Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health [2 ed.] 0470972432, 9780470972434

Citation preview

Introducing Cognitive Analytic Therapy

Introducing Cognitive Analytic Therapy Principles and Practice of a Relational Approach to Mental Health Second Edition

Anthony Ryle* and Ian B. Kerr

*Deceased

This second edition first published 2020 © 2020 John Wiley & Sons Ltd Edition History John Wiley & Sons Ltd (1e, 2002) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of Anthony Ryle and Ian B. Kerr to be identified as the author of the editorial material in this work has been asserted in accordance with law. Registered Office John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 111 River Street, Hoboken, NJ 07030, USA For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com. Wiley also publishes its books in a variety of electronic formats and by print-on-demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging-in-Publication Data Names: Ryle, Anthony, author. | Kerr, Ian B., author. Title: Introducing cognitive analytic therapy : principles and practice of   a relational approach to mental health / Anthony Ryle and Ian B. Kerr. Description: Second edition. | Hoboken, NJ : Wiley, 2020. | Includes   bibliographical references and index. Identifiers: LCCN 2019058760 (print) | LCCN 2019058761 (ebook) | ISBN   9780470972434 (paperback) | ISBN 9781119695165 (adobe pdf) | ISBN   9781119695134 (epub) Subjects: LCSH: Cognitive therapy. Classification: LCC RC489.C63 R955 2020 (print) | LCC RC489.C63 (ebook) |   DDC 616.89/1425–dc23 LC record available at https://lccn.loc.gov/2019058760 LC ebook record available at https://lccn.loc.gov/2019058761 Cover Design: Wiley Cover Image: © Jose A. Bernat Bacete/Getty Images Set in 9.5/12.5pt STIX Two Text by SPi Global, Pondicherry, India Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY 10  9  8  7  6  5  4  3  2  1

v

Contents List of Figures  vii About the Authors  ix Preface to the Second Edition  xi Preface to the First Edition (2002)  xvii Acknowledgments  xix The Structure of the Book  xxi 1

The Scope and Focus of CAT  1

2

The Main Features of CAT  9

3

The CAT Model of Development of the Self  31

4

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy  55

5

The Practice of CAT: Selection and Assessment of Patients for Therapy  75

6

The Practice of CAT: The Early Reformulation Sessions  95

7

The Practice of CAT: Later Phases of Therapy, Working at Changing and Ending  121

8

The CAT Model of Therapist Activity and of Supervision  141

9

CAT in Various Conditions and Contexts  161

10 The Treatment of “Severe and Complex” Personality-Type Disorders  225 11 The “Difficult” Patient, Contextual Reformulation, Systemic Applications, and Reflective Practice  265 Afterword  283 Glossary  287

vi

Contents

Appendix 1: The Psychotherapy File  291 Appendix 2: Cognitive Analytic Therapy (CAT) Competences for Individuals with Personality Disorder  297 Appendix 3: Personality Structure Questionnaire (PSQ)  311 Appendix 4: Repertory Grid Basics and the Use of Grid Techniques in CAT  313 References  315 Index  351

vii

List of Figures 2.1a  Key formative RR for Bobby. 2.1b  Key RRP enactments. 2.2 Rating sheet for target problem procedure 1 for Bobby. CAT-based sketch of normal development of the Self through healthy early 3.1a  infant-caregiver interactions (RRs) shown here in a ‘nuclear’ family type setting and in a particular sociocultural context. 3.1b Their subsequent ­internalisation as formative RRs within the growing child (by permission Bevan Fidler). CAT-based diagrammatic sketch of damaging and abnormal   4.1  development of the Self. 6.1 Part diagrams: sequences illustrating traps, dilemmas, and snags. 6.2 Types of cores in sequential diagrams. 6.3  (a–c) Beatrice—Self states sequential diagram. (a) Initial depiction of formative reciprocal roles. (b) Mapping of key reciprocal role procedures leading to a similar state of “deep sadness.” One of these involves enactment of a situational RR of ideally loved to ideally loving (c) mapping the outcome of key reciprocal role procedures which reinforce original formative RRs and depicting also two Self states (SS 1 and SS 2) and highlighting a key dialogic voice   using an asterisk. 6.4  (a) Depicts formative reciprocal roles; (b) mapping of most   common coping procedure (effectively a “trap”); (c) further mapping of a “dilemma” leading to a briefly enacted RRP (effectively a “snag”) undermined by a critical voice; (d) depicting possible further RRP enactments (from the parental/culturally-derived pole of his formative RR) toward Self and/or   others. Self states sequential diagram for Rita showing reciprocal roles.   7.1  B, D, and F represent childhood-derived roles which, when   activated by experiences, perceptions, or memories of A, C, or E,   lead to flashpoint X followed by either rage or the dissociated alternative coping zombie state. The consequences of these would be typically “rejection” and having “needs unmet” which in turn would reinforce underlying formative RRs.

26 27 27

33 34 57 106 111

111

115

134

viii

List of Figures 

8.1  Sequential diagram for Grace. 9.1  Simplified SDR/map for Susan showing key formative RR and key RRPs. 9.2  SDR or “map” for Tamara. 9.3  SDR/map for Alan. 9.4  (a) Key formative RRs for Sarah. (b) SDR/map for Sarah. 9.5  The client in the sessions. 9.6  The therapist in the sessions. 9.7  A problematic sequence (RRP) of thoughts, emotions,   and behaviors (a “trap”). 10.1  (a–d) Stages in construction of a stereotypical BPD-type diagram.   (c) illustrates likely dissociated Self states and (d) introduces a description of typical staff reactions around such patients and illustrates a rudimentary “contextual reformulation” (see Chapter 11). 10.2a  Deborah—grid of self-descriptions. 10.2b  Deborah—grid of self–other relationships. 10.3 Narcissistic personality disorder: the two common Self states. 10.4  (a–c) Stages in constructing a stereotypic NPD-type diagram showing   (a) underlying (formative) RRs, (b) typical initial coping RRPs and typical   Self states, and (c) potential Self states, defensive RRPs and (situational) RR enactments, including potentially with staff and others. 10.5 Olivia—sequential diagram (revised and simplified). 10.6 Sam—final Self state sequential diagram (revised and simplified). 11.1a  Schematic patient SDR or map showing (formative)   RRs and consequent RRPs. 11.1b  Schematic rudimentary contextual reformulation showing patient   SDR or map and outline possible therapist and staff team (situational) RR enactments toward patient RRPs. Some of these staff RR enactments   may be derived in part from their own formative RRs. 11.1c  Schematic extended contextual reformulation showing added layers   (like “onion skins”) of interactions arising from possible service context and broader social and political context. 11.2a  Initial description of patient’s formative RRs. 11.2b  Simple contextual reformulation showing patient RRPs and staff team reciprocal (situational) RR enactments and the split between these.   Some of these enactments may have partial origins in   formative RRs of staff. 11.3a  Initial SDR or map for Paula showing her formative RRs. 11.3b  Initial SDR or map showing subsequent RRPs and consequences. 11.3c  Initial SDR or map showing additional tendencies to dissociate or   “fragment” into at least two Self states (broken ellipses). 11.3d  Contextual reformulation showing (situational) reciprocal role interactions between staff and patient with subsequent splits   within staff team. Some of these situational enactments may   have partial origins in staff formative RRs.

151 168 182 193 203 219 220 220

236 240 240 244

246 251 253 270

271

271 272

273 276 276 276

277

ix

About the Authors ­ nthony Ryle qualified in medicine in 1949 and worked successively as a founding A member of an inner city group practice, in Kentish Town, London, as Director of Sussex University Health Service and as a Consultant Psychotherapist at St. Thomas’s Hospital, London. After retiring from the NHS he worked part‐time in teaching and research at Guy’s Hospital. While in general practice he carried out epidemiological studies of the patients under his care and the experience of demonstrating the high prevalence and family associations of psychological distress influenced his subsequent interest in the development of forms of psychological treatment which could realistically be provided in the NHS. Studies of the process and outcome of psychotherapy followed, and from these grew the elaboration of an integrated psychotherapy theory and the development of the time‐limited model of treatment which became cognitive analytic therapy. He died in September 2016. Ian B. Kerr graduated in medicine from the University of Edinburgh. After several junior hospital posts he worked for many years in cancer research. He subsequently completed dual training in psychiatry and psychotherapy at Guy’s, Maudsley, St. George’s, and Henderson Hospitals in London, and with the British Association of Psychotherapists. He worked for several years as Consultant Psychiatrist and Psychotherapist and Honorary Senior Lecturer in Sheffield, UK, and then in NHS Lanarkshire, Scotland, UK. He has been involved in teaching and researching CAT in many settings in the UK and internationally.

xi

Preface to the Second Edition This revised edition is being offered given an evident need to update, expand, and clarify aspects of the first edition which appeared now almost two decades ago, and given a keen wish by Tony Ryle to do this. Our aim was to offer a summary but comprehensive overview of the current evolved Cognitive Analytic Therapy (CAT) model, its background and comparative context, and of its range of applications, that would be informative and helpful to those new to the model, to trainees and even established practitioners. Very sadly however, as many readers will be aware, not long after being commissioned to do this Tony, who was the senior author and progenitor of the cognitive analytic therapy model, developed a serious illness from which he ultimately succumbed in 2016. Summaries of his remarkable creative personality, his career and contributions to the field of psychotherapy and mental health more broadly have been published in various obituaries which are available on the internet and in a special issue published in 2018 of Reformulation the newsmagazine of the Association for Cognitive Analytic Therapy (ACAT) in the UK, also available on-line. One of the critical tests of the achievement of any remarkable, creative, and charismatic character, which Tony certainly was, is the way in which their achievement and any model they may have created survives and prospers subsequent to their death. In this I am very clear, as are many others, that the current CAT model described in some detail in this volume is doing just that and that, given its principles and underpinnings, it should continue to play a major creative and contributory role in the future to human mental health and well‐being in various ways. That this might occur was one of his principal passions and aims. Having said that, like many of us he was recurrently saddened and frustrated by the evident socio‐political direction of the world at large. I am sure his enthusiasm to update and publish this volume despite his illness also related to a hope that the model might in some small way contribute to ameliorating and improving this situation. Certainly, the evolved CAT model seemed to us also to address a global epidemic, including and especially in more “developed” countries, of so‐called mental disorders in a much more radical, thorough‐going, and humane manner than currently dominant, more individualistic and mechanistic paradigms. As such we were sure that if human sense, compassion, and evidence prevail (about which sadly neither author was very confident) CAT will ultimately be able to offer a great deal, including in ways far beyond its use as a model of individual therapy, important as that is, into more clearly systemic and socio‐political domains. These issues and these potential applications are discussed further in the book.

xii

Preface to the Second Edition

However, Tony’s death left the final task of articulating and presenting many of these revisions to myself. These have however all been based on our extended discussions—some quite animated!—and also on our deep, essential agreement about the core of the model and what sorts of revisions needed to be undertaken. These have been also based on initial drafts that we both did and discussed, and on consideration of various review articles and books containing both theoretical and clinical developments that had appeared in recent years and presented and/or approved of by himself (e.g. Ryle et al., 2014, Kerr et al., 2015, Kerr, Hepple and Blunden, 2016; Pickvance 2017; Ryle and Kellett, 2018). Tony was very clear that he wished the revision to proceed on this basis with myself as more active co‐author despite his illness. I believe there is nothing in this volume that was not agreed and decided at least in principle with Tony, although of course its presentation, expansion, and articulation in many cases has fallen to myself notwithstanding our initial drafts. I am, therefore, wholly responsible for any serious deficiencies of content or style related to this. However, I hope that it may still represent an important “staging post” in the development and evolution of CAT in that it represents the last position and views of its creator. This should not of course be regarded as any kind of “final word”; and indeed Tony certainly did not wish this to be the aim. We were both very clear this volume could only represent a re‐statement, expansion, and clarification of Tony’s own views on the development of the model hitherto, aided and abetted in this case by myself. We were clear about the subsequent need to continue developing the model in a further integrative manner, in ways which may prove to be quite counter‐intuitive and unexpected. Nonetheless this re‐ statement may be perhaps an important reference point in that process of the development and of the application of the model by others. We agreed that there was a need for a revised and updated edition for various reasons. These include a proliferation of new understandings over the past couple of decades relating to mental health, treatment for mental health problems or disorders, understandings of psychotherapy, and in relation to the CAT model itself. These developments have occurred in fields as diverse as infant psychology, developmental neuroscience, social psychiatry, through to the social and political sciences, and also developments, for example, in understanding of factors, including common factors, relating to process and outcome in psychotherapy. Since the first edition appeared there has also been a proliferation of innovative and humane uses of CAT, some rather unexpected, for example in work with schools, refugees, police and forensic services, in consideration of broader socio‐political challenges (see e.g. Lloyd and Pollard 2018), as well as for a whole range of mental health problems (see especially Chapter 9). Feedback from and reflection on the first edition made it clear also that some clarification of fundamental theoretical concepts was needed, as well as perhaps a clearer and in places a more helpfully didactic presentation of them. Some confusion and ambiguity have occurred, in retrospect probably largely due to the history and “archaeology” of CAT and its development over many years. This has resulted in certain key concepts like procedures, reciprocal roles, reciprocal role procedures, and even repertory grids, being more predominantly focused on and stressed at different stages in the evolution of the model, and accordingly subtly changing, with these concepts sometimes being used in ambiguous or overlapping ways for these reasons. This evolution and history has undoubtedly caused some perplexity, for example to trainees over the years, and has also undoubtedly affected

Preface to the Second Edition

the way in which practitioners and supervisors, who would have trained at different times, have understood and used these concepts and how they work with the model. Although we are clear that the underpinning, relational, core concepts in CAT have remained consistent for many years, we have therefore revisited these and, we hope, helpfully clarified, amplified, and restated these in the early chapters of this revision. As regards the enduring fundamental core of the established CAT model, Tony clearly felt increasingly that this was still essentially embodied in the “Procedural–Sequence Object– Relations Model” (PSORM) notwithstanding various later refinements and enrichments, for example by Vygotskian activity theory and Bakhtinian concepts of a dialogical self, and by diverse, for example more “here and now,” clinical and other applications. The PSORM of course implies a clear presentation and understanding of early developmental internalization of (formative) reciprocal relationships (reciprocal roles, akin to although differing significantly from internal objects), and an understanding of and stress on how, on this basis, we subsequently develop and enact patterns of coping and responding (reciprocal role procedures). We were both rather concerned that the important interest in more recent years in systemic or “contextual” role enactments in the here and now (including also therefore more “situational” RRs) can potentially lead to loss of focus on deeper, historic internalized RRs and their consequences for the patient or client, given that these are of fundamental importance in clinical presentations and in therapy. Indeed, at times in therapy they may be the sole focus of activity. These issues are again addressed in the early and then later chapters. I have felt rather freer to expand as I saw fit concepts or sections for which I was originally largely responsible, for example consideration of psychotic disorders, “contextual” and systemic approaches, and the clarification and presentation of “Self” as an “organizing construct” within CAT. These have appeared to be of some importance and were developments that Tony also contributed to and fully supported, both in discussion and having read and approved various publications up to 2016—where some of these various changes and clarifications were first mooted. We also both felt the section on sex and gender‐related issues (Chapter 9) needed to be expanded considerably given important developments over recent years in this challenging and complex area, and we have attempted to do this with the assistance of others who are acknowledged in the text. We were both keen to expound clearly the importance of the socio‐cultural and political dimensions of mental health, which is implicit in the model and its applications, notwithstanding Tony’s, and my own, frustration and sadness at many socio‐political developments in the world at large. As therapists we can all too often only bear witness to these and it can feel very hard to influence them helpfully. However, we both felt that a model such as CAT can and should helpfully offer humane and compassionate, while scientifically valid, understandings of mental health and well‐being much more broadly. We have been very clear, therefore, and unapologetic about a need to locate the model in a broader context, both scientifically and clinically but also socio‐politically. We also felt it important to attempt to locate CAT broadly within the extensive field of “brand name” therapies, the distinctions between which, as discussed, are frequently spurious and appear to relate sadly more to professional narcissism, parochialism, and campanilismo. These considerations and views will be evident yet again in this edition, as they were in the first. Hence the book is, and aims to be, more than simply a summary of key features of CAT as a model of therapy and of its applications.

xiii

xiv

Preface to the Second Edition

Having said this, Chapter  9 in this edition, which aims to overview clinical uses and applications of CAT, is considerably expanded given a considerable increase in these, and also given the continuing and often quite acrimonious debate with regard to classification and nosology in the field of mental health. Challenging currently dominant but flawed paradigms (notably those of a largely more individualistic biomedical and/or cognitivist persuasion) and reconceptualizing disorders and how we might help treat them is an important part of what any good and evolving model should offer. However, it is still avowedly not an explicitly “how to” kind of chapter giving detailed descriptions of treatments by various specialist authors. Such a volume or volumes are undoubtedly needed but this was certainly beyond the remit or feasibility of a one‐ or two‐author volume. But even in the writing of this more summary book we have depended greatly on the work and input of others. Tony would have been the first to acknowledge and celebrate the fact that we all stand “on the shoulders of giants” and of many others, and depend on their very various contributions. In a very real, and dialogical, sense there is no such thing as completely original or independent work. Many others who are cited in the text have contributed to the model, its underpinning theory, and its range of applications over the years. By way of example the articulation and presentation of the very first specifically CAT volume was apparently greatly aided and abetted by Professor Glenys Parry, who has continued to be an active champion of the model in different ways over the years since then. At a personal level it has been an honor and privilege to undertake the final work of this revision, although this has also felt to be, perhaps unsurprisingly, a challenging and quite arduous undertaking. In many ways it has felt a weighty responsibility to re‐state and update what was essentially Tony’s life’s work, although the development of the model was assisted increasingly by various others who are cited in the text. It has also inevitably felt a rather poignant and solitary undertaking at times, despite helpful discussion with various current colleagues, in the absence of Tony’s “larger than life,” innovative, critical, and at times impatient presence and input. It would have been good at various moments to have been able to “chew things over” with him as I and many others would have done in the past. This revised edition has unfortunately been delayed by the inevitable distractions and intrusions of life, both personal and professional. This has included, sadly, a protracted but morally unavoidable involvement in campaigning in support of “whistle blowers” in the face of some serious incompetence, victimization, and cronyism within and around the NHS in the UK. But I have also been guilty of some procrastination, a tendency to unhelpful over‐inclusiveness, and aspiring to imagined perfect outcomes; all of this Tony with his talents was much better able to transcend, to “see the wood for trees” quickly, and to express his views articulately—if sometimes very forthrightly! As regards terminology, we have in this revision on the whole, as noted in the previous edition, referred to “patients” rather than “clients,” although we use the term interchangeably. We recognise an increasing tendency and preference among many colleagues, especially non‐clinical, to use the word “client” possibly given some of the arguably paternalistic and disempowering associations of the word “patient.” Possibly in part due to our own medical trainings and background we continue to take a view that the word patient has also an honorable history and associations implying notably a vocational and not essentially commercial responsibility to those who are in distress and are suffering. Indeed, the roots of the word lie in the Latin verb patior (I suffer). In our experience, too, people seeking help

