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Martin, A., 2024. 'There are days I don't exist': Using CAT to develop a dialogic understanding with parent caregivers of children with severe autism. Reformulation, Winter, p.14-16.
When dialogue ends everything ends…...
Two voices is the minimum for life, the minimum for existence
(Bakhtin, 1984, p. 252)
The purpose of this article is to explore how a CAT dialogic lens can support parent caregivers of children with severe autism to make meaning of their self-experience, in the context of this complex relationship. This paper is written in two parts, printed across consecutive editions of Reformulation. In this first half, I will explore the theory that has enriched my understanding of this work, along with the methodology adopted. The second half of this paper will discuss both findings and themes in more detail.
Although this study pertains to the specific case of severe autism, I have observed that dialogically distorted spaces come into existence in dyads, when the relational capacity of either participant is different or diminished. This might be through brain injury or through organic conditions such as dementia. It could also be experienced more periodically or temporarily through presentations such as dissociation or depression. Any condition that can have a relationally diminishing impact on the self, will consequently be experienced through its echoed disconnection of the other.
My interest in dialogically different relational spaces is both personal and professional. My lovely mother Florence has Alzheimer’s disease. Over the years, as her memory and verbal fluency faded, it was apparent to me that when in her company, I would operate as a relational bridge of sorts, carrying the substance of our relationship because she no longer could. Now that dementia had inhibited her ability to initiate, organize or express desires and needs for herself, I found that my energy would be directed into being an extension of her, helping her to make connections to herself, others and the world around her. I was often struck by the performance burden of this role. While this was meaningful and held her in connection with others and her environment, at the same time, by facilitating this position, I felt that I could not co-exist as an active contributor in the way that I used to. I often felt distressed by the loss of my own self-experience and was aware of how I consciously had to re-orient myself to myself, on parting her company.
In my professional life, I work as a psychologist with severely autistic children and their families. There was something so familiar about my diminishing self-experiences in relation to my mother’s dementia, and the enduring and repetitive experiences of many parents that I was seeing for CAT therapy. The impact on the self of the other’s diminished relational capacity became my focus. Through further study on the IRRAPT course, Bakhtin’s insights were transformative in helping me understand and articulate the contours of this pain and to recognize its location in that liminal inter-subjective space. These were the very tools that I needed to organize and voice these lived experiences.
The title ‘There are days I don’t exist’, is a direct quote from a mother who participated in CAT therapy. This sentence stopped me in my tracks and has stayed with me ever since - it so powerfully depicts the relational and ontological impact of this diminished dialogical space on the sense of self.
A CAT dialogic understanding of self
Mikhail Bakhtin (1895–1975) was a Russian philosopher and literary theorist who proposed dialogism as a philosophical concept concerned with the nature of meaning. This concept, alongside ideas from Vygotsky’s social learning theory were integrated into CAT theory, through the collaboration between Tony Ryle and Mikael Leiman. Language and discourse are seen as the mediums through which social meanings and cultural values, inherent in our interactions, function to construct the self. The aspect of dialogism that was emphasised here was the essential inter-dependent nature of human subjectivity (Hirschkop, 1999) - if one individual is impacted by something, so too is the other. Bakhtin (in Holquist, 2002, p.28) proposed a relational understanding of the emergence of the dialogical self:
‘It is only from the other, I get myself… to forge a self; I must do so from the outside.’
Trevarthen (1980) asserted that infants engage in dialogical relationships with others from their earliest postnatal moments. In typical development, it seemed that the presence of a responsive other functions to confirm the existence of the self. In contrast, the Brazilian psychoanalyst, Fonseca (2009), asserts that in autistic disorders, there is a ‘distortion in the construction of the dialogic space’. She stated that ‘autism involves the systematic avoidance of the ‘not-me’ (i.e. ‘other’) states’, because any intrusion of these ‘not-me’ states accentuate a fear of non-being’. She proposes that autism is essentially ‘an inability to accept and deal with otherness’ (2009, p.250).
A large body of research literature indicates the impact of early intrinsic autistic processes on key relational skills required for dialogic engagement. These are processes such as eye contact and face-to-face interactions (Osterling and Dawson 1994), language and communication skills (Stern 1985), social orientation and difficulties with joint attention (Mundy and Crowson 1997). These all have significant effects on the dyad’s ability to build up a dialogical space for the mutual experience of self and other and for the emergence of the concept (self and other). This consequentially has an impact on the self-experience of the other.
Trevarthen and Daniel (2005) demonstrate the adaptive modifications made by parents in their interactions with dialogically different autistic children. A micro analytic study of infant twins described a father who received no reinforcement for the social, inter-subjective elements of his behavioural attempts to engage his autistic twin, whilst consistently receiving this from the neurotypical twin. The absence of these common, regulated social rewards tacitly affected the father’s rhythms of interaction. With the autistic twin, the father gave up trying to regulate shared interactions in favour of frequent periods of physical stimulation. This suggests that parents may change their interaction styles to stay in relationship with their child.
Fonseca (2009) asserts that the dialogic format implies not just a tolerance of, but an expectation of, the contribution of the other. This is what led Muratori & Maestro (2007 p.97), to conclude that: ‘Classic autism could be the final step of a primary disorder of dialogical self which does not allow simple social behaviours to develop into dialogical competencies.’
