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The application of CAT within a school system; Reflections on a six-session intervention with a young person presenting with disruptive behaviour

Cite as: Bonfield, S., & Crothers, L. (2017). The application of CAT within a school system; Reflections on a six-session intervention with a young person presenting with disruptive behaviour. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 1(1), 114–129. https://www.internationalcat.org/_files/ugd/ff32b4_db4afa420d6e4ec0a8d5297da1038521.pdf

Int. Journal of CAT & RMH Vol.1 No.1 March 2017/ISSN2059-9919 

Abstract

‘Disruptive’ behaviours are often used to describe a range of actions that challenge others, as well causing harm to the individual. Such behaviours present a significant problem in the school system with recognised wide-ranging impact on the young person and those around them (Lee, 2012; Victorian Government Department of Health, 2006). Current treatment approaches recommend that multiple systems are targeted yet these interventions tend to draw on behavioural approaches (Carr, 2002; Lee, 2012; McGee, et al. 2011) and emphasise the pathological processes of the individual (Varela, 2014). This paper reflects on the application of Cognitive Analytic Therapy (CAT) with a young person exhibiting disruptive behaviours at school, and includes the role CAT played in providing contextual reformulation and a relational understanding of the school system and the impact this had on the treatment. Reflections on the effectiveness of this intervention are made alongside a discussion about what CAT offers that is different to the more traditional treatment approaches used.

 

Keywords: disruptive behaviour; school system; young people; contextual reformulation; CAT; ODD

Introduction

Disruptive behaviour is often labelled as Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD). It is recognized as being a ’major mental health problem’ in children and young people (Lee, 2012; Sawyer, et al. 2001; Zuddas, 2014). A Victorian Government Department of Health (2006) survey indicated that 17% of children and young people attending Child and Adolescent Mental Health Services (CAMHS) had Oppositional Defiant disorder (ODD) or Conduct Disorder (CD). The key feature of ODD or CD is ‘a repetitive and persistent pattern of behaviour, which violates the basic rights of others and major ageappropriate societal norms’ (American Psychiatric Association DSM-5, 2013). Indeed, such difficulties manifest as uncontrollable anger, verbal and physical aggression, destruction, defiance, extreme criticizing and blaming, and lying and stealing. A distinction has been made between ODD and CD with the former representing a less pervasive disturbance and a developmental precursor to the latter. In both cases anger and hostility are key mood states and problematic relationships with parents, teachers, peers and the wider community are a consequence. A high level of stress in any disruptive behaviour, caused to the young person or their family, peers and teachers, has been well documented (Eyberg, et al., 2008). They are also considered to be among the most costly of disorders of childhood and adolescence due to their unresponsiveness to treatment and poor prognosis, including reduced academic and employment prospects (Carr, 2002; Zuddas, 2014). Historically, emphasis has been placed on the pathological processes of the individual (Varela, 2014) and treatment approaches aimed to address this by focusing on social-cognitive skills training, emotional regulation (including anger control), medication and positive reinforcement from parenting (Lee, 2012; Steinert and Ramsing, 2007).

Multi-systemic theory recognises that multiple systems are involved in the genesis and maintenance of disruptive behaviours and that effective treatment must target as many of these systems as possible (Carr, 2002; Victorian Government Department of Health, 2006). Given the role of schools in socialising young people, and the bidirectional interactions 1 Siobain Bonfield is a Senior Clinical Psychologist and CAT practitioner. She works in the Adult Mental Health Program at Monash Health in Victoria, Australia, and with youth at headspace Frankston. She previously worked, for a number of years within the school system. between disruptive youth and educational staff (Lee, 2012), school-based interventions have been recognised as a key component in the treatment of disruptive behaviours with inclusion of both class-wide and environmental interventions (Lee, 2012; Sanders, 2000). However, whilst it has been recognised that a poor working alliance between the young person and the school perpetuates conduct problems, school-based interventions tend to reflect an individual focus and be built around ‘reward and sanction’ programmes, as opposed to having a relational focus and looking at the unhelpful interactional patterns that play a role in the maintenance of such problems (Lee, 2012; Carr, 2002).