Preface to the Second Edition

from clinicians and other health professionals are not always comfortable with the word client. However, times change and with them connotations and usages of terminology, including of diagnostic “labels” (see Chapter 9), and we recognize it is inevitably hard to know where consensus will lead. We have also in this edition deliberately drawn back from use of the term “intervention” which we felt has become increasingly and excessively used as a synonym for “treatment” or “therapy.” While the word may make some sense as a high‐level, collective descriptive of treatment approaches, it still to our mind carries unfortunate mechanistic and militaristic echoes at best applicable in health care in, for example a “doing to” public health context, but not we suggest as a description of any collaborative, humane, relationally based treatment, far less psychotherapy. Unfortunately, in an era of increasing “commodification” of health care and of staff it also carries for us a quasi‐commercial and mechanical resonance invoked by phrases such as “delivering interventions” which we felt sat uneasily with our therapeutic position and aims. Again, however, we recognize that word usage changes and it may be our views are effectively already superceded and redundant, and that the word already means something different, perhaps regrettably, to a present generation of health care professionals. We both sincerely hoped that this reworked and revised edition would be welcome and helpful to a range of people, both fellow mental health professionals and others, and I hope, despite its delayed and rather complicated coming into being, that this will prove to be the case. I very much hope that it may also contribute in some way to a more meaningfully relational and compassionate moving forward for us all much more broadly. This was, I am sure, another deeply felt aspiration and hope on Tony’s part. Ian B. Kerr—Whangarei, New Zealand–Aotearoa (2020)

xv

xvii

­Preface to the First Edition (2002) This book offers an updated introduction and overview of the principles and practice of cognitive analytic therapy (CAT). The last such book appeared over 10 years ago and was the first systematic articulation of a new, integrative model which had been developed over a period of many years. Although there have been two specialist volumes since then (Ryle, 1995, 1997a) it is significant that a restatement of the model and its applications is now necessary. There are many reasons for this. They include the fact that as a young, genuinely integrative model (as acknowledged in the influential Roth and Fonagy report (1996)), it is still evolving and developing both in terms of its theoretical base and its range of applications. In this book, a further exposition of the CAT model of development is given, stressing in particular an understanding of the social formation of the self based on Vygotskian activity theory and Bakhtinian “dialogism.” We also outline an ever‐expanding range of practical applications of CAT as an individual therapy as well as its application as a conceptual model for understanding different disorders and informing approaches to their management by staff teams. This trend has been described (Steve Potter) as “using” CAT, as opposed to “doing” it. Newer or preliminary applications of CAT reviewed here include CAT in old age, with learning disabilities, in anxiety‐related disorders, in psychotic disorders, CAT for self‐ harming patients presenting briefly to casualty departments, CAT with the “difficult” patient in organizational settings, and CAT in primary care. In part these also reflect theoretical developments of the model which are also reviewed. Its gradually expanding evidence base is also reviewed, along with some of the difficulties, both scientific and political, inherent in research in this area. CAT evolved initially as a brief (usually 16‐session) therapy. This was partly for pragmatic reasons and related to the search for the optimum means of delivering an effective treatment to the kind of patients being seen in under‐resourced health service settings. However, it also arose from consideration and evaluation of which aspects of therapy, including its duration, were actually effective. This aspect of research is fundamental to the model and continues to be important in its continuing evolution. We suggest, incidentally, that a brief treatment like CAT, within the course of which profound psychological change can be achieved, genuinely merits the description of “intensive” as opposed to much longer‐term therapies usually described as such, which we suggest might better be called “extensive.” Despite the effectiveness of brief CAT for very many patients, it is clear that not all patients can be successfully treated within this length of time. However, it is also evident from some very interesting work, with, for example, self‐harming patients but also less

xviii

Preface to the First Edition (2002)

damaged “neurotic” patients, that effective work can also be done in a few, or even one ­session. The length of treatment has thus been modified to adapt to the needs of differing patients. Longer‐term therapy may need to be offered to those with severe personality disorder, longstanding psychotic disorder, or those with histories of serious psychological trauma. Thus, there will be some patients for whom the reparative and supportive aspect of therapy over a longer period of time may be an important requirement. Similarly, more extended treatments may be offered in settings such as a day hospital, where the treatment model may be informed by CAT, as an alternative to offering it as an individual therapy. A further reason for the present book is the ever increasing popularity of CAT with mental health professionals and the demand from trainees and others for a comprehensive but accessible introduction to it. The rapidly increasing popularity of CAT with both professionals and patients is, we feel, a further indication of the effectiveness and attractiveness of the model. In part, we see this popularity as arising from the congruence of CAT with the increasing demand for “user participation” in mental health services; the explicitly collaborative nature of the model offers and requires active participation on the part of the client or patient. This “doing with” therapeutic position, in addition to being demonstrably effective, appears to be very much more appropriate and welcome to a younger generation of trainees and potential therapists. This “power‐sharing” paradigm has overall, in our view, radical implications for mental, and other, health services. The CAT understanding of the social and cultural formation of the self also highlights the role of political and economic forces in the genesis of many psychological disorders. The external conditions of life and the dominant values of current society, internalized in the individual, are seen as active determinants of psychological health or disorder. Recognizing this, we suggest that, as therapists, we should strive to avoid describing psychological disorders as simply “illnesses” and should also play our part in identifying and articulating whatever social action may be called for in response. The book is the result of the collaborative work of two authors who share responsibility for the text. Our contributions were different, in part because AR was the initiator of the CAT model and has a much longer history of writing about it. In so far as this conferred authority it also risked complacency which, he felt, needed to be challenged. IK brought a more recent experience of psychiatry and psychotherapy in the NHS, reflected in particular in the discussion of psychosis and of the “difficult” patient and contextual reformulation. He also wished to emphasize the importance of a full bio‐psycho‐social perspective. Our longest and most fruitful arguments were involved in writing the theoretical Chapters 3 and 4.

xix

Acknowledgments We should like to thank the many colleagues and patients who have contributed material to this book and who have been named in it. There are also innumerable others who have made important contributions to its production, directly and indirectly, both recently and over a period of many years. They are too many to name but we should like to express our gratitude to them collectively. Some of these contributions are referenced, although given editorial constraints we have been able, regretfully, only to cite books and peer‐reviewed publications, and material that was directly relevant to points being made in the book. We apologize to colleagues for omissions or oversights which will inevitably have occurred; however, our aim was not simply to undertake a comprehensive collation of all CAT‐related publications. This will be an important task for more specialist review literature and multiauthor books on CAT subsequently. We would like to acknowledge the support provided by the staff at John Wiley and, in particular, the early encouragement offered by Michael Coombs who commissioned the first edition, the subsequent support (and patience!) offered by Darren Read during the initial stages of this revision which he commissioned, and subsequently helpful assistance by freelance copy editor Caroline McPherson and, during the production stages, by Rahini Devi Radhakrishnan, under the strategic eye of Darren Lalonde overall. Finally, we should like to thank our partners Flora and Jane for making, in various and important ways, the writing of this book possible.

xxi

­The Structure of the Book Chapters 1 and 2 will give a brief account of the scope and focus of CAT and how it evolved and will spell out the main features of its practice. Most of CAT’s relatively few technical terms will appear in these chapters; they and other general terms which may have a different meaning in CAT are listed in a glossary. In order to flesh out this introductory survey and give readers a sense of the unfolding structure of a time‐limited CAT, Chapter 2 also offers a brief account of a relatively straightforward therapy. Chapters 3 and 4 consider the normal and abnormal development of the self and introduce the Vygotskian and Bakhtinian concepts which are part of the basic theory of individual development and change. Subsequent chapters describe selection and assessment (Chapter  5); reformulation (Chapter 6); the course of therapy (Chapter 7); the “ideal model” of therapist interventions and its relation to the supervision of therapists (Chapter 8); applications of CAT in various patient groups and settings (Chapter  9) and in treating personality‐type disorders (Chapter 10); and the concept of the “difficult” patient and approaches to this problem, including the use of “contextual reformulation” and use in “reflective practice” (Chapter 11). Each chapter commences with a brief summary of its contents and includes suggestions for further reading and references to CAT published work, and to the work of others. In addition, Appendix 1 contains the CAT Psychotherapy File, Appendix 2 the summary of CAT competences extracted from Roth and Pilling (2013), Appendix 3 contains the Personality Structure Questionnaire, and Appendix 4 a description of repertory grid basics and their use in CAT. Case material derived from audio‐taped sessions is used with the permission of both patients and therapists; we gratefully acknowledge their help. Other illustrative material is either drawn from composite sources or disguised in ways preventing recognition. We have, on the whole, referred to patients rather than clients, although in this book we use the term interchangeably.

F ­ urther Information Further information about CAT and about the Association for Cognitive Analytic Therapy (ACAT) in the UK may be obtained from the website www.acat.me.uk in the UK, from local associations in other countries, and/or through www.internationalcat.org.

Introducing Cognitive Analytic Therapy

1

1

The Scope and Focus of CAT S ­ ummary CAT evolved as an integration of cognitive, psychoanalytic, and, more recently, Vygotskian and Bakhtinian ideas. It is characterized by a predominantly relational understanding of the origins of patient problems and symptoms and an explicitly empathic, pro-active, and compassionate therapeutic stance, with an active focus on issues arising within the therapeutic relationship. From the beginning it has emphasized genuine therapist–patient collaboration in creating and using descriptive reformulations of presenting problems. As such it offers a respectful, whole-person, “transdiagnostic” approach that represents a challenge to many prevalent “diagnosis”-led services. The model arose from a continuing commitment to research into effective therapies and therapy integration, and from a concern with offering appropriate, time-limited treatment in the public sector. Originally developed as a model of individual therapy, CAT now offers a general theory of development and psychotherapy with applicability to a wide range of conditions in many different settings and in various “contextual” and ­systemic approaches. In order to locate cognitive analytic therapy (CAT) in the still expanding array of approaches to psychotherapy and counseling and to indicate the continuing developments in its theory and practice, its main features will be briefly summarized in this introductory chapter.

­CAT Is an Integrated Model One source of CAT was a wish to find a common language for the psychotherapies. While there is a place for different perspectives and different aims in psychotherapy, the use by the different schools of ostensibly unrelated concepts and languages to describe the same phenomena seems absurd. It has resulted in a situation where discussion is largely confined to the parish magazines of each of the different churches or to the trading of disparaging insults between them. Despite the growth of interest in integration and the spread of technical eclecticism in recent years, the situation has not radically altered. CAT remains,

Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, Second Edition. Anthony Ryle and Ian B. Kerr. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

2

The Scope and Focus of CAT

we suggest, one of the few models to propose a comprehensive theory that aims to address and integrate the more robust and valid findings of different schools of psychotherapy as well as those of related fields such as developmental psychology and infant observational research, neuroscience, epidemiology, and sociology. The process of integration in CAT originated in the use of cognitive methods and tools to research the process and outcome of psychodynamic therapy. This involved the translation of many traditional psychoanalytic concepts into a more accessible language based on the new cognitive psychology. This led on to a consideration of the methods employed by current cognitive-behavioral and psychodynamic practitioners. While cognitive-behavioral models of therapy needed to take more account of the key role of human relationships in development, in psychopathology, and in therapy, their emphasis on the analysis and description of the sequences connecting behaviors to outcomes and beliefs to emotions made an important contribution. Psychoanalysis overall offered three main important understandings, namely its emphasis on the relation of early development to psychological structures, its recognition of how patterns of relationship derived from early experience are at the root of most psychological distress and difficulty, and its understanding of how these patterns are repeated in, and may be modified through, the patient– therapist relationship. Neither cognitive nor psychoanalytic models, however, appeared to acknowledge adequately the extent to which individual human personality or the “Self” is formed and maintained through relating to and communicating with others and through the internalization of the meanings developed in such relationships, meanings which reflect the values and structures of the wider culture. In CAT, the Self is seen to be developed, constituted, and maintained through such interactions.

­CAT Is a Collaborative Therapy The practice of CAT reflects these theoretical developments. It has been suggested that, in contrast to the traditional polarization of health care professionals between those who are good at “doing to” their patients (e.g., surgeons and perhaps some behavior therapists) and those who are good at “being with” their patients (e.g., many dynamic psychotherapists or nurses involved in long-term care), the CAT therapist aims to be good at doing with their patients (Kerr, 1998a). This highlights the fact that CAT involves hard work and commitment for both patients and therapists, and also the fact that much of this work is done together and that the therapy relationship itself plays a major role in assisting change. The ways therapists interact with and describe their patients is important for the quality of the therapeutic relationship and transcends the “application” of any particular technique. Any techniques used, and how they are employed, must convey human compassion, acknowledgment, and value. CAT therapists therefore encourage patients to participate, possibly in ways that are challenging, to the greatest possible extent in their therapies. For many patients this may in itself represent a quite new, or previously “forbidden,” experience. Such a therapeutic approach may also feel unfamiliar and uncomfortable for many

­CAT Evolved from the Needs of Working in the Public Sector and Remains Ideally Suited To I  3

health care professionals. Therapists have usually learned helpful ways of thinking and being and are, in some sense, experts in activities that parallel parenting or teaching. But  our patients are not pupils or children and their capacities need to be respected, ­empowered, and enlarged through the joint creation of new understandings, challenges to  longstanding assumptions, acquisition of new “coping patterns,” and through a new relational experience.

­CAT Is Research Based The historic failure of psychodynamic therapists to evaluate seriously the efficacy and effectiveness of their work and their resistance to doing so, partly for understandable reasons, led in the past to a lack of serious support in the NHS (National Health Service) in the UK for therapy in general. It appears also to have contributed, paradoxically, to the current frequently indiscriminate and uninformed application of an “evidence-based” paradigm, important as evidence is, that is crude and problematic given the multidimensional complexity of mental disorder and treatments for it, and also given the increasing recognition of “common factors” in effective therapies and treatments (Castonguay & Beutler, 2006; Gabbard, Beck, & Holmes, 2005; Greenberg, 1991; Lambert, 2013; Norcross, 2011; Parry, Roth, and Kerr, 2005; Roth & Fonagy, 1996; Wampold & Imel, 2015). The outcome research that led on to the development of CAT pre-dated these developments, originating in a program dating back to the 1960s that aimed to develop measures of dynamic change. While the “formal” research base for CAT remains relatively slender (Calvert & Kellett, 2014), the evolution of the model over the last 30 years has been accompanied by a continuous program of largely small-scale but important research into both the process and outcome of therapy, and also the use and evaluation of CAT in contextual or consultancy type approaches, and this continues on an expanding scale. In addition, a number of more “formal” randomized controlled trials have been successfully undertaken in recent years, notably for “borderline personality”-type disorders (see Chapter 10). One consistent research finding has been the apparently superior effectiveness of CAT in engaging “difficult” or “hard to help” patients’ of whatever diagnosis, and retaining them in treatment (Calvert & Kellett, 2014).

­ AT Evolved from the Needs of Working in the Public Sector C and Remains Ideally Suited To It Despite the proliferation of treatment models, a considerable proportion of psychologically distressed and damaged people in the UK (and in most other “developed” countries, let alone in the “developing” world) do not have access to effective psychological treatment. It should, however, be noted that Western models of mental disorders and treatment, of whatever kind, are certainly not applicable without considerable re-conceptualization in different socio-cultural contexts worldwide. In many socio-cultural settings, psychological distress or disorder will be conceived of and responded to quite differently, or indeed not

4

The Scope and Focus of CAT

in  “psychological” terms at all. However, the concept of the socially constituted Self underpinning CAT, and its collaborative approach to meaning-making, may enable the model to be used flexibly and helpfully in these other contexts (see Chapter 9). Emerging experience with CAT around the world has certainly been encouraging (see Chapter 9). Meantime CAT, by providing a therapy that can be offered at reasonable cost, while being effective across a wide spectrum of “diagnoses” and a wide range of severity, is making a contribution to meeting the needs of many patients in many, although significantly not all, Western countries. Most CAT therapists in the UK and elsewhere have worked in the NHS, or public health services, as nurses, occupational therapists, social workers, psychologists, or psychiatrists. We are, for the most part, experienced in, and largely committed to, work in the public sector. We share a social perspective which assumes that psychotherapy services should take responsibility for those in need in the populations we serve, and should not be reserved for those individuals who happen to find (or buy) their way to the consulting room. It does, however, appear, not surprisingly perhaps, that CAT is becoming a popular model of therapy in the independent sector where, in some countries more than others, many therapists make their living, and may offer an important provision of treatment. Here, its time-limited but radical “whole-person” approach appeals to many clients who may have, possibly serious, psychological difficulties. As a model of brief therapy it is of course, for very different reasons, attractive to health insurance companies. Our own social perspective and sense of commitment is not new. The following description of the NHS was sent to demobilized servicemen in 1950: “It will provide you with all medical, dental and nursing care. Everyone, rich, poor, man, woman or child, can use it or any part of it. There are no charges except for a few special items … But it is not a charity. You are all paying for it, mainly as taxpayers and it will relieve your money worries in times of illness” (quoted in Wedderburn, 1996.) Despite the chronic underfunding of mental health services and of psychotherapy in particular, both in the UK and elsewhere, we believe that these principles can still be fought for and that CAT can contribute to their realization.

­CAT Is Time-Limited CAT is undertaken with an explicit focus on time limitation (not simply brevity), and on what we have previously described as “ending well” (Ryle & Kerr, 2002). “Ending” from a CAT perspective will be described more fully below in Chapters 2 and 7. Typically, however, an initial CAT therapy contract would be for 16–24 sessions, given that for many such a period is clearly clinically effective. A focus on time limitation also helps maintain focus and addresses the major problem of therapeutic “drift,” or creating an unhelpful dependency on the part of the patient, or indeed a mutual, ongoing narcissistic gratification for both therapist and patient. In CAT, “ending well” is seen, therefore, as an important aim in itself. However, therapy may need sometimes to be extended longer term in treating more disturbed and damaged patients (see, e.g., discussion of “borderline”-type disorders, or psychosis in Chapters 10 and 9). Therapy may also be shorter (e.g., 4–8 sessions) where the threshold to consultation is low, for more focal problems, or for less distressed or less

­CAT Offers a General Theory, Not Just a New Package of Technique  5

­ amaged patients. Some patient groups (e.g., adolescents) may find longer (or indeed any!) d formal therapies hard to engage with, and contracts may need to be modified collaboratively and accordingly.

