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Chorlton. E, 2023, Reflections on using CAT for people recently diagnosed with autism, Reformulation 56, p. 21-24
Introduction
I currently work in a psychological therapies service providing assessment and diagnosis of autism, and post-diagnostic therapy for adults (with and without learning disabilities) who receive the diagnosis. I will refer to people who have received a diagnosis as “autistic people”, which is the most popular term amongst autistic adults and their parents (Kenny et al., 2015). We provide up to 8 post-diagnostic sessions to work towards clients’ goals, which usually focus upon themes such as developing their understanding of being autistic, learning to manage some of the traits that society is less accepting of (for example in work situations) and developing coping skills related to their mental health in the context of being autistic. I’ve also worked with autistic adults in a secondary care mental health setting. As all of the clients I work with have had a ‘late diagnosis’ (i.e. missed in childhood), they have often developed complex strategies for relating to other people and a world in which they feel misunderstood and as though they don’t “fit in”, without a framework to make sense of these differences. People have described not being able to do what they want with their life (such as staying in a job long-term or maintaining connected relationships with others) and the anguish they experience because of this. People describe feeling overwhelmed, but their attempts to manage this by gaining control over their environment have lead to further difficulties with others (see Lloyd and Potter, 2008 for further exploration of this). People have described wanting to find a way through these difficulties, but they have struggled to understand what is happening or how to navigate these patterns differently. I have also often worked with people who describe an ‘autistic burn out’ (Higgins et al., 2021) which develops from a pattern of seeking to fit in and please others which can lead to exhaustion and mental health crises. The relational nature of these difficulties led me to consider how CAT may be useful to explore these themes with clients, and I began to offer this to those whom it was appropriate for. This article is a collection of reflections upon this work.
Using CAT and staying in the ZPD
Several articles have explored how CAT can be helpful to autistic people, describing that its predictability, use of visual tools and focus upon relationships can be appealing (Murphy, 2008; Victoria, 2015). SDRs can also support the development of people’s theory of mind (Murphy, 2008). Concepts of relational intelligence have also been used to theorise as to the nature of the differences autistic people experience (Lloyd and Potter, no date).
All of the clients I have used CAT with have found the process of using CAT mapping helpful in developing their understanding of patterns with others. They have generally described that the use of reciprocal roles and procedures helps the implicit interaction between people more explicit, which has helped them to understand their own relational patterns.
However, there are some differences to using CAT with autistic people. Of particular note when using CAT, autistic people can find it more difficult to access emotions, and to understand the intentions and communication of the ‘other’ (NHS, 2022). After introducing CAT, some people I have worked with have chosen a different model. However most have expressed being keen to use it, even where they have described feeling apprehensive about the focus on relationships. In these cases, in particular, I have found it has been important to make sure that the focus upon relationships and feelings within CAT does not become overwhelming and consolidate a role where people feel misunderstood and disconnected from others.
To ensure CAT remains in people’s zone of proximal development (ZPD) I have found that it is particularly important to map early using simple diagrams or one clear metaphor, and for clients to lead in the collaborative process of mapping (and on one occasion even a type of reformulation!). With one or two clients, the metaphors we used were not particularly ‘CAT-ish’ initially, but over the course of sessions we gradually elaborated upon it to introduce reciprocal roles or more of the language commonly used in CAT as they became more confident. One person particularly liked this approach, suggesting that when using CAT with autistic people, therapists should “hide the relationship stuff like hiding vegetables in food with kids”. An example of this is a person who (following our initial sessions and mapping), developed the image of a seesaw, with a fiery pit underneath, with ‘nurturing but weak and a failure’ on one side, and ‘cold and hard, but successful’ on the other side. Once they had shared this vision, we worked together to embellish this into a CAT map that helped us both to develop a more rich understanding that they could seek exits from. It helped them to recognise how this formed self-to-self reciprocal roles but also to elucidate how others experienced them and why they responded as they did (for example their employees feeling crushed by the cold, harsh feedback they gave). We came across other metaphors in our discussions, but they struggled to incorporate any images that they had not thought of independently.
Another person I worked with wrote a compassionate letter to me about her life before we had met, reframing her early life experiences, and acknowledging feelings of anger and sadness. When we spoke about the letter, she explained how being labelled autistic had naturally led her to feel more compassionate towards herself and reframe these experiences. In this way she had in some senses already ‘reformulated’ her experiences and did not need to repeat this again with me! Instead, the part she was ‘stuck’ with was understanding specifically how this affected her current relationships. We developed a target problem procedure (TPP) based on her letter, mapping this out into a simple diagram incorporating two sets of reciprocal roles (RRs) which we used for recognition and revision for the remainder of the therapy.
Although the relational patterns I have come across in working with autistic people have not been that dissimilar to ‘neurotypicals’, there is often an RR of ‘not understanding’ to ‘misunderstood’ in relation to others and also sometimes self to self. This RR is usually linked to unmanageable feelings, particularly if they have felt criticised, judged or rejected because of this misattunement with others (e.g. in family, at school, at work). Where people have felt accepted despite (and because of!) their novel perspectives, their differences in understanding / being understood by others has not felt as painful, instead fostering a more accepting self-to-self role. Many people I have worked with (particularly women have reported avoiding ‘misunderstanding-misunderstood’ through camouflaging their difficulties and seeking to please others but have subsequently found that their own needs have become forgotten and they become totally exhausted and experience ‘autistic burn out’, (Higgins et al., 2021). The map below illustrates this pattern.