Thinking more contextually, consideration needs to be given to the reciprocity between organisations and the individual, or the link between the psychological world of the individual and the organisation (Caruso, 2013, Walsh, 1996), given the co-constructive relationship between schools (as organisations) and their students (as individuals). This article aims to think more about how disruptive behaviours are elicited and reciprocated by the school system and whether CAT can offer something new to this area. As an integrative cognitive and analytic model, CAT involves looking at relationships that we have with ourselves (self-to-self) and others (others-to-self and self-to-others), with the formation of the self developing essentially in relation to others (Ryle and Kerr, 2002). Sign mediated experiences and the internalisation of the parent-child relationship (and the commensurate reciprocal role {RR} relationships that they come to represent) shape a child’s understanding of the world and their sense of self (Ryle and Kerr, 2002). When working with young people with disruptive behaviours, it was hypothesised that there were some ‘common’, unhealthy reciprocal roles (see Figure 1).

Figure 1. Translation of parenting styles to Reciprocal Roles (RRs)

 

CAT has a growing evidence base for use with a range of emotional and behavioural problems (Ryle and Kerr, 2002). Interestingly, early research conducted by Chanen, et al., (2008), looking at the application of CAT to young people with borderline personality features, found the strongest evidence of change to be a reduction in disruptive behaviours. There is also developing research looking at the effectiveness of CAT in the treatment of offenders who often present with externalising behaviour that challenges others (Pollock, 2007).

 

This article now describes a six-session CAT intervention with a young person presenting with disruptive behaviour. The intervention was conducted within the context of a school and reflections are made about the role CAT played in the case reformulation and treatment process and how it facilitated collaborative work with school staff. This is followed by a discussion about whether CAT can be applied, within the school system, to achieve better behavioural outcomes for young people with disruptive behaviour.

Six Session CAT Intervention

Sam was a 16 years old boy referred by his GP for ‘opinion and management of issues with behaviour’ under the Better Access to Mental Health initiative (Department of Health) which allows for ten mental health sessions per year. His GP further reported that his ‘parents were very worried about Sam’s attention seeking issues and not dealing with rules set by the family and school’. This referral was supported by Sam’s parents and the school’s welfare team, with all sessions occurring at the school. The referral was made to the therapist who had worked in a private capacity at the high school for five years. During this time, good working relationships with the teaching staff and the school welfare team had been developed.

 

Sam was the eldest of three boys, born to parents in their late teens. His family unit was intact and traditional in that Mum was the main carer and Dad worked outside of the home. Mum reported that both parents were actively involved in raising Sam, but that she had always felt anxious about parenting Sam because she was a teenage Mum when he was born and that Dad was ‘fairly’ strict in his parenting style. Mum reported that Sam’s behaviour had become challenging when he started high school. She reported that his mood seemed to drop, as did his interest in completing school work and being social with his family. Further, he had also hit out at his parents and siblings, been smoking marijuana and cigarettes and been ‘lying’. She was concerned about a lack of empathy and seeming indifference to being in trouble both at home and at school. He was not thought to have a developmental disorder.

 

On discussion with the teachers frequently involved with Sam, they reported that he was ‘extremely challenging’. In the classroom, he was frequently non-compliant, disruptive and argumentative. Based on past attainments, he was considered to be underachieving. Outside of the classroom he was often in trouble for breaking school rules such as leaving the school grounds, using a mobile phone, smoking and swearing at teachers and peers. When confronted, he would be oppositional, refuse requests and could be aggressive (‘pushing; shouting; intimidating’). Sam had had three suspensions within the preceding six months and any further significant incidents would result in expulsion. It was also felt that Sam’s peers were starting to ostracise him.