­ AT Offers a General Theory, Not Just a New Package C of Techniques The book aims to describe and illustrate the methods, techniques, and tools developed in CAT and its underlying theory. While largely concerned with individual therapy, applications and uses in other modalities are considered, as are the wider implications for psychotherapy theory. While some CAT techniques could be incorporated in other treatment approaches (and vice versa), the model and the method involve much more than simply application of a range of disparate techniques. Psychotherapy patients can make use of a great many different psychotherapy techniques and there would be no point in simply offering a new combination of these under a new label. So why do we need theory? One robust finding from psychotherapy research is that therapists employing some clear, credible theory generally do much better clinically (Castonguay & Beutler, 2006; Gabbard et al., 2005; Lambert, 2013; Roth & Fonagy, 1996). And in health care more generally, plausible, humane, and scientifically-based theories are also much more likely to facilitate effective treatments, including those with a major psychosocial component. Another robust finding is that the patient’s perception of the therapist as sympathetic and helpful is associated with a good outcome (Castonguay & Beutler, 2006; Gabbard et  al., 2005; Greenberg, 1991; Lambert, 2013; Norcross, 2011; Roth & Fonagy, 1996; Wampold & Imel, 2015). In one important recent study, the strength of the therapeutic alliance in working psychologically with patients suffering from psychotic disorders was noted to be the key predictor of outcome, including prediction of adverse outcomes in association with a poor therapeutic alliance (Goldsmith, Lewis, Dunn, & Bentall, 2015). This being so, a major part of any therapy model must be concerned with how to achieve this and achieve a strong “therapeutic alliance,” given that the central problem for many patients is that they are often unwittingly damaging or disruptive in their personal relationships and, mostly for very good reasons, are mistrustful and possibly destructive of offers of help from others. Working successfully with these enactments is never easy but becomes increasingly important and difficult as more disturbed patients are considered. Being helpful means more than being nice, indeed it may frequently involve being very challenging. However, in CAT this would always be undertaken in a benign, non-judgmental manner, even when clearly drawing attention to the unhelpful consequences or effects of problematic enactments on others, including on the therapist. This would be undertaken always with at least implicit reference to previously agreed reformulations (maps and letters). This also has the effect of depersonalizing and externalizing (or “defusing”) any problematic enactment beyond the immediacy of the therapy relationship and, hopefully, restoring a collaborative dialog. Such therapist “challenges” would be undertaken, therefore, in the context of, and contribute toward, a positive therapeutic alliance. This is aided in turn by working through and resolving such potential ruptures (“tear and repair” episodes) by means of the tools and the relational style of the therapy (see Chapters 2 and 8).

6

The Scope and Focus of CAT

A crucial quality required, therefore, is to respect the patient enough to be honest. Techniques need to be understood in relation to the complex human issues that are at the heart of therapy. Those used in CAT, whether adapted from other approaches or specific to CAT, have, as their main aim, the development of the patient’s capacities to know, reflect on, and ultimately control and replace unhelpful and distressing thoughts, actions, and experiences, and to benefit from the internalization of a benign, healing therapy experience. Other tools and techniques are designed to maintain the therapist’s adherence to the methods and values of the approach (see Chapter 8). These provide a framework within which a sincere and often intense working relationship can flourish. Practice embedded in theoretical clarity must be combined with accurate empathy and compassion if therapists are to be able to reach and maintain an understanding of their patients’ experiences and at the same time be fully aware of their own role in enabling and encouraging change. These may also assist in the inevitable dangers of collusion, whether with a patient in therapy, or with pressures imposed by the context of service provision. The latter may include, for example, pressures to get through waiting lists, avoid risks, or to achieve immediate, but frequently superficial, clinical “results.”

­CAT Has Applications In Many Clinical and Other Settings Overall, CAT by now offers, in our view, a robust, comprehensive framework within which various helpful clinical treatments may be offered, and which also offers a means of reconceptualizing many challenging problems (e.g., dementia, the “difficult” patient, “personality disorder,” psychosomatic disorders, psychosis, and so forth; see Chapters 2 and 9). We note that, inevitably, further major conceptual and clinical challenges exist for CAT, as for any other current model, some of which are addressed elsewhere in the book. This book is primarily addressed to those in training or already working therapeutically with psychologically distressed or disturbed individuals, but also to those colleagues who, while not “doing therapy,” have important clinical and other (e.g., managerial, judicial) responsibilities. We believe that psychological and relational understandings should play a larger part than is now the case throughout health services, such as the NHS, and beyond. This would include management of groups such as psychiatric patients with major mental disorders, forensic patients, the “mentally handicapped” or “intellectually disabled,” and also, for example, in schools and in other social settings (see Chapter 9). We believe that psychotherapists should ideally play a central role in supporting and training staff in these fields. In all these fields experience is accumulating of applying CAT, and the model appears to be accessible and useful to many patients and clinical staff (see Chapters 9 and 11). While both psychodynamic therapies and cognitive therapy have contributed historically to these fields, neither, in our view, adequately conceptualizes or mobilizes the therapeutic power of the relationship between patients and those looking after them in a way that is clear, structured, and, above all, clinically helpful. Importantly, CAT also appears to offer an effective, relationally underpinned, structured, and containing framework within which health professionals frequently feel empowered and “liberated” to enact, properly and safely, the care and compassion that most bring to their work. For many this may be repressed and disallowed in many present day, commodified, and highly defensive health

­CAT Has Applications In Many Clinical and Other Setting  7

care systems (see Lees, 2016; Lowenthal, 2015). Nonetheless, these qualities are recognized to lie at the core of any effective health (or social) care (see Youngson, 2012). We believe that CAT has a major generic contribution to make in these areas, offering a distinct, coherent, and teachable model of social and interpersonal development, interaction, and wellbeing that can enable individuals, staff groups, and services to respond helpfully, rather than react collusively, to their patients, and which may also have important applications outside clinical practice (see Chapters 9 and 11).

9

2

The Main Features of CAT S ­ ummary Cognitive Analytic Theory (CAT) theory focuses principally on the way in which early ­relational, including socio-cultural, experience is internalized in the developing Self as a ­repertoire of (“formative”) reciprocal roles (RRs) and the emergence of “responsive,” “coping” patterns or reciprocal role procedures (RRPs). These are also understood to incorporate internalized values and beliefs. Theory also addresses the ways in which this possibly damaged repertoire of RRs and RRPs is enacted and repeated in current relationships, in self-management, in problematic symptoms, and on the ways in which they may prevent revision of dysfunctional or unfulfilling ways of living. More severe and complex developmental damage may result in a tendency to dissociation and fragmentation of the Self into disconnected Selfstates, with loss of Self-reflective capacity and enactment of frequently extreme and desperate RRPs. Successful therapeutic change is understood in terms of change to these deep structures and processes, and subsequently to socio-relational context. This body of theory has evolved from the earlier Procedural Sequence Object Relations Model PSORM. This was modified by the introduction of Vygotskian and Bakhtinian ideas on the social and dialogical formation of mind and the Self, although it remains the foundation of CAT. The practice of CAT is based, for good theoretical reasons, on a collaborative and empathic therapeutic position. The therapist adopts a whole-person, “transdiagnostic” approach aiming firstly to acknowledge and validate a patient’s presenting problems and story. The therapist aims to make joint sense of these with the patient, and to create, as quickly as possible, a jointly agreed provisional narrative and diagrammatic reformulations (as a letter and a “map”) of their story and of their difficulties. These will aim to describe, non-judgmentally, apparent historic relational origins of RRs, of subsequent, often dysfunctional and symptomatic, RRPs, and the ways in which these may be played out currently, including importantly within the therapy relationship. Therapy subsequently involves describing and helping to revise and change these key RRs and RRPs (seen as “target problem procedures” or “key issues”), and, if helpful, resultant presenting problems (“target problems”), and to help create more fulfilling alternative or modified RRs and RRPs (“exits” or “aims”). Therapy will also aim at gradually making joint sense of, or “working through”, both historic issues and current difficulties in living. This later period of therapy may involve use of complementary techniques such as “no-send” letters, behavioral Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, Second Edition. Anthony Ryle and Ian B. Kerr. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

10

The Main Features of CAT

experiments, “empty chair” work, art or music therapy, or more formal trauma processing work. All of these activities would be undertaken, however, in the context of prior reformulations. Therapy will also aim from the beginning to pick up ways in which the therapist will, inevitably, be implicated in (reciprocate) the frequently distressed or desperate enactments of a patient’s RR repertoire, and how this may lead to misunderstandings or ruptures. A key task of therapy is to address and resolve these, assisted by the jointly agreed “map” and letter. Importantly, the therapy relationship aims to offer a new experience (a new “situational” RR) of being listened to non-judgmentally, contained, and empowered, rather than colluded with or against. This experience is understood to be gradually internalized and healing in itself. For more damaged and distressed patients, this aspect of individual therapy may be important over a longer period. It may also be helpfully complemented or consolidated, depending on context, by other approaches such as group or social therapy. Focus throughout, however, is maintained on time limitation and “ending well.” This is marked by the exchange of summary “goodbye” letters that reflect on therapy and the future from the perspective of both patient and therapist. Therapy would always be undertaken in the supportive context of, at least, peer supervision given the ever-present likelihood of unwitting collusion with the patient’s relational repertoire, and the inevitable risks of professional stress and “burn out.” CAT-based approaches are also being used increasingly to address problematic systemic, organizational, and indeed socio-political dynamics arising both in clinical settings and beyond. This chapter will offer an overview and definitions of the key theoretical concepts of CAT and of the key features of CAT as a model of therapy. We will offer a summary of the historical development of CAT in so far as this is relevant to an understanding and appreciation of the current CAT model. This will include some consideration of other models from which, and alongside which, it has evolved and with which it continues to share certain commonalities (see e.g., Young, Klosko, & Weishaar, 2003; Bateman & Fonagy, 2012; Hayes, Kirk, Strosahl, & Wilson, 2012; Meares, 2012; Leichsenring & Leibung, 2010; and see overviews in Yakeley, Johnstone, Adshead, & Allison, 2016). We shall illustrate the use of CAT with a brief case history, while others will be included later in the book to illustrate different aspects of practice. These will include the extension of CAT into more contextual and systemic settings, group work, and reflective practice. The focus will be principally on individual psychotherapy, given that this is where the initial and most current work has been and is undertaken. Given the evolution of CAT into a, by now widely accepted, “stand-alone” model of development, disorder, and therapy, fewer references to the origins and development of CAT and fewer comparisons with other models will appear in the text than was the case in the first edition of this book. Much about CAT has, however, remained constant, including the aim of providing effective, evidence-based practice to those in need, following the original principles of the National Health Service in the UK, and a recognition of the constraints of publicly funded services. This remains the case notwithstanding the deeply regrettable and increasing commercialization and commodification of health care in recent years in the UK and in many other countries. Although CAT was not defined and named as a separate model until the mid-1980s, it was derived from practice and research carried out over several previous decades. As this pre-history explains many of its current features, this chapter will begin by summarizing these sources. These sections may, however, be reasonably skimmed over by those less ­interested

­Backgroun 

in, or preoccupied by, more detailed aspects of the development of its underlying theory. Further historical and summary accounts of CAT are given by, for example, Denman (2001); Dunn (2002); Kerr (2005); Kerr and Ryle (2006); Ryle and Low (2013); Ryle, Kellett, Hepple, and Calvert (2014); Kerr, Hepple, and Blunden (2016); McCormick (2017); Corbridge, Laura Brummer, and Coid (2017); and Potter (2020).

B ­ ackground Several decades ago, there was hardly any evidence to show whether psychodynamic therapy worked, and cognitive therapy was still at a very early stage. To measure the effectiveness of therapy it is necessary to declare at the start what the aims are. This is a task easily accomplished by behaviorists where aims are defined as the relief of symptoms or modification of behaviors, but more difficult for psychodynamic therapists whose aims are complex and are often poorly articulated, or only emerge in the course of the therapy. One early pre-CAT study was undertaken to address this problem (Ryle, 1979). This involved a careful reading of the notes of a series of completed therapies with the aim of finding out how early in therapy the key problems had been identified. This revealed that most therapies were concerned with only one or two key themes and that these had usually been evident early on, often in the first session. It also showed that much of the work of therapy had been directed to trying to understand why the patient had not revised the ways of thinking and acting which maintained these problems. On this basis, the “dynamic” aims of therapy could be defined early on as the revision of the identified, repetitive, or maladaptive patterns of thought and behavior. Three patterns explaining this non-revision were identified; these were labeled dilemmas, traps, and snags. These patterns would now be understood as varieties of reciprocal role procedures (RRPs)—see below. Dilemmas prevent revision because the possibilities for action or relationships are seen to be limited to polarized choices; the only apparent options are to follow the less objectionable choice or to alternate between them. Traps represent the maintenance of negative beliefs by the way they generate forms of behavior which lead to consequences (usually the responses of others) that appear to confirm the beliefs. In snags, appropriate goals are abandoned or sabotaged, because (or as if) it is believed that their achievement would be dangerous to self or others or otherwise disallowed. Further studies combined ratings of these patterns with the use of repertory grid techniques (Brockman, Poynton, Ryle, & Watson, 1987; Ryle, 1979). (The basic principles of this technique are summarized in Appendix 4 for those interested.) At the start of therapy, patients completed such grids by rating how far a range of descriptions (constructs), partly elicited and partly supplied, were true of a range of elements consisting of significant people. In the case of the dyad grid (Ryle & Lunghi, 1970), the elements are the relationships between the self and significant people. Analysis of such grids provided a number of measures of the individual’s way of construing self and other. Measures that reflected the issues which had been noted clinically and described in psychodynamic terms could be identified, and the changes in these seen to be desirable in terms of the aims of therapy could be specified. Repeating the grid after therapy showed how far such changes had occurred. Through the use of such repertory grids, described in Ryle (1975, 1979, 1980), it became

11

12

The Main Features of CAT

possible to derive measures of change between pre- and post-therapy testing that indicated how far dynamic aims had been achieved. What started as an exercise designed to provide evidence of the effectiveness of dynamic therapy proved to be successful. Outcome research could now be based on identifying and measuring change in patients’ “dynamic” problems, described as patterns of traps, dilemmas, and snags at the start of therapy, and on measuring change in the associated repertory grid measures. But the main effect was incidental to this aim, for this process, which involved explicit, joint work with the patient to identify and describe problems, had such a powerful positive effect on the course of therapy that conventional dynamic therapy was abandoned. The joint reformulation of the patient’s problems became a key feature of what developed into CAT. Clear identification of and agreement between therapist and patient about aims, goals, and objectives is now well recognized as a common factor enabling and predicting successful therapy outcomes (Castonguay & Beutler, 2006; Castonguay, Boswell, Zack et al., 2010; Gabbard, Beck, & Holmes, 2005; Greenberg, 1991; Lambert, 2013; Norcross, 2011; Roth & Fonagy, 1996; Wampold & Imel, 2015).

­The Early Development of CAT Practice The “Psychotherapy File” was developed at this stage and was the first specific CAT tool. A version of this is reproduced in Appendix 1. This is usually given to patients to take away at the end of the first session. It gives explanations and examples of dilemmas, traps, and snags and invites patients to consider which may apply to them; these will be discussed with the therapist at the next session. The File also gives instructions in self-monitoring of mood changes and symptoms, based on cognitive therapy practice, and contains screening questions concerning instability of the self. Positive answers to the latter suggest “borderline” type features. The use of the File introduces patients to active participation in the therapy process and initiates them in the task of learning self-reflection. For many patients it is also reassuring to realize, given that the File exists, that many others must experience similar problems. At this point readers may find it useful to go through the File with a patient, and perhaps with themselves, in mind. Practice diverged from the psychodynamic model and was now based on the active, joint creation and use of the reformulation. Thereafter, historic difficulties, daily life, and the evolving therapy relationship were understood in terms of this reformulation and patients were involved in homework on issues related to recognition and revision of the identified patterns. Self-monitoring of symptoms and behaviors to identify when they were activated contributed to the creation of a written list of target problems (TPs) and underlying target problem procedures (TPPs), the latter in the form of dilemmas, traps, and snags. TPPs (in therapy now often simply described as “key issues”) would now be understood as varieties of RRPs. Changes in TPs and TPPs were rated by patients on visual analog scales and discussed at each session. This procedure was not popular with therapists from psychodynamic backgrounds, but for them and for many patients it served to maintain the focus and to encourage the patient’s self-observation and assist its accuracy.

­The Theoretical

Mode 

Despite the introduction of these “cognitive” practices, the main form of early sessions was exploratory and unstructured and particular attention was paid to “transference– counter-transference” enactments and feelings, and to their relation to the identified patterns. Change in therapy was seen to be the result of the patient’s heightened, conscious, focused ability to recognize and, in due course, attempt to revise the unhelpful patterns, and of the therapist’s ability to avoid colluding with and reinforcing them. In addition, within the framework defined by the descriptive reformulation, a wide range of different techniques might be employed toward the revision of problem procedures and their integration. Several accounts of this early brief CAT work have been given (see, e.g., Ryle, Spencer, & Yawetz 1992). All of these activities would be understood to occur within a benign, collaborative relationship that was implicitly healing in itself.

T ­ he Theoretical Model The theoretical basis of practice was initially formalized in the Procedural Sequence Model (PSM), and this remains an important aspect of CAT. This offered a general model of how  events are responded to, how intentional aims are pursued, and of how revision might or might not occur. The procedure or procedural sequence became the basic unit of description, providing the understandings needed to elucidate repetitive circular patterns of activity, including those problematic ones (dilemmas, traps, and snags) which were not revised. The sequence traces out and describes the following stages: 1) External factors: events, cues, and context. 2) Mental processes: (a) appraising the situation and the possibilities for action; (b) relating these to (possibly conflicting) existing beliefs, values, and aims; and (c) the selection of a response or action plan or role on the basis of predictions of its efficacy and outcome. 3) Action, including playing a role in a relationship. 4) Mental processes: (a) evaluating the consequences of the role or action; (b) confirming or revising the aim and/or the means used. This model (described in Ryle, 1982) was compatible with current cognitive models but offered a more comprehensive and apparently more helpful description of the ways in which problem procedures remained unrevised. Affect, cognition, meaning, and action were seen to be intimately linked and were not studied in isolation from each other and the individual was understood in relation to past and present relationships with others. Many psychoanalytic concepts, including the relation of development to structure, could be restated in these terms. But it differed from both cognitive and psychoanalytic theories in its emphasis on the way in which the individual’s interactions with others constantly reflect and largely maintain their self processes. This basic theory needed further development in order to explain the formation of the self in early life and to clarify the problems in self-management and relationships which are a principal concern of psychotherapy. This initially involved bringing ideas derived from object relations theories into the model. All procedures involve, frequently unconsciously, predicting, or seeking to achieve, certain outcomes. In seeking relationships with

13

14

The Main Features of CAT

another, one plays a role based on the expectation of, wish for, or the attempt to elicit, one particular outcome, namely their acknowledgment and reciprocation (see Ryle, 1985). These procedures were therefore named “reciprocal role procedures” (RRPs) and were ultimately understood to emerge from early reciprocal roles (RRs) experienced with caregivers, siblings, and peers. These RRPs are seen, non-judgmentally, as representing a person’s “best efforts” at coping with frequently challenging or traumatic interpersonal experience. These concepts became of key importance in the revised model—the Procedural Sequence Object Relations Model (PSORM), and this remains the foundation of the CAT model. It should be emphasized that “role procedure,” as used here, implies action linked to memory, meaning, affect, and expectation. The common lay meaning of the subjective experience of playing a role can be understood as a state of mind or state of being. In contrast, the terms RRs and RRPs (see definitions below) describe somewhat more complex theoretical constructs.