I was interested in exploring what happens to the ‘self’ of the parent caregiver when the ‘other’, is, for the most part, non-participative and non-reciprocal, with limited motivation or capacity to engage relationally and socially? How painful it must be to feel an enduring sense of personal irrelevance or invisibility in relation to your own child, whilst at the same time meeting their every need. Were there similar relational positions inhabited that could be formulated into reciprocal roles (RRs)? Potter and Lloyd (2014), advocate for smarter relational responses from staff in their care-giver interactions with severely autistic people. They propose that the ‘relational gap’ is genetically structured, and that staff need to draw upon their empathic resources and skills to ‘carry the full weight of the relationship’. I wondered about the personal cost to the parent caregiver of carrying the relational weight, and what if this experience was already internalised from the caregiver’s formative, childhood RRs?
Bakhtin (cited in Holquist, 2002, p.29) asserted:
‘The materials available for the creation of a self are provided by the other’ and that ‘the more there is of the other, the more there is of the self’’
It seemed to me that when the enduring relational space a parent caregiver inhabits is a diminished dialogic position, it follows that their experience of the mechanism through which their ‘self’ is acknowledged, (i.e., the other), also becomes diminished and that it is therefore also likely that:
The less there is of the other, the less there is of the self……
Methodology
Over the course of two years, eight mothers individually attended 16 or 24 session CAT with presentations including depression, anxiety, and complicated grief. CAT is an integrative psychotherapy model, offering a relational understanding of autism and a dialogic understanding of the self and (autistic) other, helping clients find meaning in their self-experience.
CAT afforded these mothers the opportunity to consider their relational experiences and to explore possible links between historic RRs and current distress, through procedures and learnt ways of being. With their consent, this clinical material was explored through a dialogic theoretical lens, to identify common RRs and maintaining problematic procedures, in the context of chronic caregiving. Like RRs, autism shapes care-giver behaviour and impacts the way individuals experience the positions they inhabit in relation to the other. RRs capture interaction patterns of how an individual relates to others and themselves. It is proposed that autism (like parents perhaps) enforces rather than navigates certain RR patterns.
The second half of this article, published in the next issue of Reformulation, will demonstrate how this proposal was explored, along with the formulation of common RRs in this work.
I am an Irish psychologist working in Dublin who recently completed IRRAPT training and loved every minute of it! I can be contacted at: aoifecatpsychotherapy@gmail.com
References:
Ashton, P. (2018), From the Brink: Experiences of the Void from a Depth Psychology Perspective, New York: Routledge
Bakhtin, M. (1984) Problems of Dostoevsky's Poetics, Edited and Translated by Emerson, C., Theory and History of Literature, Volume 8, University of Minnesota Press: Minneapolis, USA and London, UK
Fonseca, V.R. and Bussab, V.S. (2006), ‘Self, other and dialogical space in autistic states’, International Journal of Psychoanalysis, 87, 439-45
Fonseca, V.R. (2009), ‘The autistic dialogic style: a case of Asperger’s syndrome’, Journal of Child Psychotherapy, 35:3, 250-251
Hirschkop K. (1999) Mikhail Bakhtin, An aesthetic for democracy, Oxford University Press
Holquist, M. (2002). Dialogism: Bakhtin and his World, 2nd Edition Routledge
Kimber-Rogal, N., 2008. Relationships and CAT. Reformulation, Winter, pp.28-29
Mundy P, Crowson M. Joint Attention and Early Communication: Implications for Intervention with Autism. Journal of Autism and Developmental Disorders 1997;6: 653-76
Muratori, F. and Maestro, S. (2007) Autism as the consequence of a difficulty in primary intersubjectivity. International Journal for Dialogical Science, Fall, Vol. 2, No. 1, 93-118
Oppenheim, D., Dolev, S., KorenKarie, N., Sher- Censor, Yirmiya, N. & Salomon, S. (2007). Parental resolution of the child’s diagnosis and the parent-child relationship. In D. Oppenheim & D, Doldsmity (Eds.), Attachment theory in clinical work with children (pp.109-135). New York: Guilford Press
Osterling J, Dawson G. Early Recognition of Children with Autism: A Study of First Birthday Home Videotapes. Journal of Autism and Developmental Disorders 1994: 24: 247-53
Potter, S., and Lloyd J., (2014) ‘Relational Intelligence’, in Lloyd, J. and Clayton, P. (eds.) Cognitive Analytic Therapy for people with Intellectual Disabilities and their Carers, Jessica Kingsley Publishers
Ryle, A., and Kerr, I.B. (2002). Introducing Cognitive Analytic Therapy: Principles and Practice. John Wiley & Sons: England.
Ryle, A. and Kerr, I. (2020). Introducing Cognitive Analytic Therapy: Second Edition, Wiley & Sons Ltd
Stern D.N. (1985) The Interpersonal World of the Infant. New York: Basic Books
Trevarthen, C., (1980) The Foundations of Inter-subjectivity: Development of Interpersonal and Cooperative Understanding in Infants. In Olson, D. (ed.) The Social Foundation of Language and Thought. New York: Norton
Trevarthen, C., & Daniel, S. (2005) Disorganized rhythm and synchrony: Early signs of autism and Rett syndrome. Brain & Development, 27(l1), pp. 25–34