Within CAT, the focus of treatment is on collaboratively developing an understanding of how early attachment relationships have impacted on the individual’s unconscious and subconscious interpersonal and inter- relational expectations, responses and behaviour. Understanding these early relationships and maladaptive responses (problem procedures) and then developing adaptive strategies (exits) to change stuck patterns of relating and behaving, could potentially have an impact on FND symptoms.

 

Accounts and evaluations of using CAT with people with functional neurological symptoms are emerging within the literature. For example, Jenaway (2011) and Jenaway et al (2018) have reported outcomes of CAT treatment for small samples of patients with functional neurological disorders. Although described as medically unexplained symptoms, Jenaway describes functional neurological symptoms such as non- epileptic attack disorder and functional paralysis and spasms, and presents promising initial outcomes using CAT with this client group. Jenaway discusses using the CAT model to understand how early attachment relationships impact on the way an individual relates to themselves, with their body and their physical symptoms. For example, where an individual may have internalised a critical-criticised/demanding- not good enough reciprocal role pattern, they may be pushing the body and ignoring signals to rest, and struggle to respond to their physical needs with kindness and compassion.

 

Some clients whom I have met in the neuropsychiatry clinic, have experienced early abuse and emotional neglect. This often leads to a coping strategy throughout life of being the ‘caring’ other and putting one’s own needs aside. It often feels as though the individual is exhausted from a lifetime of caring and may have not had an opportunity or have developed an internal ‘self to self’ relationship to consider and attempt to meet their own needs. When the FND symptoms begin, often triggered by illness or injury, and perhaps alongside a loss of the role in caring for others, the individual may feel dismissed again by professionals who are unable to provide a clear medical diagnosis for their symptoms. Within their personal relationships, they may find that their loved ones find a way to provide care and support by making demands on the professionals instead. Sometimes the demands for the affected individual to provide care cease, and they can give themselves permission to rest and be cared for.

 

This is a generalised example of the way a reformulation may develop. The reality is that with this client group the functional neurological symptoms, the causes, course and treatment responses vary significantly from person to person. CAT enables the clinician to explore many aspects of the individual’s experience, including early life and their relationships with others, themselves, their symptoms, their body and their experience of the medical professionals (including the therapist). The reformulation is developed collaboratively, creating a dynamic person-centred approach that has the openness, curiosity and flexibility to explore and learn.

 

What follow are two cases to describe in more detail the use of CAT with clients with functional neurological disorders. Both cases are anonymised, and the clients have kindly given their permission to be included in this paper.

 

Case example 1:

Suzy was referred to the neuropsychiatry service with a diagnosis of functional neurological disorder (FND) after many years of physical investigations that were inconclusive. Suzy reported experiencing pain in her back which was as the result of a previous injury, along with acute functional stroke-like symptoms such as slurred speech, facial drooping and weakness on her left side. When I met with Suzy for her initial assessment, she expressed frustration that an organic cause had not been found for her stroke-like symptoms and she insisted that some tests had not yet been performed. In order to progress forward with the therapy, we agreed to keep an open mind about the cause of her physical symptoms and during the initial 3-4 sessions, Suzy continued to meet with the consultant neuropsychiatrist to discuss her concerns.

 

We talked about how growing up, Suzy’s parents were not very affectionate, but she was initially very reluctant to share more about her family. As an adult, Suzy had entered abusive relationships where she experienced her needs being completely disregarded, and she would assume the role of caring for others without support or care in return. She injured her back and then experienced a traumatic incident. The stoke symptoms started at this time and she spent the next year searching for the cause or a diagnosis. Suzy seemed preoccupied with feeling powerless in relation to dismissive and uncaring professionals whom she perceived were withholding important examinations from her and letting her down. In our relationship, I identified with the frustration, feeling that important information about her past was being withheld from our discussions. We talked about how her experiences and responses to the health professionals were reminiscent of her experience of her ex-partner, with whom she also seemed to remain very angry. We also talked about feeling powerless in relation to her pain, and having to accept a lifestyle that didn’t fit with her expectations of herself.

 

We talked about the way that she related to her physical symptoms. She seemed to respond to her back pain with criticism and demanding that she push herself to do more and more until she would be exhausted and collapse in intense pain, spending many days in bed recovering. She would then punish and criticise herself for letting herself and her daughter down, leading to an increase in physical activity when she was well enough to compensate. Thus, the cycle continued.

 

During these initial stages of therapy, Suzy seemed increasingly interested in the formulation and contributed to the development of her diagram. She identified a snag fairly early on in the therapy of – ‘If I accept that my symptoms have a functional cause, rather than a physical one, I will have put my family through years of stress for nothing – if it’s in my head, I could have stopped it ages ago’.