­ he Development of a Vygotskian and Bakhtinian T Object Relations Theory By the mid-1980s, the CAT model of self processes therefore incorporated ideas concerning procedural sequences linking internal (mental) and external events, but the origins of these in early development were not clearly described. Current theories appeared unsatisfactory. On the one hand, the dominant object-relations school, largely derived from theory-based speculative hypotheses regarding psychological development based on the psychoanalysis of adults, emphasized innate conflicting, frequently destructive, drives, largely neglected the role of experience, and paid little attention to the expanding body of observational studies of real life, early infant development. On the other hand, simple cognitive descriptions, such as were included in the original PSM, while useful as guides to identifying negative or maladaptive patterns, did not offer an adequate understanding of structure or of their relational developmental origins. The introduction into CAT, initially by Mikael Leiman (1992, 1994a, 1997, 2000), of Vygotsky’s understandings of the social and historical context and formation of higher mental processes and of the key importance in human learning of meaning-making and sign mediation, linked with Bakhtin’s illuminating understandings of the role of interpersonal and internal dialog, allowed a radical restatement of object relations ideas. The theoretical language now referred to RR relationships and accompanying dialog acquired in interaction and meaning-making with caretakers and others, mediated by signs that are used first in outer and then in inner dialog. The theory supported the use of the concrete mediating signs and meaning-making created (partly through the “psychological tools” of diagrams and letters) through the reformulation process in CAT. This relational “mediation” was understood as being the medium of the internalization through which change of the patient’s internal psychological structures and processes could be achieved. These theoretical developments have also been informed and supported by the extensive body of observational and experimental research into infant–caregiver interactions over the past few decades (see Hobson, 2002; Lyons-Ruth, 2008; Reddy, 2008; Stern, 2000; Trevarthen, 2001, 2017; Tronick, 2007; and see also Chapter 3). CAT was now able to move on from the

­The Development of a Vygotskian and Bakhtinian Object Relations Theor  15

traditional psychoanalytic model (or one dominant version of it) of an internal world populated by frequently conflicting “objects” or “part objects” derived from ego and others, frequently driven by endogenous destructive forces, and operating like little “ghosts in the machine.” The emerging CAT model described instead internalized relationships and associated “voices” located within a Self, the structure of which is actually constituted by (as opposed to simply “representing”) these internalized relationships. These have been acquired in activity, interaction, and conversation with others, but are now equally involved in external and internal communication, activity, and control. (A more detailed account of the CAT concept of the Self and its formation is given in Chapter 3.) By this point, the key CAT concepts of “reciprocal roles” and “reciprocal role procedures” reached their current point of evolution and therapeutic application. These are currently best understood as follows (and see Glossary): A Reciprocal Role (RR) is a relational position between Self and other. An internalized (formative) reciprocal role, originating largely in relationships with caregivers in early life, comprises implicit, therefore often unconscious, relational memory, possibly traumatic, and also the emotions, cognitions (including cultural values and beliefs), expectations, and bodily states associated with it. A RR may be associated with a clear specific or general dialogical “voice.” An internalized reciprocal role is understood to comprise the experience of the whole relationship, that is both poles of that subjective experience, both childhood-derived and parent/culture-derived. RRs may be enacted in both “external” interpersonal situations and in “internal” self-management. Being in or enacting a reciprocal role always implies another, or the internalized “voice” of another, whose reciprocation is anticipated, sought, or experienced. A Reciprocal Role Procedure (RRP) is an aim-directed “coping” or “responsive” stable pattern of interaction, with associated emotions, cognitions, and memories, arising out of the experience of formative reciprocal role(s). RRPs are usually long-standing, often unconscious, and highly resistant to change. They determine current patterns of relationships with others and self-management, and may be highly maladaptive, symptomatic, and self-reinforcing. RRPs may be enacted in both “external” interpersonal situations and also in “internal” self-management. RRPs may be described as “traps,” “snags,” or “dilemmas” depending on their configuration. Playing or enacting a role procedure always implies another, or the internalized “voice” of another, whose reciprocation is anticipated, sought, or experienced. Formative RRs are understood to determine and underlie our sense of Self, of Self in relation to others, and also the repertoire of “responsive” (as initially described by Leiman) or “coping” patterns we subsequent develop (“reciprocal role procedures”). Common RRs range from, for example, “properly caring for/loving—properly cared for/loved” at one extreme, through to “emotionally neglecting—emotionally neglected,” or, “abusing— abused” at the other. The actual verbal description of a RR in therapy, however, would be always be negotiated with a patient to whom it must make personal sense. Importantly, the experience or enactment of a RR or RRP always unconsciously anticipates, or attempts to elicit, an expected reciprocal reaction from a historic or current other. In CAT, all mental “activity,” whether conscious or unconscious, is understood (following Vygotsky) to be

16

The Main Features of CAT

rooted in and highly determined by our repertoire of RRs, as is, correspondingly, virtually all human psychological distress and disorder or “psychopathology.” We note an important theoretical and clinical distinction that should be made between early “formative” or developmental RRs that are internalized to constitute aspects of the developing Self, and those “situational” RRs subsequently or currently encountered (e.g., a “benign” therapeutic role, or an adverse “victimizing” role; for example, in a bad marriage, or possibly in a “demanding” or “rejecting” mental health service). One of us (TR) has previously illustrated the idea of such a “situational” RR by the example of a “self—fishmonger” situational RR experienced when shopping for fish! A situational RR could also be experienced (e.g., “teaching–taught”) in a training workshop. However, these situations might also further evoke or trigger other underlying formative RRs (e.g., “criticizing–criticized”). Importantly, these latter situational roles may also gradually be internalized, although evidently very much less fundamentally than formative RRs. Indeed, this is a desired outcome of the therapy relationship itself. In reality, formative and situational roles exist on a spectrum, but the distinction is important especially with regard to conceptualizing the early formation (or deformation) and constitution of the Self. The idea of internalization of relational experience as formative RRs is analogous to the concept of internalized “object relations” (albeit in some very diverse conceptualizations), upon which the PSORM is founded. It may also be important therapeutically when sharing such understandings and their consequences with patients. While clinical experience suggests that formative RRs may be modified and attenuated, in part simply through their naming and recognition and through their emotional processing, they are never entirely negated, and their enactment and re-experiencing may recur under conditions of stress or difficulty at any time. This may be a point worth anticipating with patients, for example close to termination of therapy, or in “goodbye” letters. These differing forms of RRs should be borne in mind and helpfully noted in diagrams (see Chapters 4–6). These key concepts (RRs and RRPs) can be seen as representing, broadly, the “analytic” and “cognitive” aspects of CAT respectively. We note here also that a particular CAT concept of Self, as described in the first edition, has increasingly come to constitute a key “organizing construct” in CAT theory and practice. As such the word has been capitalized to imply a substantive entity used in this particular manner (see Glossary and Chapters 3 and 4 for further explication). Within CAT, the process of development is understood to result in a Self that is subjectively and “objectively” fundamentally different and diverse depending on formative interpersonal and socio-cultural experience. This point has also been made from the perspective of crosscultural psychology and psychiatry (Bruner, 2005; Bhugra & Bhui, 2018; Bhui & Morgan, 2007; Paris & Lis, 2013; Kirmayer & Ryder, 2016) and further elaborated elsewhere from a CAT perspective (Kerr & Ryle, 2006; Kerr et  al., 2015). This developmental process also generates our values and beliefs and our very “felt sense” of individual self, and of relations to others. Indeed, the very notion of an individual self would be inconceivable in most more traditional cultures (see Chapter 3). CAT stresses, therefore, the importance of social and cultural factors in contributing to mental disorder and also in limiting the likely outcome of treatment. These would include, for example, inequality, powerlessness, poverty, unemployment, hopelessness, collective demoralization, and so forth as documented and corroborated by various authors from different fields (e.g., Dorling et al., 2007; Hagan &

­The Development of a Vygotskian and Bakhtinian Object Relations Theor  17

Smail, 1997; James, 2018; Stieglitz, 2012; Trevarthen, 2017; Weich & Lewis, 1998; Wilkinson & Pickett, 2009; Weich, Patterson, Shaw, & Stewart-Brown, 2009). From this perspective, therefore, it is understood that in an important sense there can be no such thing as an “individual,” just as Winnicott postulated with regard to the nursing mother and baby. Rather, the individual is seen also as a dynamic fragment of a social whole, and, correspondingly, individual mental health and well-being can only be considered as part of that overall socio-cultural context. The concept of Self would be currently described from a CAT perspective as follows (see also Chapter 3 and Glossary): The Self in CAT is understood to be a bio-psycho-social entity that emerges through a synthetic or dialectical, semiotically-mediated developmental process involving all these dimensions. It is understood to be characterized by a sense of agency, coherence, continuity, of embodiment, of subjective and reflective awareness, identity, and for some by a sense of spirituality. The structure and function of Self is understood to include and integrate such functions as perception, affect, memory, thinking, selfreflection, empathic imagination, relationality, creativity, and executive function. It is understood to comprise both subjective and experiential as well as observable functional aspects. The Self is also characterized by a tendency both to organize and be organized by experience. It emerges developmentally from a genotypic Self characterized by various innate predispositions, notably to intersubjectivity and relationality, so enabling and needing engagement and interaction with others from the beginning of life. The mature, phenotypic Self is considered to be fundamentally constituted by internalized, sign-mediated, formative interpersonal experience and by dialogic voices associated with it (reciprocal roles), and to be characterized by a repertoire of emergent adaptive, “coping,” or “responsive” patterns of interaction (reciprocal role procedures). Although profoundly rooted in and influenced by early developmental experience, the Self is understood to be capable of a degree of choice and free will. The Self is understood to be dependent on others and on social location for its well-being both during early development and throughout life. It became, however, gradually clear through work with patients with “borderline” personality-type disorders (BPD) that harmonious and consistent mobilization of RRs and RRPs within a well integrated Self does not always occur. This topic will be discussed further in Chapter 10. Many borderline features are best explained as the result of the partial dissociation of the patient’s core RR and RRP repertoire, dissociation being understood in part as discontinuities in, and incomplete access between, different RRs and procedures. This response is understood to occur in the face of extreme adversity, emotional deprivation, or overt trauma. These are seen to result in abnormal development of the meta-procedural system in subjects possibly more genetically predisposed to dissociate (see Chapter 10). This borderline structure is depicted in diagrams by describing separate cores to the diagram indicating what are best described as different Self States (dissociated RRs and associated RRPs). This somewhat clumsy title helps to prevent confusion between the theoretical concept of the Self State and the subjective experience of a state of mind or state of being. At any one time, the behavior and experience of an individual with borderline-type problems is

18

The Main Features of CAT

determined by only one of these Self states. The switches between, and the procedures generated by, these discrete states are mapped in Self-state sequential diagrams (SSSDs) or “maps.” Similar structures are found to some extent in many patients who do not meet full criteria for borderline personality-type disorders (see the case history at the end of this chapter). This conceptualization, implicit in CAT, of increasing degrees of severity and complexity in relation to damage and dysfunction of the Self and its structure and processes represents, we suggest, a more helpful dimensional and “transdiagnostic” approach to the understanding and description of mental distress and disorder.

­The Development of the Basic Model of Practice The habit of showing patients the accounts of their assessment interviews and of writing down the agreed list of identified problems and problem procedures had been established from the beginning as part of the attempt to be as open and non-mysterious as possible. This led on to the present practice of covering the same ground in a reformulation letter addressed directly to the patient. (These were initially referred to as “prose reformulations” to distinguish them from the TP and TPP lists—not because verse was an option!) These letters are reconstructions of the often jumbled and perplexing stories told by patients. They summarize key formative experiences and events in the past and suggest, in a nonblaming way, how the negative patterns learned from early experiences are being repeated, or how alternative patterns developed in order to avoid these early ones have themselves become restrictive or damaging. Working on the basis of the PSORM, the patterns identified as traps, dilemmas, and snags (various RRPs) will be linked to the individual’s repertoire of RRs. In some cases, deriving the dilemmas, traps, and snags from the history and the discussion of responses to the Psychotherapy File can be a helpful way to start the reformulation process. Perhaps more often an immediate reflection on, and possibly initial rough mapping of, the role patterns evident in the patient’s account of early experiences and current relationships, including “in the room” feelings and enactments, may be helpful. This is akin to the approach described by Potter (2017) as “map and talk”. However, ideally the two approaches are mutually complementary.

­ he Development of Sequential Diagrammatic T Reformulation (“Mapping”) The description of problematic sequences is a central aspect of reformulation, but clear verbal descriptions of complex processes can be difficult to construct and remember. With experience, they were increasingly supplemented or replaced by the use of sequential diagrammatic reformulation (SDR). More detailed discussion of the construction of these diagrams or “maps,” with illustrative examples, can be found in Chapter 6. In their simplest form they were flow charts, which may arise from an initial, joint sketch of a patient’s core “subjective self,” linking aims to outcomes and indicating how problem, possibly symptomatic, procedures fail to achieve the intended aim. With the development of the PSORM

­The Development of Sequential Diagrammatic Reformulation (“Mapping”  19

they came to be drawn in a way which demonstrated the generation of problem procedures from the patient’s (formative) RR repertoire, which was listed in a box as the core of the diagram. This activity remains central to the practice of CAT and has the additional powerful effect of validating a patient’s experience and strengthening the sense of working together, and so of the therapeutic alliance. An idea of hierarchy was implicit in the model, in that the very general patterns described in reformulation were seen to be manifested in a variety of detailed actions and roles in everyday life and including in therapy. (The patterns themselves are, of course, generalizations arrived at during reformulation from the consideration of these various detailed examples.) Also implicit was the assumption that procedures were mobilized appropriately in terms of the situation and according to the individual’s aims, through the largely unconscious operation of meta-procedures which also served to link together and harmonize the array of available procedures. Recognizing and describing the RR and RRP repertoire provides a new basis for the patient’s self-reflection and is of particular value in helping therapists to avoid reciprocating (colluding with) the patient’s damaging or unhelpful role procedures. In contrast to most short-term therapies, CAT does not select a limited focus but seeks rather to identify and describe these general, high-level procedural patterns and their underlying relational origins (RRs). Such “strategic” patterns will have been formed by, and will be manifest in, a range of detailed “tactical” behaviors. People are often only dimly aware of these general patterns, which are developed in early childhood. But they are not “dynamically repressed” (that is, their inaccessibility does not have the function of avoiding painful or forbidden memories and desires), and their description and recognition can allow rapid change over a wide spectrum of situations. An essential CAT therapist skill during reformulation is to be good at seeing what overall patterns are suggested by detailed events or repetitions. Discussing with a patient whether a particular episode is an example of a more general pattern nearly always elicits parallel examples which may confirm or modify the pattern. Verbal or diagrammatic descriptions of these patterns should ideally be made in joint work using, as far as possible, the patient’s own words and images. These are essentially descriptions abstracted with the therapist’s help from the patient’s witnessed or reported strategies. It is often possible to identify the repertoire without discussing early developmental history in any detail, although therapists may make suggestions such as, for example, “do you think this pattern might come from your relationship with your father?” or, “it sounds from what you say as if these early experiences left you feeling unworthy and only lovable if you were always there for others”? The recollected patterns of interaction in the childhood family (even though their historical accuracy may be uncertain) are often the clear precursors of key current procedures. However, many important relational experiences in the first few years of life, including possibly in utero, occur pre-verbally and long before the ability is developed to lay down recoverable memories. Nevertheless, these will also be internalized and incorporated (literally), often at a deep level, psychologically, neuro-biologically, and bodily, with important implications for therapy (see Cozolino, 2014; Corrigan & Hull, 2018; Gantt & Badenoch, 2013; Kerr et al., 2015; Northoff, 2014; Panksepp & Biven, 2012; Schore, 2012; Siegel, 2012; and see Chapters 3, 4, and 6). The aim of historical inquiries is not, therefore, to literally reconstruct the past, nor to blame those involved, so much as to explore what conclusions have been drawn from it. These may be

20

The Main Features of CAT

based on partial or distorted memory but are seldom pure fantasy. CAT therapists base their comments on what can be seen or has been reported; they do not offer interpretations of a, possibly autonomous, “unconscious.” However, comments like “you seem to finish up acting as if everyone is bound to leave you” might well be appropriate. The vast majority of relevant mental processes are unconscious, but claiming to know what the patient could not know, as in so-called “deep” interpretations, plays no part in CAT practice. Such interpretations are likely to be reflections of (dubious) theory at least as much as they are linked to the patient’s processes.