 

In the first session Sam presented as disengaged and shutdown. Whilst he freely came to the appointment he provided limited responses to questions and made little eye contact. The therapist asked many questions to establish that he was often in trouble at school and at home and that he ‘hated’ school. Reference was also made to self-doubt, changeable moods and feeling ‘confused’ about who he was. In response to Sam’s presentation the therapist noticed that she was asking a lot of questions and doing most of the talking, including hypothesising answers; that this was different to her normal interviewing style and that it felt ‘authoritarian’, ‘bossy’ and ‘controlling’. This reflection was shared with Sam and he was asked if he had ever experienced others in this way. In response to this, Sam reported that he experienced teachers as ‘forceful and controlling’. In this very early stage Sam was able to articulate that the reciprocal to others being ‘forceful and controlling’ was ‘controlled and attacked’. Procedurally, Sam knew that this led him to ‘zone out’ which meant that he ‘couldn’t think’. Both these roles were mapped out and noted to cause frustration (see Figure 2).

Figure 2. The core reciprocal role and mood state initially described by Sam

 

Establishing diagrammatically, in the therapy very early on, the core reciprocal role by reflecting on the relational dynamic being experienced in the room helped the therapeutic alliance start to develop. Noticing the invitation to take up a forceful and controlling role provided insight into the problems Sam was experiencing at school; namely how Sam experienced others and how others (or ‘the school’) experienced him. Noticing the ‘invitation to dance’ a controlling to controlled reciprocal role meant that the therapist was able to introduce a new reciprocal experience and use an alternative role of ‘gently questioning and encouraging’ to feeling ‘open and encouraged’. This was in recognition of Sam being familiar with the position of feeling controlled and the need to give him a different experience. The aim was to assist Sam in expressing himself in a more flexible way, allowing for a collaborative therapeutic experience; a highly effective concept recognised as being central to the practice of CAT (Kerr, 1999). What was observed was that Sam shifted from his ‘shut-down’, ’zoned out’ state and started to talk. He reported that he found it difficult to articulate what his problems were and that he felt frustrated with himself for not being able to ‘figure them out’. Thinking ‘too hard’ or feeling pressured to provide an explanation further led him to ‘zone out’. It was hypothesised that there was a self-to-self enactment of ‘forceful and controlling’ to feeling ‘controlled and attacked’.

 

Following assessment Sam agreed to contract for six sessions of CAT- informed therapy following which there would be a review and further sessions offered if needed (as per Medicare guidelines). Six sessions were agreed upon as Sam remained ambivalent about engaging in therapy and it was felt that this time-frame would provide Sam with some exposure to therapy (and a good enough experience), allow for a reformulation to be completed, as well as strategies to be explored that followed on from the reformulation.

 

In the second session, mapping was used straight away as it was hypothesised that something visual would assist Sam in communicating his experiences given his response to the diagrammatic representation of the core reciprocal role in the initial session (see Figure 2). The map gave a sense of sharing and collaboration within the room and provided scaffolding around developing a shared understanding of the target problem, leading to a verbal reformulation which initially Sam struggled with. Looking back, this was how the therapist stayed in Sam’s zone of proximal development, a concept that Lev Vygotsky developed about learning (Wertsch, 1985).

 

Development of the Sequential Diagrammatic Reformulation (SDR) was made a priority in the second, and subsequent, sessions. Whilst more traditional CAT focuses on the development of the SDR after the reformulation letter in session four, it has been recognised to be of benefit earlier on in therapy (Ryle, 1997b). In this case, its value was highlighted by Sam’s feedback that he could ‘think more clearly’ when his experiences were being mapped out which was paralleled by the experience of the therapist. Consequently, the reciprocal role procedures (RRPs) and main mood states were established (see Figure 3).

 

In exploring Sam’s early experiences and through having phone contact with Mum, it was hypothesised that Mum compensated for her anxiety about being a good enough parent by being ‘overly strict’. This parenting style was experienced by Sam as ‘controlling’. Sam’s perspective on Dad was that he was ‘good at everything that he did’, expected Sam to be the same and was ‘harsh and critical’ when these expectations were not met. In exploring Sam’s early parenting experiences, we developed an understanding of how his sense of self developed (other- self internalisation), which is depicted in the core reciprocal role in Figure 1. We were able, to talk about how this core reciprocal role is played out in his relationship with himself (self-to-self), with the school and his parents (others-to-self and self-to-others). The sequential diagrammatic reformulation detailed the impact of these reciprocal roles and procedural enactments on Sam, in the form of a ‘sunk low’ mood state (see figure 3).