 

When I drafted the reformulation letter there was a sense that I had limited information as Suzy still held on strongly to the belief that her stroke-like symptoms had a physical cause that had not yet been discovered, and she was reluctant to share information about her early life. The reformulation letter was short and full of questions, but upon reading it to Suzy she started to open up more about other aspects of her life that have been difficult, including how she has, throughout her life, felt blamed and criticised by her parents and siblings for ‘failing’ in her relationships, and for the way she parented her daughter.

 

We explored the possibility that Suzy was fighting with the medical professionals in a way that perhaps she felt she couldn’t with her family and ex-partner. We talked through her relationship with herself, her pain, her family and medical professionals. The exits from her stuck patterns included learning to acknowledge and accept her emotional pain, developing her ability to protect herself and assert her needs with her family, and accept a ‘good enough’ life for her and her family, rather than expect the ‘perfect’ life. Understanding the way that functional symptoms develop, and contacting local FND charities, became important to help Suzy develop a more accepting and understanding relationship with her symptoms.

 

At the end of therapy, Suzy reported that she experienced the stroke- like symptoms less frequently and she had ceased the search for a ‘medical diagnosis’. She reported an increase in confidence as a parent and was able to think about what she wanted to do, rather than give in to her family’s demands on her. She reported having more self-compassion, treating her body with more loving kindness and care, which led to an improvement in her experience of pain.

 

Case example 2:

Mary was referred to the service with non-epileptic attack disorder. She had four grown up children living locally whom she saw on a regular basis, and she lived with her husband. She had eight grandchildren, one who was sadly killed at the age of four, knocked down by a car which Mary had witnessed. Mary and her husband were understandably very frightened by the non-epileptic attacks which happened daily. Mary had stopped cooking and did not go out on her own, fearing she would be injured or be vulnerable if she had an attack.

 

Mary had not had any talking treatments before. She identified herself as a mother, who always put her children first. We talked about her early life and she described physical abuse at the hands of her father and witnessing domestic violence, seeing her mother not being able to control what was happening, or protect her and her siblings. Being the eldest and with her mother being in bed with depression often, she became the carer for her siblings. Mary left home as soon as she could and devoted her life to her husband and children. The non-epileptic attacks started after a period of significant stress when her husband had difficulties at work, her daughter had some serious health conditions and her grandson had been killed two years before. Mary’s mother, who lived some distance away, was increasingly frail and unwell and Mary was very worried about her. She had been struggling to visit her though, stating that she was unable to tolerate her mother crying when they parted.

 

Mary was open and curious about the therapy, but found it hard to speak about some things, especially her grandson’s death. We talked about how she had seen her mother appearing weak and unable to protect her, which was terrifying. She recognised how she had vowed not to be weak and vulnerable and so had always been strong and pushed any feelings of vulnerability away. When we explored this, Mary could see how this had affected her. We included on her sequential diagrammatic reformulation (SDR) or map, a ‘protective-protected’ reciprocal role along with a ‘vulnerable/weak-vulnerable/terrified’ reciprocal role. We explored the idea that her strategy of pushing her feelings away to protect herself and avoid the terror of being vulnerable had perhaps predisposed her to developing the non-epileptic attacks, and then the recent series of traumatic events and family difficulties left her feeling as though she was powerless to protect her family. This may have precipitated the development of the non-epileptic attacks. Mary talked about how the non-epileptic attacks had taken control of her life and had become the new terror, and that now she was the one being cared for and protected by her family. This led to further feelings of vulnerability and anxiety, further exacerbating the frequency and intensity of the non-epileptic attacks.

 

In our work, we explored how Mary could both allow herself to be vulnerable safely and allow her mother to be vulnerable but without experiencing the terror. We also explored how she could let go of the caring role in relation to her mother and accept that her siblings could take more responsibility for supporting her, as they lived nearby. Mary visited her mother and was pleased to report that she coped with her mother’s tears and her feelings of responsibility when they said goodbye. Mary also started to allow herself to be vulnerable in the therapy, talking about her grandson and her early relationships with her parents and her siblings. We gradually worked on her allowing herself to be vulnerable with her husband. This involved telling him how she was really feeling, and allowing herself to cry in front of him. This was the stage when the non-epileptic attacks reduced significantly. The final piece of work was supporting Mary to re-build her confidence with cooking and going out on her own. This required some negotiation and psychoeducation with her family, but by the end of the therapy she was more independent, going on public transport to the town to meet friends and cooking meals for her family. Mary continued to accept her family’s need to provide her with care and protection.