­The Course of Therapy Initial Phase The “phases” of therapy in CAT are seen as broadly conceived and will overlap considerably. They are not seen as completely separate compartments of a manualized approach, which CAT would see as unresponsive, dialogically inappropriate, and unhelpful. That said, by the end of the first few sessions a sequential model of problem procedures and a narrative reconstruction of their origins in the reformulation letter and map will usually have been jointly constructed and recorded. This may depend on, for example, the distress, disturbance, or distrust and wariness (seen as a RRP) of the patient, and correspondingly on the development of the therapeutic alliance. Paradoxically, with very distressed, disturbed, or angry patients it can be extremely helpful and containing to attempt to jot down a few words on paper almost immediately to acknowledge, validate, and capture some of the patient’s current distress and its possible relational origins. Ideally, reformulation, and mapping in particular, should be seen as an ongoing part of the therapy dialog and not something that involves stopping therapy to undertake separately (see also Potter, 2017). Some therapists may feel more comfortable than others in working in this way, although it is also a clinical skill that can be acquired through experience. It may well be the case that therapeutic work on underlying RRs and their possibly traumatic context may not be desirable or possible at this stage (see, e.g., Carradice, 2013). But noting and acknowledging a patient’s broad subjective formative experience or “story” is usually extremely helpful, especially around a so-called “difficult” patient (see also Chapters 10 and 11), and should always be an early aim. This demanding and often intense phase, culminating in explicit narrative and diagrammatic reformulations, usually creates a strong working alliance. As patients feel understood and “contained” by the reformulation, they are frequently able to recall memories and experience feelings that have been muted or denied. Such memories, feelings, or dreams may be supplemented by biographical writing or other forms of exploration such as drawing. Direct challenges to problematic or avoidant behaviors are seldom called for, and the phrase “coping strategy” or “coping pattern” is preferable to the potentially pejorative word “defense”. Symptoms, mood swings, and unwanted behaviors which had been monitored since the first session are increasingly understood in terms of their relation to the identified procedural patterns which are in need of revision. At this stage, the need to recognize problem procedures as they are manifest is emphasized, and the focus of routine self-monitoring and diary keeping may shift from recording symptoms or

­The Course of Therap  21

moods to the identification of enacted problem RRs and RRPs. The classic “three Rs” of CAT are, in order, Reformulation, Recognition, and Revision. It is important to establish recognition before directing attention to revision, for one cannot reflect on or try to change that which has not been identified. It is also likely to be collusive, and reinforcing of formative RRs, to work simply on symptoms and behaviors. This early reformulation phase may in itself constitute an adequate basis for subsequent care planning, “team working” with and around a patient. It may also represent an adequate, “stand-alone” form of mini-therapy that may be powerful and helpful. This constitutes an increasing use of and application of CAT for whose effectiveness clinical evidence is accruing (see Chapters 9–11).

Mid Phase Following the more active and exploratory work of reformulation, the mid phase of therapy is characterized by a more open position in relation to the issues that the patient may spontaneously bring or which may gradually emerge. These may relate to problems in living in the “here and now” (for example, in relationships or at work), or may relate to historic issues from the past (for example, unresolved grief or losses, remembered experiences of severe relational adversity, or overt trauma and abuse). Some of these may possibly not have emerged in the early sessions and reformulations, or may have been provoked and facilitated by them. This phase represents an opportunity to discuss, process, and “work through” these various issues. During this phase, it is important that the therapist maintains focus and activity on the agreed aims of therapy (e.g., identifying and working on TPPs), but is also able to be receptively open, rather than always actively directive, and able to tolerate “not knowing” and uncertainty about what may or may not still emerge or require attention. This may also involve an ability to tolerate and facilitate productive (rather than persecutory) silences. For many trained in the more proactive, problem-solving type approaches typical of most health services, this can be an unfamiliar and difficult capacity to acquire and may be a major challenge in training. This may also be a phase in which more “existential,” or for some patients, even “spiritual” issues arise and need to be responsively and respectfully addressed. Some of these may be related to the different (from the therapist) cultural or religious backgrounds of patients. These may play an important role in their lives and difficulties, and may occupy an important place on the “map.” All of these issues arising and brought by the patient, as well as inevitable ongoing “transference–counter-transference” issues would be reflected upon jointly and always, ultimately, related back to the prior joint reformulations. This may greatly assist and enable “meaning-making,” understanding, and processing in a non-judgmental way, and, in the case of therapy-threatening enactments, may help to identify and resolve them (see above and also Chapters 6, 10, and 11). This work may subsequently helpfully contribute to the further development and revision of the reformulations. These should always be seen as provisional “works in progress,” and as representing a formal expression of the dialog of therapy. As such they are understood to constitute “psychological tools.” Therapy during this phase may be productively enabled by and may require use of various adjuvant “techniques” depending on the issues arising, the skills of the therapist, and the context of therapy. This might include “empty chair” work, use of “no-send” letters, creative or body therapies, or more formal trauma processing work. Some of these may require input from

22

The Main Features of CAT

specialist colleagues either during or subsequent to a course of CAT. The phase of uncomplicated commitment to and hopefulness about therapy may fade out sometime subsequent to the reformulation phase and as the end of therapy becomes a more real prospect, and also as disappointments in the limits of what may be achieved begin to be thought about. It is important to identify and name both the early commitment and cooperation, and possible later emergence of negative feelings (including in relation to the therapist), and to link them to the reformulation. Failure to discuss and accept “transference” feelings and link them to the reformulation represents a missed opportunity and is likely to associated with dropping out and poor outcome. On the other hand, the matter-of-fact acceptance, description, but non-reciprocation of hostility or emotional withdrawal—and equally of idealization—may be powerfully healing. Throughout this phase an eye should be kept on the fact that therapy will aim to be time-limited, and this should be helpfully raised and noted in discussion at least intermittently, if not every session.

­Time Limits and Ending The time-limited nature of CAT owed a lot to the work of James Mann (1973), and his emphasis on the importance of naming the session number, especially as the ending approaches, as a part of CAT practice. Working to predetermined time limits is not the same as using longterm techniques for a short time. The process is intensified and most of the problems addressed in long-term dynamic psychotherapy can be satisfactorily dealt with. Indeed, some patients with more severe disorders are more responsive and appear more safely helped in time-limited work where the dangers of over-dependence are much reduced and where the realistic disappointment which allows separation is clear from the beginning. For these and other reasons, “ending well” is seen in CAT as an important aim of therapy in itself. Nonetheless, it is recognized that for some more damaged and distressed patients longerterm, supportive, and reparative work may be required. For many such patients, depending on context, complementary or consolidating approaches such as group therapy can be extremely helpful. However, longer term work should only be undertaken following discussion and reflection in a supervisory context (see also Marx, 2011; Pickvance, 2017), and should always maintain focus on ultimately “ending well,” and ideally moving on from therapy. Termination is inevitably an issue, however, and the last sessions are seldom easy for the patient or the therapist. Almost no therapist (including the authors!) will ever feel that enough has been done and that “a bit more” might not be helpful. In CAT, the practice was introduced of exchanging “goodbye letters” at the penultimate (probably preferable to enable subsequent discussion), or last session. The aim of the therapist’s letter is reflect on and to offer an ideally accurate (not blandly optimistic) account of the course of therapy and on what has and has not been achieved (jointly) in terms of modifying problem RRs and RRPs and relieving problems, to look to the future, and to identify where further work may be helpful. The tone of the letter should aim, as ever, to be collaborative and dialogical, and be informed by a genuine relational involvement (but not collusion) on the part of the therapist. The letter should stress that this is simply the view of the therapist. Feelings of disappointment, anxiety, or possibly anger by the patient, despite what may have been achieved, are expressly noted or predicted and thereby, incidentally, also “allowed.” This letter gives the patient a reminder of the unidealized person

­The Clinical Aims of CA  23

of the therapist (assisting the “withdrawal of transference”) and of the tools of the therapy, and is intended to help the internalization of the experience overall. In the same way, the letter from the patient (always suggested but not always produced!) invites thoughtful reflection and open expression of feelings, including about the therapy relationship. For many this represents a new experience (a new RRP), and an important change from previous coping patterns (RRPs), for example of “disempowered and silently soldiering on at great personal cost.” These exchanges are seen as an important aspect of “ending well.” Follow-up at about 3 months is usually arranged. In many cases, change is maintained or expanded more thoroughly than either therapist or patient expect. If this is not the case, further follow-up or “top up” sessions may be arranged or possibly treatment through another modality (e.g., group therapy or trauma processing work). Decisions about further treatment of whatever kind are best postponed until the effects of the therapy have become stabilized and the experience of termination has been completed. They should always occur in the context of reflective discussion in supervision (see Marx, 2011; Pickvance, 2017).

­The Clinical Aims of CAT The aims of CAT therapists are, in a sense, modest. We seek to remove the “roadblocks” that have maintained restriction and distress and have prevented the patient’s further growth, and we aim to assist in the development of more adequate “route maps” and of ways of being and of living life. This occurs partly through the experience of a new, benign, therapeutic relationship. In so doing we also aim to engender some hopefulness where previously there may have been little or none. But we do not offer to accompany the patient along the road. Obstacles to change are various and in CAT are seen to include: self-reinforcing ineffective procedures; restricted, avoidant, or symptomatic procedures; sabotaging inner critical “voices”; and disconnected, dissociated Self processes. We do not believe we should seek to explain, let alone claim to share or replace, the wisdom and creativity of artists, writers, and philosophers. CAT also developed as a pragmatic model. In the inner-city London out-patient service where CAT developed, it appeared to be a satisfactory treatment for over two-thirds of patients and of some benefit to many of the remainder. Similar outcomes are reported in naturalistic studies in other countries (e.g., Garyfallos, Adamopoulou, & Mastrogianni, 1998) and in more recent comparative studies in the UK (e.g., Marriott & Kellett, 2009). Some of these went on go on to further treatment, such as more CAT, group therapy, or cognitive-behavioral work on unrevised procedures, assisted by prior reformulation (Dunn, Golynkina, Ryle, & Watson, 1997). More recent outcome data suggests similar results are being obtained across an increasing range of patient problems, severity, and settings (see Calvert & Kellett, 2014). It may also be that CAT is more effective for some patients if undertaken over a somewhat longer time, or in separate blocks with intervals. Its combination or alternation with other interventions, such as creative therapies, psychodrama, or group work, would almost certainly be helpful for patients who are hard to engage emotionally or who need more time to explore alternatives. Further and ongoing research is of course needed, although funding and support remain in general hard to find for psychotherapies, and notwithstanding that some approaches appear more “politically” acceptable and better promoted at any given time.

24

The Main Features of CAT

Which aspects of CAT are the effective ingredients in successful therapy has not been fully demonstrated, but research summarized later in the book has shown that the reformulation process can produce accurate summaries of key issues with good inter-therapist reliability (see Chapter 8), although its impact appears, perhaps unsurprisingly, to vary for different patients with different problems. Research has also shown that systematic linking of “transference–counter-transference” enactments (seen as representing a sub-set of RRs and RRPs) to the reformulation is associated with good outcome (see Chapter 8). Our belief is that the main factors associated with good outcome include: (a) the experience of a benign and collaborative, although at times challenging, therapeutic relationship; (b) as part of this and contributing to it, the joint creation and use of reformulation tools (in written and visual form) and ongoing use of them in and around therapy; and (c) the internalization of these tools and their meanings in the course of and following a collaborative and non-collusive relationship. These factors cannot be isolated from the other features of the theory and practice that allow intense but contained connections between patients and therapists, and of course the overall systemic and socio-cultural context of therapy. To end this chapter, we present an abbreviated and revised account of a typical CAT therapy in order to illustrate its stages and the use of the various tools. Case History: Bobby (Therapist Steve Potter) Bobby, a mature student in his early 30s, presented to a lunchtime on-call session at a student counseling service with depression and “agitation.” Since the break-up of a 4-year relationship, over the previous 2 years he had been sleeping badly, drinking, and smoking excessively despite having asthma, eating irregularly and neglecting his studies, while indulging in fantasies of becoming a famous musician. He had had two previous experiences of therapy and felt he would need it always. Background Bobby was the youngest of a large family, alternately spoiled (especially on the many occasions when he was ill) and neglected; in part this was because his mother was frequently away in hospital. He recalled frequently lying in his bed calling quietly for his mother, crying into his pillow and feeling inconsolable but afraid of a telling-off from his brother, by whom he was frequently bullied. He was also bullied later on at school, although he had one best mate there with whom he shared fantasies of becoming a famous pop star. Assessment and Reformulation After two assessment sessions he was offered 16 sessions of CAT. He was given the Psychotherapy File (see Appendix 2) and he started to keep a symptom diary. The Psychotherapy File and some of his diary keeping confirmed the initial patterns he had described and also set him thinking that perhaps he was not as bad as he used to be. We identified what he wanted to change (target problems) and how his patterns of relating to others and self-neglect and self-comfort fed into these. By Session 4 Bobby felt much improved in morale. He had used the provisional diagram, begun self-monitoring, and was keeping a diary.

­The Clinical Aims of CA  25

At Session 4, a letter was read to him which is reproduced in part: Dear Bobby, Here, in writing, is what we have talked about in recent weeks. I hope it can help us keep on track in the weeks ahead and serve as a reminder to you of what we have been working on. … One thing you remember of your childhood is either feeling especially loved and treasured, or being a nuisance and ignored and smacked and told to shut up and go to sleep (for example by your brother). You felt you were cared for if ill but otherwise ignored by your older brothers and sisters. You tried to please them and win them over but always felt scared. This pattern seems to have been echoed in your close relationships with women and with a therapist previously, as well as in the way you either neglect and ignore your own needs or seek comfort through drink or smoking dope … You are usually neglectful of your body and have not seen a doctor or got proper care (for asthma and other ailments) … We have named a number of patterns of feeling, thinking, and behaving: 1) You long for special care but fear it won’t last, so you tend to cling anxiously and alienate others (as with Elizabeth your partner), leaving you still uncared for. 2) Feeling depressed leads you to drink or smoke dope and ignore problems which then build up making you feel low and even more depressed. 3) You receive care, but only if “special,” so you strive to create special claims but feel you must suffer to deserve it and so neglect yourself and become “agitated” and drink or smoke dope. These patterns undoubtedly arose from the ways you coped with the limited options of your childhood; they seem to have given you some intimacy and relief but they have been costly … Already in our relationship we have seen how you push to get me to provide comfort and hold you through this difficult time when you are no longer in a relationship with a woman who will rescue you. By learning to recognize these patterns in therapy you will be better able to explore more satisfactory ways of doing things. You have said you have been impressed with my help (a bit like the honeymoon phase in one of your relationships), but I suspect it will be hard to imagine how short and limited our relationship is (16 sessions), and how you will cope with tolerating the disappointment when I cannot meet your current pattern of neediness … Our aims in therapy will include: ●● ●● ●●

learning to be less clinging and demanding in relationships getting help with your health focusing on working for your degree and on more concrete “out there” activities and achievements.

With best wishes He was moved and tearful as the letter was read out. He said he had learnt more in five sessions than in 4 years of previous therapy. He began to see his helplessness within a wider emotional narrative. The state of forlorn “agitation”—which seemed deeply part

26

The Main Features of CAT

of him and just swept over him, especially at night-time—had hitherto seemed beyond his understanding. Now it began to be seen as part of an emotional story. However, he did not like the ending being mentioned in the letter. He asked if he would be better after 16 sessions.

The Course of Therapy Before the next session, he left a note in which he said his relationship with Elizabeth his partner was definitely over and could he have an extra session? I said I couldn’t see him for an additional session and he later left a letter saying he wanted to stop the therapy: I think I am going to have to stop the therapy for now. It has been very revealing but is too much at the moment and I must concentrate on my studies. I am writing so you can allocate tomorrow’s session to someone else but if you would like to see me I am on the phone. If not, then I ‘d like to thank you for all your hard work and for helping me to see so many things about myself which need to be changed. On the telephone I said I felt strongly that we should have one session to review how his wish to end fitted into the patterns we had already identified. At the next session he said that he had felt very relieved by my telephone call. He wanted to continue and had had a “breakthrough” by seeing all the places on the diagram where he could do different things. In particular he had made a feature of having 15 minutes’ self-care time when he felt most agitated. He had other plans of self-care such as going to the gym and not smoking at night. He described what he called his third-person perspective as a way of standing back and looking at himself: not being in a state but looking at the state he was in. A simplified version of the diagram showing a key RR (Figure 2.1a) and the enactment of a key RRP (Figure 2.1b) is shown in Figure 2.1. From session 4, Bobby had rated his progress on his aims of recognizing and revising his identified problematic procedures (TPPs). Figure 2.2 shows a rating sheet for the first of these.

Termination uncertainly caring for

uncertainly cared for

Figure 2.1a  Key formative RR for Bobby.

In session 11, he noted he had five more sessions and asked if I could spread them out to make them last. We talked about his continuing health problems (a recurring theme) and wondered if he might now seek medical help. We looked at it in terms of the diagram and linked this to the old pattern of having to suffer to achieve or get love. We discussed how he could continue to work after therapy on how my “abandonment” might be a helpful experience. He seemed helped by the idea of asking for realistic care from self and others. We wondered what a realistic

­The Clinical Aims of CA  27

(self to self)

poor self care uncertainly caring for

become ill seek special care alienate others

uncertainly cared for

(situational RR)

always seek therapy anxious clinging

previously dependent

Figure 2.1b  Key RRP enactments.

Figure 2.2  Rating sheet for target problem procedure 1 for Bobby.

28

The Main Features of CAT

“okay” relationship with Elizabeth might be like. He talked about me abandoning him and how maybe he could learn from it. He paid detailed attention to his not sleeping pattern and noted that the “agitation” was provoked by thoughts about how forlorn and neglected he was. We wondered what he could do to change his going to bed routines and how to promote self talk whenever he did wake in the night so as to dispute the forlorn feeling. Bobby rang 2 days before the final session asking if it had to be the last. I restated that it was tough, but asked how he would learn about managing on his own, using what he had learnt with me, if he did not end the therapy. In the final session, as he read out his goodbye letter, he was in tears and had to stop several times. He wrote: I can see how I throw myself in and expect too much. I don’t know how to hold back. I tried to rope you in to make it impossible for you to reject me, but you were having none of it and I appreciate that. I can’t give my whole self to people and expect to be looked after. I have to look after myself. I am beginning to look after myself. The few months we have been seeing each other have seen possibly the biggest changes in me, at least in my way of thinking. I have worked hard at it and will continue to do so because I have seen that it is possible to change. I’m feeling more able to live in the “external reality” and this seems to have come from protecting my “self” a bit more.

Follow-Up In the follow-up session after his final exams, Bobby said he could now see the revised diagram in his head and use it. He could now tolerate shifts in mood, which still came but were now less extreme. There had been some tough times and he had rung Samaritans once just to talk to someone. Things were not all resolved and there were still times of despair, but he felt he could survive and work his way out of, or into, relationships with more mutual understanding. He had seen his GP and was seeing the asthma nurse regularly. He had resumed a more balanced relationship with Elizabeth, was sleeping better and living a more healthy, self-caring lifestyle. He had been able to sustain academic work with a more normal sleep pattern, obtained a degree, and had a more realistic career goal not based on fame. He no longer thought he needed long-term therapy and was on better terms with his mother, brother, and sisters.