Figure 3. Sam’s Sequential Diagrammatic Reformulation (SDR) or ‘map’ incorporating the core Reciprocal Role (RR), the Reciprocal Role Procedures (RRP) and Main Mood States being enacted at school

Given the reciprocity between organisations and the individual, and how unhelpful individual procedural enactments can amplify dysfunctional organisational processes (Walsh 1996), the authors started to think about what reciprocal roles existed within the broader school system. Schools must have clear rules and boundaries to function effectively (Victorian Government Department of Health, 2006) yet we wondered if appropriate rules and boundaries would translate into a reciprocal role of ‘authoritative’ to appropriately controlled and containing.

 

Given Sam’s core reciprocal role he was sensitive to authoritarian environments and may have been likely to experience (or misinterpret) authoritative as authoritarian, himself feeling powerless, thus responding oppositionally to gain control and inviting others to become ‘controlling and forceful’. However, Sam wanting (or needing) more control and in trying to move out of feeling ‘trapped’ pulls others to impose more rules and limits, and further contributes to him feeling ‘trapped’ and wanting (or needing) more control. The aim of therapy with this model is to promote self-awareness through mapping these reciprocal role procedures (RRP); or the mechanics of what happens when we move from one relational stance to another. In mapping, it becomes clearer how specific behaviours, thoughts and feelings (or procedures) are intended to provide ‘a way out’ of an uncomfortable (or intolerable) self-state. However, when there are limited internalised reciprocal roles, there are limited reciprocal role procedures (RRP) leading to greater enactment and perpetuation of disruptive behaviours (and confirmation of the restricted stances).

 

Interestingly, Sam identified that he ‘felt better’ when with certain teachers, which led to discussion and reflection about what relational positions were being enacted at these times. It was detailed that the teachers with whom Sam felt that he got along, took a ‘firm but clear and respecting’ role, which allowed him to feel ‘respected and accepted’. When this role was taken, Sam would feel irritated, but found this to be a manageable feeling and that he would usually comply (see Figure 4).

 

Linking back to Walsh, (1996), the SDR (or therapy map) in the case presented here provided a means of understanding the unhelpful relationship that had developed between the individual (Sam) and the organisation (the school). This understanding helped to make sense of how certain situations and interactions were perceived by Sam and the school, and resulted in an escalation of Sam’s disruptive behaviour and the school feeling overwhelmed and imposing ‘harsh’ consequences. The ‘therapy map’ provided a visually accessible means of the problem interactions and allowed Sam, and the school, to take some ownership over the unhelpful procedural loops.

 

At this point in the therapy stage the map was used to increase reflection on what patterns were being enacted and the idea of ‘exits’ was introduced as alternative ways of relating and responding to unhelpful interactions. Ryle and Kerr (2002) state that recognition should be established before attention is directed to revision. However given that Sam was at risk of school expulsion and there was concern about maintaining his engagement in therapy, the notion of exits was introduced early on. It was hoped that identifying some feasible exits would provide Sam with some immediate alternatives, strategies and ways of coping, as well as highlighting the concept of ‘exits’ that could be further built on over time.

Figure 4. Alternative reciprocal role experienced by Sam with some teachers

 

Sam’s goal was to recognise when he was in the ‘controlled and attacked’ position (the bottom pole) and when he ‘came out fighting’ was moving into the ‘controlling and attacking’ position (the top pole). Sam identified the following ‘exits’: complying; negotiating (if appropr- iate); or walking away (if it would prevent an escalation in anger). We also discussed more cognitive-based ‘exits’ such as identifying and chall- enging cognitions, with a theme around control, and identifying coping statements that he could say to himself.