Similar to Higgins’ et al. (2021) description, many of the people I worked with talked about finding exits to this cycle by spending time in relational interactions where this expectation to camouflage and please others was not present. For one person I worked with it was a neurodiverse friend who she felt understood her; for another it was her circle of friends who had known her for her entire life (including before she learnt to camouflage) and so she felt accepted; and for another it was spending time with her dog who provided company but didn’t have the social expectations that a person would. I worked with one person who had found a partner who they felt helped in this way to some extent, but this pattern was only helpful whilst the partner put most of her own needs and feelings ‘on hold’. When she placed expectations on the person I was working with and asked for her own needs to be met too, the relationship became problematic.
Seeking Attunement
In my experiences so far, I have noticed when using CAT with autistic people that the process of developing and maintaining attunement has often felt qualitatively different to working with ‘neurotypicals’. I have often had a sense that we are both travelling towards a similar destination (the client’s goals) and even going along the same route, but we are looking out of opposite windows and aligning our perspectives can feel impossible despite both of our best efforts. This experience of misattunement was particularly clear with one person I worked with, and it left us both feeling frustrated and tired. In naming, exploring and mapping this, we reduced some of our frustration. We identified an ‘exit’ of accepting the misattunement, and valuing the difference in our perspectives as well as the effort we were both exerting to try to understand one another. To me an important (and difficult!) aspect of this was that as a therapist I had to ‘let go’ of the goal of seeking the attunement I would normally achieve with neurotypicals. This was uncomfortable and disorientating, but ultimately improved our therapeutic relationship.
Helpful strategies
Some of the strategies I have used to enable me to develop better relationships with autistic people, and for them to get the most out of CAT have included.
Being concrete and explicit in my language when describing CAT, writing reformulations, and drawing SDRs. Some have found it helpful to liken reciprocal roles to specific (caricatured) famous people to help them conceptualise these
Suggesting concrete tasks to aid recognition and revision, for example to directly observe nurturing behaviours where this is more obvious (e.g., adult to child) to learn how to behave towards themselves
Being prepared for autistic clients to be blunt in their language – not to instinctively map this with the client having an intention / expectation about how the other (myself) will experience it but instead recognise it as being unwitting. Lloyd and Potter (no date) describe how autistic people can seek control in familiar, narrow ways, but unwittingly rejecting others by restricting and attacking them.
Endings
Connected to this, I have experienced endings in therapy with autistic people as often quite different to working with ‘neurotypicals’. I have experienced people seeking abrupt endings, for example because it coincided with the end of a month or year and that felt ‘right’ to them. I’ve noticed that people I’ve worked with have often seemed less upset by the possibility of endings, or rather less distressed by the relationship itself ending, (particularly when it ends as planned and expected), which has felt surprising. When talking this over with one person, they described how our work together ending was like ‘when the yoghurts are moved to a different shelf in the supermarket’. They were uncomfortable at the prospect of therapy ending, but not because they would miss their relationship with me or the experience of therapy. Instead, it would be because something had changed to their routine – something was no longer there that had been there before. I’ve found this challenging at times, feeling as though something is ‘missing’ from the ending. I have supervised a trainee working with someone (not using CAT) who presented in this way at the ending, following a brief therapy where the trainee had felt misattuned to the client. The trainee had similar experiences of feeling unsatisfied as if there was something ‘missing’ from the interaction. In these cases, I’ve found it helpful to give myself space to acknowledge my own feelings about the ending, even where the client is not receptive to hearing / responding to these, and to remind myself ‘it’s not personal - you’re a yoghurt on a shelf!’
Summary
To summarise, my experiences so far of using CAT with autistic people has been largely positive, and those people I’ve worked with have found it helpful in developing their understanding of relationships, and in adding skills to cope with the difficulties they encounter in their lives. There are some qualitative differences that I have found to be important to attend to in this work, to maintain the clinical quality of therapy offered. Whilst this work has challenged my clinical skills, it has also brought a richness through diversity which has improved my abilities as a clinician. I would encourage other CAT practitioners to try using CAT with autistic people, hopefully the reflections in this article will help people to feel more confident in doing this. I hope this will be an area of development for CAT, for example hearing more from autistic people about their experiences of CAT, research into its effectiveness in autistic people and accounts from autistic or neurodiverse therapists about their experiences of using CAT.
Dr Emma Chorlton, Clinical Psychologist in Specialist Psychological Therapies Service in Leigh, Greater Manchester Mental Health NHS
echorlton@protonmail.com
References
Higgins, J. et al. (2021). ‘Defining autistic burnout through experts by lived experience: Grounded Delphi method investigating #AutisticBurnout’. Autism, pp. 1-14
Kenny, L. et al. (2015). ‘Which terms should be used to described autism? Perspectives from the UK autism community’. Autism, 20, pp. 4. https://doi.org/10.1177/13623613155882
Lloyd, J., and Potter, S. (2008) The ‘neurological outsider’: Using relational intelligence to link multiple aspects of autism. Available at www.mapandtalk.com/download (Accessed 16 December 2022)
Murphy, N. (2008). ‘CAT Used Therapeutically and Contextually’. Reformulation, Summer, pp.26-30.
NHS (2022). What is Autism? Available at http://www.nhs.co.uk/conditions/autism/what-is-autism Retrieved 16 December 2022
Potter, S., & Lloyd, J., (no date). Heroic or stoic: why do we try so hard, or give up so easily, in helping with autism? Available at www.mapandtalk.com/download (Accessed 16 December 2022)
Victoria (2015). ‘Talking myself into and out of Asperger's Syndrome: Using Cognitive Analytic Therapy (CAT) to rethink normal’. Reformulation, Summer, pp.18-22.