Concluding Remarks This chapter has aimed to give a summary account of the theory and practice of the CAT model and its prior development. It is clear that the model will need to continue to evolve in the light of further developments and advances, both in background disciplines and in the light of research and experience in various clinical and other applications. Some of these currently ongoing developments are outlined subsequently elsewhere in this book, although inevitably some may be unpredicted, surprising, or counter-intuitive; for example, CAT as basis for a “self help” tool (Meadows & Kellett, 2017). Further discussion and a largely

­The Clinical Aims of CA  29

s­ ympathetic critique of the model from more explicitly socio-political perspectives has been offered, for example, by Fozooni (2010) and more recently by various authors in Lloyd and Pollard (2018). While acknowledging the strengths of CAT, some of this critique has centered on the evolution and role of the model within established Western mental health care systems, the extent to which the model may collude with their predominantly biomedical, arguably largely apolitical, character, and an alleged uncritical acceptance within CAT of conventional diagnostic systems. Such critiques have much in common with those properly articulated by critical psychologists and psychiatrists such as Ingleby (1980), Johnstone and Dallos (2013), Hobson and Leonard (2001), Bracken and Thomas (2005), Lowenthal (2015), and Middleton (2015a, 2015b). These debates represent important aspects of a struggle toward more meaningful and humane conceptualizations of and responses to “mental disorder.” In our view, the CAT model, as outlined above and subsequently detailed below in this book, can make a significant and critical contribution to this struggle given that it is clearly predicated on a fundamentally, although not entirely, relational and socio-cultural model of the Self (see Chapters 3 and 4) and correspondingly of the origins and character of mental health problems. Notwithstanding these important debates, the core of the CAT model and its clinical style as outlined in this chapter has, in our view, remained essentially constant and scientifically valid over a number of years now and should, we hope and anticipate, continue to inform and support a range of further developments both as a model of therapy and beyond.

31

3

The CAT Model of Development of the Self S ­ ummary Cognitive Analytic Therapy (CAT) is based upon a fundamentally relational and social ­concept of the Self that has important implications for psychotherapy. This concept is based on clinical research and, to varying extents, on consideration of emerging understandings from the fields of developmental and infant psychology, neuroscience, genetics, sociology, and evolutionary psychology, as well as other models of psychotherapy. In CAT a mature “phenotypic” Self is understood to be the result of a process of development through which an original “genotypic” Self interacts and communicates with caregivers and others. This process occurs on the basis of an inherent human capacity and need for intersubjectivity and relationality, in the context of likely genetic and temperamental variation. Importantly, the Self also “internalizes” the social meanings and cultural values implicit in these interactions. From a Vygotskian perspective, “internalization” is seen to involve meaning-making and sign-mediation and, as it proceeds, to result in transformation of the psychological structures involved. This results in a considerable cross-cultural diversity of the Self. Such development takes place optimally, through benign, collaborative “activity,” in the infant’s “zone of proximal development.” The CAT model also developed from a consideration of Kellyian personal construct theory, cognitive therapy, and psychoanalytic object-relations theory, but has diverged increasingly from these in its emphasis on the social formation of mind and Self, based on consideration of recent developmental psychology, Vygotskian activity theory, and Bakhtinian concepts of the dialogic self. The Self is understood in CAT as having developmentally internalized, and as being fundamentally constituted by, a repertoire of reciprocal roles (RRs) and emergent adaptive, coping reciprocal role procedures (RRPs), and as characterized by a varying emergent capacity for agency, self-reflection, empathic imagination, relationality, executive function, creativity, and, for some, a sense of spirituality. A more complete although tentative definition of the Self from a CAT perspective is offered. The theory and practice of CAT is based on a clearly defined and radically relational and social concept of the Self. As noted previously, we have deliberately capitalized the concept of “Self” to imply a substantive “organizing construct” while recognizing that this remains

Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, Second Edition. Anthony Ryle and Ian B. Kerr. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

32

The CAT Model of Development of the Self

a problematic concept requiring careful definition that must remain at present provisional and tentative (see also discussion in Chapter  2). Indeed, its multidimensional nature (extending “from the epigenetic to the existential”) represents a currently insoluble challenge for any model of mental disorder and treatment. Despite lip service paid by mental health professionals of various backgrounds, ranging from the biomedical to the sociocultural, to some form of “bio-psycho-social” approach, in practice most workers focus, perhaps inevitably, on their own area of interest, to the exclusion of a sustained consideration or attempt at integration of other factors. In this chapter we shall offer an outline of the process by which the Self is understood in CAT to be formed, and outline and consider some of the background factors that play a role in determining and influencing the outcome of that process. The more detailed therapeutic implications of abnormal or damaging development of the Self are considered further in Chapter 4. Some of this background may, again, reasonably be skimmed or read selectively by those more immediately interested in the clinical use of the model.

­The CAT Concept of Self The mature, individual, “phenotypic” Self is understood in CAT to be formed through a process of development during which an original, infant (possibly foetal) “genotypic” Self, with a set of inherited characteristics, including an evolutionary predisposition to and need for inter-subjectivity and relationality, interacts reciprocally with care-giver(s) and others in a given culture. In time, the developing Self psychologically internalizes and is shaped by this experience and their “voices.” These patterns of relationship and “voices” (RRs), when established, convey the values of the immediate family and the wider culture and contribute to the subsequent formation of a repertoire of responsive “coping patterns” (RRPs) embodying feeling, thinking, memory, meaning, and action. In CAT the social meanings and cultural values intrinsic to such interactions are seen as contributing fundamentally to the dynamic structure and processes of the Self. The processes of internalization as described by Vygotsky will be considered more fully later in this chapter. Combined with the ideas of Bakhtin, they offer a transformation of object-relations theories by embodying social, cultural, and semiotic understandings and a fundamentally different perspective on the role of collaborative relationality and meaningmaking in development and, by implication, in therapy. These ideas were principally introduced into CAT by Leiman (1992, 1994a, 1994b, 1995, 1997, 2002, 2012) and subsequently further elaborated by others (Affleck, 2014; Hepple & Sutton, 2004; Pollard, 2008; Ryle & Kerr, 2002). These Vygotskian and “dialogic” Bakhtinian views have been an important influence on the CAT model of development and mental activity (see also Holquist, 1990). Leiman has also, through his clinical work and by means of his technique of “dialogical sequence analysis” (Leiman, 1997, 2004, 2012), demonstrated that it is possible and productive to work explicitly with such “voices” in psychotherapy. This would, to some extent, now be a routine part of CAT practice. However, it should be noted that in our view, the notion of a purely dialogical self does not in itself represent a fully adequate account of the Self, as some authors appear to suggest (e.g., Hermans and di Maggio, 2004), although it offers an important contribution to it.

­The CAT Concept of Sel  33

The process of development of the Self as understood in CAT is depicted in the drawings in Figure 3.1. This stresses the interaction between caregivers and a young child predisposed to intersubjectivity, relationality, and therefore “reciprocal role” enactments. The ideal outcome of this process of development is a mature, phenotypic Self characterized by a repertoire of more or less healthy formative RRs and adaptive RRPs, living in a supportive and healthy social setting. These RRs (shown as completed internalized circles in Figure 3.1b) operate internally (“Self–Self”) as well as in interpersonal, “Self–other” relationships. In the healthy Self, these RRs and RRPs co-exist and complement each other in a seamless and integrated fashion. This also results in the unique, subjective sense of continuous and integrated existence and of agency (Knox, 2010) that most of us take for granted, but which is so strikingly and distressingly disrupted in individuals suffering from severe personality-type disorders and, more radically, in acute psychotic disorders. This subjective sense of Self is accompanied by a life-long need to experience and enjoy a sense of individual and collective “pride” and purpose (Apter and Williams, 2018; Bruner, 1990; Reddy, 2008; Stern, 2000, 2010; Trevarthen, 1993, 2001 2017) and of personal and social meaning embodied in narrative. This view of the importance of the narrative self, which we share with others (Bruner, 2003; Crits-Christoph, 1998; Holmes, 1998; Meares, 1998, 2005; Schafer, 1992; Spence, 1982; White & Epston, 1990), is explicitly addressed and acknowledged in CAT through reformulation and the relational work of therapy. Ultimately, the process of development of Self in relation to others results in an emergent capacity for higher level processes such as selfreflection, empathic imagination, relationality, creativity, and executive function, and,

(a) WIDER WORLD COMMUNITY

RELIGIOUS ELDERS

NURSERY/SCHOOL TEACHERS

WIDER FAMILY

INNER FAMILY

Figure 3.1a  CAT-based sketch of normal development of the Self through healthy early infantcaregiver interactions (RRs) shown here in a ‘nuclear’ family type setting and in a particular sociocultural context.

34

The CAT Model of Development of the Self

(b)

Figure 3.1b  Their subsequent internalisation as formative RRs within the growing child (by permission Bevan Fidler).

importantly for some, a sense of spirituality (Kerr et al., 2015; Samuels, 1985; Symington, 1999). A further exploration of the relation of CAT theory and therapy to more overtly spiritual approaches, such as mindfulness and Buddhism, including consideration of states such as “no-self” (anatman), are offered by Low (2000) and McCormick (2017). In CAT, many Self processes are described in terms of relationships or dialog with internalized figures or voices, for example the “voice of conscience,” or of “encouragement,” or of “relentless criticism,” although not every role has its recognizable figurehead. Nor is it clear how far the “I” is unitary rather than a federation or from where, in the infant–caregiver conversation, it (I) finds its (my) voice. If individuals come to experience and know themselves through early reciprocal relationships with others and their culture(s), with which role or voice is the “I” identified? One might expect that in the internal dialog with others the child would identify “I” with the child’s voice. From a dialogical and relational perspective, however, this “child’s voice” would also be understood to be largely constituted by the voices and relational experiences of others. And given that the “I” is more a federation than a single nation, the internalized voices of others can dominate the dialog, defining reality and providing a running commentary of judgment which may determine what aims may (or may not) be pursued. The confusion and conflict experienced by most of us at different times, but especially when psychologically disturbed or damaged, in making sense of these various “voices” (embodied in RRs) and their power and persuasiveness, represents an important, and never fully resolvable, challenge in life or in therapy. Several tensions or paradoxes, including its subjective and more objective aspects, are clearly also evident in such a conception of the Self. These in the end dissuaded writers such as Kohut from attempting any formal definition of such an entity. The concept of “Self” is thus a reification of a complex set of dynamic phenomena and functions. It combines, as William James (1890) noted, the joint existence of the “I” as unitary knower, experiencer, and agent and the “me” as an aggregate of bodily, social, spiritual, and other aspects. It is, as Rycroft (1991) put it, “not only an experiencing subject, but also its own object.” The “self” has

­Neuroscience Research and the Sel  35

been seen as both a structural and an experiential, narrative-based, fluid entity (de Waele, 1995; Holmes, 1998, Kerr et al., 2015; Meares, 1998; Samuels, 1985) capable of, although later very resistant to, at least some change. More extended reviews of the history of the concept of self from a broader philosophical perspective are offered by Stevens (1996), Armstrong (1999), Seigel (2005), and Elliott (2013), and a review from a more CAT-oriented perspective, along with its currently understood neuroscientific and psychological underpinnings, is offered elsewhere (Kerr et al., 2015). Within the latter, a more extended, provisional, generic definition is offered. The current CAT understanding of Self, expanded somewhat from that offered in the previous edition of this book in the light of these various advances, is now described as follows (see also Chapter 2 and Glossary): The Self in CAT is understood to be a bio-psycho-social entity that emerges through a synthetic or dialectical, semiotically-mediated developmental process involving all of these dimensions. It is understood to be characterized by a sense of agency, coherence, and continuity, of embodiment, of subjective and reflective awareness, identity, and for some by a sense of spirituality. The structure and function of Self is understood to include and integrate such functions as perception, affect, memory, thinking, self-reflection, empathic imagination, relationality, creativity, and executive function. It is understood to comprise both subjective and experiential as well as observable functional aspects. The Self is also characterized by a tendency both to organize and be organized by experience. It emerges developmentally from a genotypic Self characterized by various innate predispositions, notably to intersubjectivity and relationality, so enabling and needing engagement and interaction with others from the beginning of life. The mature, phenotypic Self is ­considered to be fundamentally constituted by internalized, sign-mediated, interpersonal experience and by dialogic voices associated with it (reciprocal roles) and to be characterized by a repertoire of emergent adaptive, “coping,” or “responsive” patterns of action (reciprocal role procedures). Although profoundly rooted in and influenced by early developmental experience, the Self is understood to be capable of a degree of choice and free will. The Self is dependent on others and on social location for its well-being both during early development and throughout life.

­Neuroscience Research and the Self There has been a profusion of research in recent years from the field of developmental neuroscience relevant to understanding and making therapeutic use of such a concept of Self, in particular with regard to its relational and developmental dimensions. We can only highlight some of this here as it appears relevant, but those who wish to pursue these understandings further may do so through the references offered and related literature. This research includes work by a range of authors over recent years (e.g., Adolphs & Anderson, 2018; Cozolino, 2014; Damasio, 2012; Glover, 2011, 2015; Knox, 2010; Meares, 2012; Moffit & The Klaus-Grawe Think Tank, 2013; Northoff, 2014; Northoff et al., 2006; Panksepp & Biven, 2012; Qin & Northoff, 2011; Schore, 2012; Siegel, 2012; Toth & Cicchetti, 1998; Tsakiris, Costantini, & Haggard, 2008; Uddin, Clare Kelly, Biswal, Xavier Castellanos, & Milham, 2009). Some of this research postulates firstly the

36

The CAT Model of Development of the Self

e­ xistence of a deeper “core” or “proto” Self located neuro-anatomically largely around deeper mid-brain areas such as the superior colliculus and periaqueductal gray (PAG). This ­concept Panksepp also capitalizes to imply a substantive entity. This core Self, which develops early, is responsible functionally for our fundamental, unconscious, bodily sense of proprioception, and sensorimotor and rhythmic (possibly proto-musical) awareness of Self and the outside world. Integrity of this domain is likely to be important for subsequent coherence and continuity of the Self both subjectively and clinically. Recent research suggests that higher putative sub-cortical structures of the Self include the limbic system (involved in emotion processing and recording of associated memories), and the default mode network (DMN) which is active when an organism is otherwise ­inactive, and is involved in introspection, rumination, processing, and probably in contributing also to a subjective sense of Self (Raichle et al., 2001; Uddin et al., 2009). Research over recent years has suggested that it is principally right brain structures that are involved in more complex aspects of a more “autobiographical” or “idiographic” Self (Damasio, 2012; Panksepp & Biven, 2012; Schore, 2012) and also of (internalized) relational ­experience, however conceived of (e.g., as “internal objects,” “schemas,” or “reciprocal roles,” or the collective “nos” described from a group analytic perspective (Ormay, 2012). The right brain is increasingly understood as the location of more complex, synthetic, “bigger picture,” often unconscious and intuitive, decision making and creativity. Importantly, these structures develop on the basis of relational experience most critically over the first few years of life, that is to say pre-verbally and at a stage before retrievable memories are laid down (Corrigan & Hull, 2018; Damasio, 2012; Panksepp & Biven, 2012; Schore, 2012). Relational interactions are also understood to be mediated by and have broader neuro-biological underpinnings through, for example, the endocrine system and neural hormones such as dopamine and vasopressin (see e.g., Decety & Ickes, 2009; Gantt & Badenoch, 2013) and also to be mediated in part by stress hormones of the hypothalamo–pituitary (HPA) axis, such as cortisol. It is well documented that stressrelated abnormalities of the latter (including antenatally) may be transmitted trans­ generationally by epigenetic mechanisms (i.e., involving control of gene “dosage” rather than the structure of DNA) and may have life-long adverse effects on all aspects of health  and well-being (see Chapter  4 and Glover, 2011). The human capacity for ­intersubjectivity, empathy, and relationality is also now understood to be mediated in part by networks of “mirror neurones” (Ammaniti & Gallese, 2014; Iacoboni, 2008; Rizzolatti & Sinigaglia, 2007). These may in turn be impaired in disorders such as autism and impairment in the capacity to generate a “theory of mind.” However, some argue rather for the importance of difficulties with emotionally mediated interactions in the genesis of autism (Hobson, 2002). Variations in these various capacities (such as in autistic “spectrum” presentations), although also possibly adaptive and advantageous in certain contexts, may play a greater role than hitherto appreciated in more general problems in living and formal mental disorder (Happe & Frith, 2014; Lloyd and Clayton, 2013; Trevarthen, 2017). The role of the autonomic nervous system with regard to relationality has also been further detailed and described in recent years through an important body of work, notably through the “polyvagal” theory developed by Porges (2011). This describes the important role of notably the parasympathetic nervous system (normally a

­The Permeability of the Sel  37

“soothing” antithetical force to the “fight or flight” responses activated by the sympathetic nervous system) largely mediated by the tenth cranial (vagus) nerve which is seen as part of a “social engagement system.” This acts through its innervation of and feedback from, for example, the heart, lungs and breathing, facial and throat muscles, and visceral digestive organs. All of these are implicated in the expression of emotion and in mammalian social engagement and safety-seeking in response to threat, with important implications for normal psycho-physiological development and, implicitly, of the Self overall. Specific implications of this theory involving trauma and dissociation are further elucidated by Corrigan (2014). This work can be seen also to complement the work of developmental psychologists such as Narvaez, Wang, and Cheng (2016) who note the importance of an “Evolved Developmental Niche” for mammalian, but especially human, infants. This implies the need for a long period of attuned support, nourishment, and affectionate care from parents, family, and a whole community. By contrast, the left brain is seen increasingly in evolutionary terms as more of an intellectual “add-on” involved in more rational, concrete calculations and logic and language, but as essentially subservient to the right brain and sub-cortical processes when it comes to affectively important or intuitive actions or decision making (see McGilchrist, 2009; Trevarthen, 2017). Nonetheless, important aspects of human psychology, or of the Self, are at least partly influenced by and mediated through left brain function, including more conscious beliefs and values. Furthermore, use of (verbal) language is an important mediator of thought and experience and is an important means of storing and accessing human culture overall and of enabling communication and social function (and see below). Indeed, talking therapies operate mostly in this domain, albeit accessing also in this way deeper, signmediated, and symbolic levels of affect and memory. The emerging findings noted above clearly raise questions about the importance of addressing deeper and non-verbal domains of the structure and function of the Self, as well as its relational and social context, especially perhaps for the effects of profound, especially early, relational trauma. All of these structures and processes may, it appears, be disrupted and damaged by relational adversity, psychological trauma, and stress (see further discussion in Chapter  4). This body of work evidently has considerable important implications for psycho-social development, mental disorder, and its treatments.