 

The therapy map was shared with two key teachers who were regularly involved with Sam at school. These teachers were also known to be compassionate towards Sam, as identified by Sam and his Mum as being ‘better able to manage him’. Working within the school system there is commonly a divide between teachers who hold a more traditional ‘authoritarian’ perspective on behavioural management and those who are willing to be more dynamic in their management of individual students. Given this, and that the intervention required teaching staff to take a specific relational stance, it was important to engage teachers that would support and become involved in the process. The aim of sharing the therapy map with the identified teachers was to provide an alternative non-blaming reformulation of Sam’s disruptive behaviour. It was well received which was reflected by the acknowledgement of how different responses impacted on Sam’s presentation. This led to further discussion around feasible management strategies (or ‘exits’) which included teachers taking a ‘firm, but clear and respectful’ role. It was further agreed that Sam could walk away (as opposed to being aggressive) with the incident being discussed at a later time, when Sam was less angry (and that he would be accepting of any consequences). These teachers took the role of communicating the ‘management plan’ (via e-mail and verbally) to other teachers who were likely to come into contact with Sam.

 

Over the course of three weeks, the intervention was monitored in session with Sam and through regular discussions with the two key teachers. Sam reported that he was ‘amazed’ that the teachers also had to ‘try and behave differently’ and that they were willing to do this. Acknowledgment of the contextual influence on Sam’s disruptive behaviour and the possibility of more positive ‘other-to-self’ relational experiences enhanced his motivation to engage with the intervention. In these sessions, the focus was on increasing Sam’s recognition skills in relation to the therapy map and to facilitate revision. At the end of session six, the outcome reported by both Sam and the two key teachers was encouraging. Sam had noticed a difference in the way some teachers had approached him and that combined with his growing recognition and ability to ‘take different exits’ meant that a number of situations had been defused. Sam said that he felt more ‘listened to’ and ‘understood’. The number of incidents resulting in Sam getting into trouble had reduced and feedback provided was that Sam had generally presented as ‘less defiant’ when approached.

 

Unfortunately, before further sessions could take place, Sam suddenly left the school. In a follow-up, and final, session that occurred outside of school Sam reported that there had been an incident with a teacher whom he experienced as ‘forceful and controlling’ and that he had felt ‘targeted’ and as a result behaved angrily. Following this incident, he ‘decided to leave’. It was reflected to Sam that this was an enactment of Sam being ‘forceful and controlling’ to himself, but Sam responded that he just did not think he was suitable for school. Sam did not want to engage in further therapy sessions at this time but was excited about new opportunities outside of school. It was left open for Sam to make contact should he want to re-engage in treatment in the future.

Reflection and Discussion

The intervention described above, although brief, showed how the core relational component of CAT translated into practice. This was done primarily through the use of the therapy map by the individual and the system. Walsh, (1996), talked about how developing a sequential diagrammatic reformulation in individual therapy can provide insight into organisational processes and enable a non-blaming approach to be taken. Being able to diagrammatically form a description of the context in which Sam’s disruptive behaviour occurred and the reactions it elicited in others, had a clear impact on the therapeutic process. The CAT framework showed how Sam’s disruptive behaviour was influenced by the school system and that both Sam and the teachers had a role to play through the enactment of an unhelpful reciprocal role and reciprocal role procedure. Sam was increasingly able to reflect on the unhelpful reciprocal role pattern being enacted and how different ways of relating could be explored. The teachers involved were also able to reflect on how different ways of relating could generate different responses and how the school (as a psychological organisation) could influence the psychology of the self (Walsh, 1996).

 

Feedback from the teachers involved was that they ‘liked this approach’. They found the ‘therapy map’ enabled them to more clearly understand the unhelpful reciprocal role procedure being experienced. Further, they were more able to see how Sam’s core reciprocal role procedure was being enacted at school and how the school system’s authoritative role was contributing. It also opened discussions around how Sam had internalised such reciprocal roles, enabling them to hold a less blaming and more compassionate stance when confronted with his disruptive behaviour. On reflection, it might have been therapeutically beneficial to have mapped with the teachers first their experience of Sam, which could have then been integrated into Sam’s map.

