that she felt her attention was drawn back only slowly to what was going on in the consulting room. When it was, she realised that Fleur had got up from the sofa, clutching her stomach and then, gathering her things, she swept out of the door, weeping and muttering her apologies.
The Therapist was a little startled and was slow to react. She then found herself alone in the now silent consulting room, with a full twenty minutes of the session still remaining. The Therapist told her Supervisor that, immediately after the intensity of the moment, she realised that her first response was to actually offer herself reassurance: Then I became conscious of the transference and recognised what had happened and how I was feeling.
CAT, the Therapeutic Relationship and Working with People with Learning Disability
The Therapist said she felt disappointed that she had not managed the session better and not realised in the moment that she had become a symbol for Fleur and Fleur was re-creating in the consulting room the dynamics of the problem she had with her mother. The Therapist said that she felt that she may have been captured in the dynamics of the story or it may have even touched some vulnerability of her own.
She said that, had she picked it up, she and Fleur could have discussed in advance how they would deal with a need to escape, should it occur during one of their sessions. She went on to quote sections of the ethical code questioning her competence, whether she had promoted the well-being of the client and if she had even avoided harm. The Supervisor was alert to the danger of creating a parallel process in supervision and wanted to avoid a relationship between herself and the Therapist which would mirror the relationship between Fleur and her mother.
The Supervisor encouraged the Therapist to be curious about her own vulnerabilities.