­The Permeability of the Self Although most of us have a strong sense of our individuality and separateness, more ­especially in Western cultures, we argue here that this individuality is essentially rooted in, formed, and maintained in relationships, immediate and extended, with others. In this historical period, in which individualism is a dominant, largely unconscious, experience and belief, the view articulated here may be felt to be counter-intuitive. Indeed most psychotherapeutic models, even those overtly espousing an interpersonal perspective, remain in our view essentially monadic in their view of human beings, with the partial exception of group analytic approaches (see, e.g., Brown & Zinkin, 1994; Ormay, 2012; Gantt and Badenoch 2013). A fuller understanding of the ways in which external social and internal

38

The CAT Model of Development of the Self

psychological processes are mutually influenced will require continuing study, but for this to be productive we believe the Vygotskian and Bakhtinian perspective or paradigm needs to be taken on board. The following quote from Bakhtin (1986) provides, by way of example, from a literary source, a persuasive and poetic account of the apparent paradox of the Self’s existence, but only through and dependent on the other: “I am conscious of myself and become myself only while revealing myself for another. The most important acts constituting self-consciousness are determined by a relationship toward another consciousness (toward a thou) … not that which takes place within, but that which takes place on the boundary between one’s own and someone else’s consciousness, on the threshold … a person has no internal sovereign territory; he is wholly and always on the boundary; looking inside himself, he looks into the eyes of another or with the eyes of another.”

­Cultural Relativity of Models of Self Although the preceding discussion of concepts of Self reflects to a considerable extent the individualistic concerns of our present Western culture, any model of psychotherapy including CAT should nonetheless be able to offer an account of cultural variance in the development and “disorder” of the Self. The detached and increasingly aspirational individualism of the Western world would be inconceivable in more traditional societies. The distinction between these extremes has been described in anthropological terms as that between “egocentric–contractual” and “sociocentric–organic” modes of social being (Shweder & Bourne, 1982). In terms of the model outlined, the Self, its procedures, and sense of narrative, would be experienced in a traditional, closed culture as largely defined by existing relationships with others, implying both powerful attachments, fusions, and sustenance but also restrictions (see Stevens, 1996 and see, e.g., Bhugra & Bhui, 2018; Kirmayer, 2005; Kirmayer & Ryder, 2016; Markus & Kitayama, 1991; Mills, 2014). This contrasts with the “inflation” of the detached self in our contemporary culture, manifest pathologically in those with, for example, “­narcissistic” disorders, both “vulnerable” and “grandiose” (see Chapter  10). Many recent authors have highlighted this “narcissistic” trend as a feature of our “post-modern” culture and have expressed concern about its deleterious effects on our (common) well-being (e.g., Frosh, 1991; Gordon, 1998; Samuels, 1985; Symington, 1999; Tacey, 1997; Twenge & Campbell, 2009). Models of psychotherapy must consider these issues if not resolve them. We believe that this is an area where the CAT model may have something to offer. Any model of psychotherapy should be able to generate some meaningful account of cultural and ethnic diversity as manifest in the range of individuals and their problems who may, or may not, experience them as “mental” problems, or present for “treatment” (see, e.g., Bhui & Morgan, 2007; Burman, Gowrisunkur, & Sangha, 1998; 2007; Dalal, 1992; Krause, 1998; Kirmayer, 2005; Mills, 2014; Paris & Lis, 2013; Tseng, 1999). In some cultures, emotional distress may be experienced and present as somatic symptoms, in some as overt anxiety or depression. In others, including our own, distress may also be “repressed” through, for example, “coping” or “soldiering on” role procedures. Expression of distress may vary considerably over time within a given culture. A century or so ago in Europe, for example,

­Studies of Infant Developmen  39

“hysterical” or “conversion” disorders were more common, at least in certain classes, as addressed by authors such as Charcot, Janet, and Freud (see e.g., review by Schwartz, 1999). Another example of how culture is manifest in terms of self-identity is evident in the ways in which meaning is ascribed to gender. The diversity, increasing understanding, and cultural acceptability of variously gender-related “identities” is a clear, and in the West still rapidly changing, example of how understandings, cultural values, and morals are internalized and enacted. These issues require an appropriately sensitive and flexible model to address them. (Some of these issues are addressed further in Chapter 9.) We would argue that some form of “culture mapping” should be at least implicit within any model of psychotherapy and that psychotherapists should ideally aim to be free of normative cultural values. Although this represents an important aim it can clearly never, by definition, be fully achieved given our own varying cultural formation. But CAT’s practice of collaborative reformulation does aim to reflect on and make joint sense of what each patient brings to therapy, including their cultural assumptions and formation, and including in relation to our own. Every CAT diagram should in fact represent effectively a “micro-cultural” reformulation. Consideration of these issues led to a renowned cultural psychologist such as Bruner to suggest that Homo sapiens should be considered as a “localized species” (Bruner, 2005).

­Studies of Infant Development One important influence on CAT has been the body of literature which has emerged over the past couple of decades from the observational work of infant researchers and developmental psychologists, notably Stern (2000, 2010), Murray (1992), Trevarthen (1993), Aitken and Trevarthen (1997), Tronick (1998, 2007), Brazelton and Cramer (1991), Reddy, (2008), Hobson, (2002), Gratier and Trevarthen, (2008), Braten, (2009), Apter and Williams, (2018). The field overall, along with many of its considerable implications for psychotherapy, is extensively reviewed by Trevarthen (2017). Many of the findings emerging from this fascinating body of work have illuminated in unexpected ways our understandings of early infant experience, abilities, and development. In particular, they have contradicted and disconfirmed many of the speculative ideas developed previously within the psychoanalytic tradition. This work describes an infant busily engaged from birth in a process of recognizing, remembering, and interacting with significant others, notably the mother, capable of perception, and demonstrating an increasingly dominant intersubjective focus. Many of these early processes have been described in terms of a fundamental “communicative musicality” apparently underpinning, pre-verbally, all human interaction (Malloch & Trevarthen, 2009). This has important implications for the modality and effectiveness of any subsequent therapy (Compton-Dickinson & Haakvoort, 2017; Malloch & Trevarthen, 2009; Trevarthen, 2017). An important feature of this developmental process is a collaborative playfulness which, from the beginning, is imbued with social meaning and makes use of signs, as in Winnicott’s famous “transitional object.” The developmental importance of play, its role in creativity as well as its relevance to therapy, was stressed historically in the object relations tradition by Winnicott (1971). These issues have been further emphasized and explored by later writers such as Trevarthen (1993, 2017) and Meares (2005) and, from a CAT perspective, parallels with the work of Winnicott have been noted by Leiman (1992).

40

The CAT Model of Development of the Self

The psychological predisposition to behave in these ways has been described by Aitken and Trevarthen (1997) as an innate or “intrinsic motive formation” (IMF), and also as implying the inherent psychological existence within infants of a “virtual other” (Braten, 2009). These studies demonstrate a rudimentary, pre-verbal, sense of self existing from birth. This sense of self is developed and transformed in the context of a constant interaction with others, resulting eventually in a capacity for self-reflection and a subtle awareness of others. This culminates normally in the development of an empathic, imaginative understanding of others (a “theory of mind”) by the age of 3 to 4 years (see also Povinelli & Preuss, 1995). These observations refute earlier theories which suggested “fused” or “symbiotic” states in early development; rather than “fusion,” the presence of an exquisite, active intersubjectivity between baby and mother is now stressed. The predominant affects reported in these studies of infants and children are those such as joyfulness and curiosity, albeit tempered by intermittent frustration, shame, or depression (Stern, 2000; Trevarthen, 1993, 2017). These observational studies provide no evidence for such postulated entities as a “death instinct” or any innate dominant predisposition to destructiveness or to pervasive, endogenous anxiety. They also refute the idea that infants can undertake the complex, mental operations such as “splitting” or “projection,” as postulated by Kleinian writers. The damaging effects of insecurity and of externally generated anxiety on infant development are, however, stressed in this literature, and CAT would regard this as a critically important developmental issue. Such damage would include the effects of maternal depression and other ways in which the infant’s need for interaction are denied (Apter & Williams, 2018; Murray, 1992, Trevarthen, 2017). Some of these effects are described in the disturbed patterns of attachment behavior observed in the “strange situation” experimental tests as developed by Ainsworth (Ainsworth, Blehar, Waters, & Wall, 1978 and see overviews in Cassidy & Shaver, 2016; Mooney, 2010). These observational studies overall confirm the importance of real, social experience in the formation of mind or of the Self. They also confirm the Vygotskian emphasis (see below) on the importance of a competent, caring, and enabling other in development and on the active, collaborative participation of the infant in this process (see also Boyes, Guidano, & Pool, 1997; Cox & Lightfoot, 1997). These findings have important implications for the way in which therapy, or any treatment, is offered to those with mental health problems. Stern (2000) concludes his survey of the implications of observational research for a model of development by insisting on the primacy of experience over fantasy, as follows: “It is the actual shape of interpersonal reality, specified by the interpersonal invariants that really exist, that helps determine the developmental course.” This assertion has major implications for certain forms of psychodynamic psychotherapy. In some of these, the traditional aim to construct, by interpretation, the unremembered past and the implicit requirement to find evidence for the effects of such entities as the Oedipus complex or for a “death instinct” have deflected attention from the indirect evidence for, or memories of, childhood ­experiences presented by patients. But even the increasing emphasis in some parts of the psychoanalytic tradition on “here and now” interpretations of transference or on a “something more than” approach recognizing the importance of “implicit relational knowledge” (Stern et al., 1998) have remained apparently constrained by these traditional requirements of psychoanalytic theory and practice (Ryle, 2003). Preceding and parallel to many of these developments in infant psychology was the pioneering body of work by John Bowlby, (also a psychoanalyst), that became known as

­The Contribution of Vygotsky’s Idea  41

attachment theory (AT). Although Bowlby’s development of AT initially provoked considerable hostility from, and was neglected by, the psychoanalytic community, it has by now been enthusiastically embraced by many (Schwartz, 1999). Many of the more implausible aspects of psychoanalytic theory were derived from the attempt to construct a model of personality based on drives embodied in conflicting structures, or internal objects (seen in some accounts as largely arising from endogenous psychic impulses) within some “mental apparatus.” Bowlby offered a more acceptable biological basis in ethology, suggesting in particular that experiences and behaviors related to attachment and loss could be seen as examples of complex innate behavior patterns found throughout much of the animal kingdom. This revision, easily linked with some versions of object-relations theory and in Bowlby’s view constituting a version of it (Bowlby, 1988), drew attention to the profound importance of the quality of real experience and of the infant’s bond with the mother. This constituted a radical and humane revision of contemporary psychoanalytic theory despite its being received with much hostility and misrepresentation at the time (Schwartz, 1999). The theory was developed using cognitive psychology concepts to describe the early formation of internal “working models of relationships” responsible for the subsequent shaping of relationship patterns. Workers in the AT tradition have also carried out important research describing how the form and content of parents’ recollections of childhood are linked to the patterns of attachment displayed by their own children. From a CAT perspective, Jellema has offered a series of thought-provoking papers on the importance of an AT perspective particularly in considering personality-type disorders (Jellema, 1999, 2000, 2002). However, in its initial form a least, in seeking a respectable scientific base in biology, AT largely ignored what is essentially human, namely the formative role of culture and its meanings and values, and from Bowlby’s “working models of relationships” on, has largely adopted restricted, cognitivist assumptions. The creation and maintenance of other self processes and the transmission of social values in the mother–child relationship were not explicitly considered. It appears that AT was enthusiastically over-extended in an attempt to account for all aspects of development (including the generation of “theory of mind”) and psychopathology. In our view, and that of many others (Aitken & Trevarthen, 1997; Brown & Zinkin, 1994; Gilbert, 1992; Leiman, 1995), this theory, although important, described only some of the factors involved in healthy growth and development. Although the issues that attachment theorists stress are important, in particular loss and attachment throughout the life cycle (Bowlby, 1988), AT does not, in itself, at least in its earlier ­formulations, appear to offer an adequate account of the complexity and subtlety of ­development or of psychopathology. However, in recent years, the scope of AT has itself broadened very considerably with the result that its field of study appears now almost ­synonymous with, and to include, most other domains of developmental psychology (for overviews see Cassidy & Shaver, 2016; Mooney, 2010).

­The Contribution of Vygotsky’s Ideas Many of the criticisms made of classical psychoanalytic theory and practice during the evolution of the CAT model, and many features of the specific methods employed, were grounded in a wider perspective with the incorporation of a Vygotskian perspective into CAT theory (Leiman, 1992, 1994b, 1997; Ryle, 1991). Useful reviews of these ideas are given

42

The CAT Model of Development of the Self

in Volosinov (1973), Burkitt (1991), Wertsch and Tulviste, (1992), Wertsch, (1985), and Stevens (1996); and see Vygotsky (1978). This involved the application of ideas originally concerned with intellectual development to the formation of the self. Four distinctive aspects of Vygotsky’s thought have been important for the development of CAT theory.

The Social Formation of Mind Individuals are not self-generated or self-maintained. Born with a unique genetic endowment, their individuality is shaped and maintained through their relationships with others. This rejection of the monadic view of personality is shared with Mead (1934) and many others (see Burkitt (1991) for a useful survey of the field, and see Ormay (2012) for a group analytic perspective). It emphasizes that the activities of learning and becoming a person take place essentially in relation to others. In this process our activity and the acquisition of facts and of their meanings are inseparable. We do not store representations to which we apply a mayonnaise of meaning. “Representations” become a fundamental part of emerging psychological structures. They are inextricably imbued with the meanings acquired in the course of our activity in an intersubjective universe, through our relation to others, notably parents, whose own meanings in turn will reflect those of the wider society. Childrearing practices are guided by deliberate educational intent to a small extent only and their impact on the growth of the self is registered without conscious reflection on the part of the child. Just as the realization that the world was not the center of the cosmos was resisted for a long time, so to think of the individual self as being formed and maintained in this social, interpersonal way, rather than as being the central source of thought and action, does seem to present major conceptual difficulties to many members of our ­contemporary professional culture. This point is returned to at the end of this chapter.

Sign Mediation Long before language is acquired, children are active in the presence of others who, by gesture, expression, movement, rhythms, mimicry, sounds, and by jointly created rituals and symbols, communicate wishes, intentions, and meanings. Repeated parental responses which reflect, amplify, control, or ignore the child’s actions and expressions offer a ­commentary on the child’s activity, whether its object is a part of its own or its mother’s body or a pattern of light or a spoon or a toy. These responses shape the child’s understanding of the world and also constitute a defining example of the parent–child relationship and are hence a source of the sense of self. From a Vygotksian viewpoint, signs are created and used between people or within cultures. A well-known example of the creation of meaning and intention is provided by Clark’s (1978) extension of Vygotsky’s account of what happens when a child attempts to reach an object beyond its range. Whether it elicits from the caretaker assistance, encouragement, or removal from possible harm, the fact of the response transforms the attempt into a gesture which, with repetition, can come to serve as a statement of intent and as a means of influencing the caretaker, that is to say it becomes a jointly elaborated interpsychological sign (see Leiman, 1992).

­The Contribution of Vygotsky’s Idea  43

Within psychoanalysis, Winnicott’s understanding of the transitional object as standing for the mother in her absence was an example of such an interpsychological sign and was related to his insistence that the mother–baby dyad was the proper focus of attention for developmental psychology. Language is a shared system of signs which is “de-contextualized” and hence flexible, allowing more abstract and theoretical forms of thought. It creates for the individual (as it did, in the course of evolution, for the species) the possibility of conscious self-knowledge and it represents an important human way of making sense of the world. However, as noted previously, important formative, early, relational experience also occurs pre-verbally in the first couple of years of life. As such this remains beyond the reach of conscious linguistic memory or recall although its effects may be incorporated at a deeper bodily level and be profound.

Internalization One of Vygotsky’s well-known statements was: “What the child does with an adult today she will do on her own tomorrow.” In this he was proposing a two-stage learning process whereby interpersonal activity, involving the development and use of skills and the acquisition of concepts which convey meaning, always precedes internalization. In this way, speech, which is first acquired in conversation with others, is practiced in conversation with the self (the instructions and commentaries and judgments of their own actions of young children bearing witness to this) before finally “going underground” as the internal speech which is a main component of conscious thought. It is important to recognize that the “protoconversations” between mother and infant (see Braten, 1988, 1998; Trevarthen, 1993, 2017), and the RR relationships they embody, which are major determinants of the development of personality, involve pre-linguistic mediating tools and are, as a result, largely unavailable to conscious reflection. It will be clear from this account that internalization of external interpersonal activities takes place by way of signs conveying meanings (see also Boyes, Guidano, & Pool, 1997; Cox & Lightfoot, 1997) and is quite distinct from representation. An important feature of Vygotsky’s concept of internalization is that the process is also understood to transform the psychological structures that mediate it.

The Zone of Proximal Development (ZPD) This is defined as the gap between what a child is able to do alone and what he or she could learn to do with the provision of appropriate help from a more competent other, who may be parent, teacher, or peer. The good teacher will aim to work in the ZPD, not assuming that current performance is a measure of capacity, by providing what Bruner (Wood, Bruner, & Ross, 1976) described as a “scaffolding” in the form of support and the provision and development of the appropriate conceptual tools which are then “handed over” to the pupil. Importantly, this also implies a “prospective” view of development (and of therapy). The aim is to explore where one can get to rather than interpret where one came from, as in some forms of psychoanalysis. This stance has some commonality with the “synthetic” and prospective therapeutic position stressed in analytical (Jungian) psychology (Samuels, 1985). It is clear that individual therapists should aim to work within the ZPD, but the same is true of the opportunities for learning through peers as provided in groups.