 

The therapist had been working at the school for several years and had built up good working relationships with the teaching staff and welfare team which enabled the contextual reformulation to be more readily received. A new professional to the school might further have exacerbated Sam’s unhelpful reciprocal roles by placing expectations on the teachers to engage with the contextual reformulation and try out new ways of relating, triggering resentment and frustration. Instead, it seems as if the positive outcomes of this piece of work came from ‘other to self ’. When the therapy was terminated prematurely, Sam had decided that he did not want to continue psychological work (which was dis- appointing for the therapist) but he did reflect that he found the work helpful, useful and non-blaming. The authors reflected that the piece of work had given Sam permission to leave school and not to have to continue with something that ‘he hated’. If Sam had stayed engaged in the therapy then the next step would have been to write a re-formulation letter and to help Sam increasingly recognise when he (unintentionally) invited others into a controlling pattern (self-to-other).

 

Working within the school system an implicit (or explicit) aim of psychological work is often to improve behaviour at school. With the intervention described here, the CAT process identified the target problem as being that Sam became anxious when he felt controlled. Whilst the focus of this intervention remained around the school, Sam’s Mum reported being more aware of how the ‘authoritarian’ role triggered his disruptive behaviour both at home and school, however there remained tension between what Sam wanted to do and what his parents were willing to agree to. Greater involvement of Sam’s parents in the contextual reformulation and how it related to home may have further enhanced their understanding of his disruptive behaviour, and facilitated different relational experiences at home. Whilst it was outside of the scope of this piece of work, it is recognised that caregiver participation is considered critical for young people with ‘disruptive behaviours’ who are considered to be at high risk of negative outcomes (Lee, 2012).

 

In using a contextual reformulation, it is necessary to consider whether helpful reciprocal roles have been established within and between the organisation, as this will facilitate the therapeutic process. In the case presented here whilst there were teachers who were actively willing to make changes to their relational style to work better with Sam, there were also teachers who were less willing to do this instead believing that the school needed to maintain a core ‘authoritarian’ position which should not be modified for individual students. Given that schools have to manage a large number of young people with varying needs and behaviours, it is an important point to consider and further research in this area could help explore what reciprocal role schools tend to take and whether an appropriate authoritative position is the ideal.

 

In this intervention, it was felt that CAT provided a way of communic- ating that suited the different individuals and organisations involved and reinforced its effectiveness as a case reformulation and consultation model. Given the interface between organisations and individuals (Falchi, 2007; Parry, n.d) there are benefits to using contextual reformulations to better understand challenging relationships within systems. In fact, Falchi (2007) argues that it is necessary to look at the organisation first and the psychology of the individual second. In the case presented here, the reciprocal role concept helped explain why teachers felt and responded differently towards Sam. This clinical example described here suggests that the power position of the teacher-to-student mirrors the parent-child role that is established in a child’s early life; a theoretical concept that is central to CAT (Ryle and Kerr, 2002).

 

Providing contextual reformulation that focuses on role relationships within an organisation has been found to be containing, educational and enabling of communication (Walsh, 1996). It was felt that these things were experienced in the case described here.

 

Given the high rates of oppositional and conduct disorders seen in children and adolescents, the recognised levels of stress caused by such problems and their unresponsiveness to treatment, developing theoretic- al approaches that will assist in their treatment is of great interest (Sawyer, et al., 2001; Victorian Government Melbourne, 2006; Zuddas, 2014). Multi- systemic theory talks about the need for treatment approaches to incorporate systemic level interventions and it is suggested that the relational nature of CAT, with its reformulation tools, can offer something unique to the treatment of disruptive behaviours. Indeed, the contextual reformulation can be used to assist the student and the school in their awareness of unhelpful relationship patterns (and the invitation to enact these) and thus explaining alternative ways of relating and responding to conflict that ensues. Such benefits have implications for enhancing school-based interventions that aim to reduce the impact of behavioural disorders within a school setting (Victorian Government Department of Health, 2006).

 

The application of CAT described here, although short, provides an indication of CAT’s potential when working with young people with disruptive behaviour within the context of the school system. More thought needs to be given to the role of CAT when working with disruptive behaviours within the school system and how this relational model can develop an understanding of unhelpful relationships that are often seen between students and teachers and which are often found in schools with high prevalence rates of behavioural disorders and high rates of suspensions and expulsions (Erford, et al., 2014). Given that there does not seem to have been much written about the use of CAT as an individual therapy model and as a contextual reformulation tool within this context, further psychotherapy research in this area would help establish its effectiveness and be of great benefit.

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