44

The CAT Model of Development of the Self

­Developmental Studies of Role Acquisition The key importance of RRs in CAT theory was first fully presented in Ryle (1985). However, it was derived from early work with the dyad grid and from clinical experience and was discussed prior to the evolution of CAT as such (Ryle, 1975). This involved in particular a restatement of ideas put forward by Ogden (1983). From a quite different background (see also Boyes, Guidano, & Pool, 1997; Cox & Lightfoot, 1997), the basic importance of RRs in early development are described by Oliviera (1997, p. 116) in her summing-up of a detailed and sensitive Vygotskian study of interactions between children in day care aged between 1 and 6. She writes: “From birth, the child is involved in social matrices in which meanings are constructed in each baby–caregiver dyad. Then, in the dynamic process of coordination of the roles that the partners assume in the here-and-now situation, a confrontation of needs, goals and senses is created. While playing roles … the individual has to follow, not necessarily in a conscious manner, a way of acting that involves complex abilities, dealing with postures, gestures and emerging representation… Children become able to master several role ­relationships … while interacting with others with their own and maybe opposite intentions. The as-if atmosphere created in symbolic play and in other situations … allows them to ­examine and modify some rules and images mediating their interactions.” Oliviera’s study traced the development of forms of collaboration from the 1-year-old’s use of expressive gestures and reciprocal imitation through the creation by 2-to-4 year-olds of “a collage of fragments of experiences” integrated by a range of signs or “starters,” including the use of language to take turns and reverse roles. Between 4 and 6 this “memory in action” is increasingly replaced by speech and by rule-governed playing as the process of alternate imitation and reciprocation continues. Oliviera’s paper serves as a reminder of the extent to which other children are involved in the acquisition of RRs, but it is important to recognize the particular power of parents who may impose rather than negotiate their RR patterns and who have the power to define the agenda. The parents’ personal restrictions and distortions may create idiosyncratic and confusing patterns and they may be unable to supply mediating concepts with which to make sense of some aspects of reality. This last point can be underlined by paraphrasing Vygotsky as follows: “what the child does not do or say with the adult today she will not do or say on her own tomorrow.” Further evidence for the powerful way in which observed and experienced role enactments are internalized and re-enacted by children comes from a fascinating projective test known as the “the teddy bears’ picnic” developed by Mueller (1996). In this test, young children are asked to describe what would happen next during a story about a picnic, using teddy bears and props such as a cart and picnic basket. The range of responses to imaginary situations, such as the cart getting a puncture, is remarkable. In the case of “daddy” teddy bear, for example, the child may describe a calm, reassuring, and problemsolving response or, at the other extreme, an angry and abusive outburst directed toward “mummy.” These results correlate well with the quality of the family background and with a child’s psychopathology, much of which might have been undetected by conventional clinical interviewing. Many other projective tests can be interpreted similarly in terms of RR enactments.

­Bakhtinian Contribution  45

­Bakhtinian Contributions Although Vygotsky and Bakhtin were contemporaries and worked in overlapping fields they did not collaborate and their perspectives were different in important ways. Leiman (1992, 1997, 2002) introduced the ideas of both into CAT thinking and has drawn on the latter to propose a “dialogic” model of the self (Leiman, 1997) that bears some similarities to those proposed by, for example, Hermans (see Hermans & Di Maggio, 2004) or from a clinical perspective by Seikkula (see Seikkula et  al., 2006). Further contributions to the dialogic dimension of CAT have been made since then by a number of writers as noted above. A further, illuminating discussion of the implications of the differences between Vygotsky and Bakhtin is offered by Cheyne and Tarulli (1999) which, although at first reading is apparently rather esoteric, in our view merits consideration. They note that Vygotsky was primarily concerned with the ways in which the skills and knowledge of the culture were acquired by the child. A narrow interpretation of his theory of the social formation of mind would define the parent or teacher as an agent or interpreter of the wider culture, aiming to transmit what the culture values and knows to the receptive child. For Bakhtin, on the other hand, the emphasis is different; for him, open-ended dialog is seen as the essential and most valued basis of human consciousness: “To live means to participate in dialogue: to ask ­questions, to heed, to respond, to agree and so forth. In this dialogue a person participates wholly and throughout his whole life: with eyes, lips, hands, soul, spirit, with his whole body and deeds” (Bakhtin, 1984, p. 293). Dialog is a fundamental human activity; every utterance will be directed to an addressee who may be “an immediate participant-interlocuter in an everyday dialogue, a differentiated collective of specialists … a more or less differentiated public, ethnic group, contemporaries, likeminded people, opponents and enemies, a subordinate, someone who is lower, higher” (Bakhtin, 1986 p. 95). To this model of dialog, Bakhtin adds a highly significant idea, that of the third voice or “super-addressee.” In the address of the first (e.g., parent, teacher, therapist) voice to the second (child, pupil, patient) voice there is this implicit third voice, representing the wider culture or some part of it. The third voice (super-addressee) legitimizes the first one who is in effect its conduit to the second voice. What is transmitted might be the current ­paradigm of a branch of science, the membership rules of a club, the articles of faith in a religion, the definition of gender roles, and so on. The social formation of mind, in this view, can be seen as a distillation of the whole range of human history and culture, while being inevitably focused and filtered by the particular time, place, and family into which the child is born. The discussion by Cheyne and Tarulli on the forms of dialog employed as scaffolding sets the comments made above on the effect of different styles of parenting in a wider context. Drawing on Bakhtin’s ideas, they propose a spectrum of scaffolding styles from the authoritative “Magistral” dialog typical of religious training in the Middle Ages through the “Socratic” questioning dialog to the “Menippean” upturnings and carnival. The voice of Menippean dialog is described (Cheyne & Tarulli, 1999) as a mocking and cynical questioning after the Menippean satire which Bakhtin considered and associated closely with the notion of carnival. The “Magistral” voice provides a restrictive scaffolding which imposes compliance on the pupil or initiate. In the “Socratic” form of dialog, the scaffolding is less

46

The CAT Model of Development of the Self

rigid; the first voice (parent, teacher, etc.) will question the second (child, pupil) but may in turn be questioned. Through this, the child, pupil, or patient not only receives a broader and more complex introduction to the conceptual tools of the culture but may actively enter into dialog, using, modifying, and elaborating the ideas provided by the other voices and not necessarily arriving at an agreed conclusion. This is clearly the preferred therapeutic mode, although Cheyne and Tarulli, in a significant aside, point out that some psychotherapies, while supposedly “Socratic,” in reality impose a disguised form of the “Magistral” approach in which clients are taught to ask the right questions. Such an approach would clearly militate against beneficial change. Psychotherapists should aim to provide a reparative scaffolding, explicitly “Socratic,” respecting and caring, creating descriptions of current roles and procedures in words and diagrams that open for reflection the patterns that have operated automatically since their early formation. It is of interest that whole cultures may be characterized by certain dominant modes and voices in this fashion. Protestant cultures, for example, would be partly characterized by harshly (self) critical (or “Magistral”) voices and the task of therapy may be at times to work explicitly with a patient to question internalized culturally derived voices. In Bakhtin’s words: “Just as the body is formed initially in the mother’s womb (body), a  person’s consciousness awakens wrapped in another’s consciousness” (Bakhtin, 1986, p. 138). In a related understanding, Winnicott’s “there is no such thing as an infant” emphasized the need to make the unit of observation in understanding development this infant– caretaker dyadic system rather than the infant alone. In essence, the dialogic approach replaces the “I think, therefore I am” of Descartes with “We interact and communicate, therefore I become.” This dialogic model presents an unproblematic way of understanding the acquisition of a theory of mind. In a more overtly “political” contribution, the Bakhtin-inspired philosopher Terzakis explicates further the enmeshment of the socio-political with the intrapsychic, as ­illustrated by the following quote: “We should then talk of official consciousness and unofficial consciousness, official language and unofficial language: this reformulation does not only re introduce the dialogic principle deep into what we tended to consider as strictly the intrapsychic but also reincorporates the artificially isolated island of the self in a great field of social and ideological currents. Behind every individual symptom hides the conflict between opposing significations of the world. The problem of so-called psychopathology is always in the last analysis a political problem: managing relations between the individual and the group, choosing a moral or political stance” (Fotos Terzakis unpublished, personal communication).

­Contrasts with Other Concepts of Self The CAT model of Self and its formation shares much with the different conceptions of self formulated historically by various clinical writers. These would include notably Jung (see Samuels, 1985), although Jungians have tended to neglect the social dimensions of the self, Sullivan (1953) within the North American “interpersonal” tradition, and Kohut (1977). CAT shares with Kohut an emphasis on the damage which can be done to the developing self by empathic failure or overt neglect but places more emphasis on active abuse and

­Contrasts with Other Concepts of Sel  47

trauma. CAT also shares a central interest in social conceptions of the self with group analysts. Foulkes, for example, saw individuals in a social fashion as being nodes in a “social matrix” (Foulkes & Anthony, 1957). Later group analytic writers (e.g., Brown & Zinkin, 1994; Pines, 1996) have also developed an interest in the (Bakhtinian) dialogic aspects of the self. Although object-relations theorists were a major influence on the development of CAT, they were on the whole little interested in the concept of self. However, the current CAT model is close to some later authors in the object relations tradition, such as Sutherland (1980), Ogden (1990), and Sandler and Sandler (1998). It is also close to Bowlby’s attachment theory (1988) and to subsequent work influenced by this (Fonagy & Target, 1997; and see Bateman, Brown, & Pedder, 2000) in their descriptions of the important role of internalization, and there are some similarities with more recent developments in cognitive psychology stressing the importance early interpersonal experience and of attachment patterns (see Gumley & Schwannauer, 2006; Guidano, 1987, 1991; Liotti, Cortina, & Farina, 2008; Neisser, 1993; Perris, 2000; Young, Klosko, & Weishaar, 2003). However, these authors do not take the further, and, in our view, important, conceptual leap of seeing the self as being essentially constituted by early, socially meaningful, sign-mediated interpersonal experiences, as opposed to “representing” them mentally. Nonetheless, object-relations theories made a considerable contribution by indicating the importance of early development in determining personality, by offering an account of how parental figures were “internalized” to form a part of the personality, and by recognizing the parallel, linked features of intrapsychic and interpersonal processes and their emergence in transference relationships (see also discussion in Ryle, 1996, 1997c). However, the attribution of these phenomena by some psychoanalytic object-relations theorists to “splitting” and “projective identification,” and the location of “psychopathology” in the posited internal system of object relations and to “ego weakness,” innate destructive instinctual forces, and unconscious fantasy is seen as unhelpful and untenable from a CAT perspective. The phenomenon of projective identification, whereby others are powerfully induced to experience feelings or play roles which the person cannot tolerate, is not regarded as a defense in CAT; it is seen to represent an exaggerated example of the normal empathic processes of RR relating. CAT understands Self states (dissociated RRs) to be precarious and to leading the person to induce powerful identifying responses in, or to forcefully seek reciprocations from, others even where these are harmful. While usually discussed in relation to destructive procedures, CAT would understand that the same intense pressures can characterize the seeking for “good enough” or ideal care.

Cognitive Psychology and Cognitive Therapy One important early influence in the development of CAT was personal construct theory (Kelly, 1955), an approach which challenged both psychoanalytic and behavioral assumptions and which, especially if linked with social constructivism, goes some way toward acknowledging the specifically human, cultural influences on personality. The dominant cognitive theory of the last decades, however, influenced by artificial intelligence research and computer metaphors, has been concerned with information processing and storage. In our view this is still largely the case, although some authors began to show an increasing

48

The CAT Model of Development of the Self

interest and awareness of the effects of early interpersonal experience and of the importance of (social) meaning in development and in therapy (see Brewin, 1988; Salkovskis, 1996; Safran & McMain, 1992; Stiles, 1997; Perris, 2000). An important contribution of these cognitive and behavioral theories to the CAT model was their demonstration of the value of analyzing and describing sequences (for example, linking behaviors to outcomes, cognitions to emotions) and their demonstration that many problems can be understood without postulating unconscious forces. The cognitive component of CAT theory was derived initially from the work with repertory grids and, to a degree, from personal construct theory. Miller, Galanter, and Pribram (1960) and Neisser (1967) were also significant influences. In Ryle (1982), the Procedural Sequence Model (PSM) was compared in some detail to Beck’s model of cognitive therapy (Beck, 1976), to Roth’s model of learned helplessness (Roth, 1980), to Rehm’s model of depression (Rehm, 1977), to Rotter’s model of generalized expectancies (Rotter, 1978), to Forstelling’s attribution theory (Forstelling, 1980), and to Bandura’s model of self-efficacy (Bandura, 1977). In terms of practice, the use of patient self-monitoring was derived from Beck and became one important aspect of the reformulation process, but in CAT the focus of attention was shifted as soon as possible from symptoms to procedures. Later developments in cognitive-behavior therapy (CBT), for example the work of Guidano (1987) or Neisser (1993) focusing on a concept of self, and those stressing the importance of early interpersonal experience and of attachment patterns, including in relation to dissociation (see Gumley & Schwannauer, 2006; Liotti et al., 2008; Perris, 2000), or interpersonally-derived “schemas” (Young et al., 2003), or even those seeing the self as a set of information processing systems (Prescott, 2015), show some convergences with CAT. This would include clinical work noting and addressing ways in which so-called “therapy interfering behaviors” or “resistance” may arise (Leahy, 2001). These have to some extent shifted attention to higher level functions and more complex disorders but important differences remain, as will become clear in later chapters. Notably, such approaches still lack, in our view, a clear and coherent means of understanding and effectively addressing “therapy interfering behaviors,” “resistance,” or therapeutic challenges and ruptures in a ­productive and non-blaming way (see also Chapter 9). The early CAT model (PSM) therefore resembled cognitive ones but differed essentially in that the unit of observation—the procedural sequence—involved linking together environmental, mental, and behavioral phenomena and their implicit underlying relational origins. The level of address in CAT is on whole-person Self processes and structures understood in developmental and contextual terms, whereas CBT remains usually focused on particular beliefs, symptoms, or behaviors and pays little attention to development or structure, or to socio-cultural context. Some important differences deriving from these and as manifest in the clinical practice of CBT and CAT are further considered in Chapter 9.

­Genetics and Temperament It is well documented by behavioral geneticists, as well as by evolutionary psychologists, that we arrive in this world with a considerable psychological “baggage” in the form of both individual temperamental characteristics and also more general evolutionary predispositions to

­Genetics and Temperamen  49

behave in certain ways in certain situations (Aitken & Trevarthen, 1997; Braten, 2013; Gilbert, 1992; James, 2018; McGuire & Troisi, 1998; Plomin, 1994, 2018; Stevens & Price, 1996). Thus, the human infant is very far from being a completely malleable and motiveless naive being or “tabula rasa.” Some of the variance in observed patterns of human behaving and thinking (personality) is due to variation in inherited temperamental factors. Of these, the so-called “big 5” (neuroticism, extraversion–introversion, openness to experience, conscientiousness, and agreeableness) are perhaps the best known and documented (Costa & McCrae, 1992). It is similarly clear that a varying but significant amount of the variance in the prevalence of frank mental disorders is due to genetic factors. It was previously suggested that this may range from about 0.5 (i.e., about half) for manic depression and the schizophrenias (e.g., as tested in identical twins reared apart) to much lower but still significant figures for “neurotic” disorders such as depression and anxiety (see also discussion by Plomin, 1994, 2018). More recent work has, however, challenged these estimates (see James, 2018), which apparently remain uncertain. Plomin makes the interesting point that in social settings characterized by, for example, pervasive inequalities, some more subtle genetic effects may be obscured that when understood may also enable us to better address these social effects (Plomin, 2018). However, it has also been argued, in the light of the relative failure of genetic mapping projects to identify clear dominant loci associated with mental disorder, that the genetic causes of common mental disorders have been greatly overstated and are in fact minimal (James, 2018). Even for major psychotic disorders the results of genome wide association studies appear currently to suggest that subtle effects are caused only collectively over a large number (more than a hundred) of genetic loci (Schizophrenia Working Group, 2014). These figures also indicate the need to understand what sort of factors contribute to the greater remainder of the variance. But the implications of possible inherited characteristics for psychotherapy are considerable since they imply that a certain amount of what may be described as personality may be the effects of temperament rather than of developmental experience. As such they may be relatively immutable, raising the question of whether, in that case, the task of psychotherapy may be, in part, to help an individual to live with and manage their particular temperamental characteristics as well as to make sense of their consequences. This would apply also to those with established and disabling disorders (such as psychosis or anorexia) whatever their, possibly complex, origins The effects of temperament are rarely direct and will, importantly, include the complex effects whereby the behavior of a child will actually modify the responses of others and so their experience (Plomin, 1994, 2018), which will then, in turn, be internalized. These effects would also include the consequences of differing experiences within a group of siblings. Thus, a demandingly aggressive or a highly anxious child will elicit very different responses from a parent or siblings and peers compared to a more placid sibling. This mechanism (“non-shared family environment”) accounts in part for the very different developmental experience which siblings may have within the same family. It should be noted also that certain temperamental characteristics may confer a degree of developmental resilience in whatever conditions a child develops, while others may do very well indeed but only in certain favorable conditions, the so-called “dandelion–orchid” hypothesis (see review by Kennedy, 2013). These inherited characteristics may be usefully conceived of overall in terms of “vulnerability” and “resilience” factors (Plomin, 1994, 2018; Rutter et  al., 1997 and see Figure  4.1), although it does seem that some factors could operate as one or the other depending on

50

The CAT Model of Development of the Self

c­ ircumstances. But importantly, too, given understandings from recent developmental psychology and the social formation of the self, it is clear that much of what is called currently called resilience represents in fact the internalization of developmental social context (and its health), and experience of social context subsequently throughout life. But it can be seen that an increased predisposition to anxiety (broadly speaking “neuroticism” in terms in the “big 5”) could compound the damaging effects of growing up in an abusive family resulting in a severely damaged self. However, lack of anxiety in another dangerous setting, such as a primitive jungle or a modern motorway, could result in disastrous consequences. Similarly, a degree of temperamental disinhibition or elevated mood could be invaluable in a creative artist or business entrepreneur, but in a chronically stressful, unsupported setting could result in overt manic depression in someone so predisposed. It is probable that hitherto unclear protective psychological factors exist in the face of otherwise damaging adversity and trauma. It is not yet clear, however, how far such factors may be innate and how far affected by developmental deprivation or damage. Genetic variability may, for example, partially account for a tendency to dissociation in the face of trauma (Corrigan & Hull, 2018; Liotti et al., 2008; Silk, 2000). This may also have been evolutionarily adaptive in the face of overwhelming anxiety or stress, but if chronically and excessively endured during a traumatic childhood may have catastrophic effects on the developing Self (see also Chapter 4). It has also been suggested that individuals with a predisposition to obsessional or perfectionistic behavior are more vulnerable to developing disorders such as anorexia. Although these factors are not the immediate focus of ­psychotherapy, we suggest that it is important to bear them in mind and also to acknowledge them as appropriate in reformulations, especially given a common psychotherapeutic tendency to attribute difficulties or psychopathology entirely to an individual’s developmental history and to think that personality is malleable and “mendable” in all cases.

­Our Evolutionary Past Natural selection apparently favored individuals who were biologically endowed with the potential to be socially formed and responsive and who were therefore capable of living in groups and able to adjust flexibly to a wide variety of physical circumstances and social structures. There is an increasingly large, although at times rather contradictory and acrimonious, literature on the acknowledged effects of our evolutionary inheritance on our mental functions, making sense of which is still challenging (Barrett & Dunbar, 2007; Buss, 2005; Donald, 1991; Evans & Zarate, 1999; Gilbert, 1992; McGuire & Troisi, 1998; Nesse, 2005; Plotkin, 1997; Rose & Rose, 2000; Slavin & Kriegman, 1992; Stevens & Price, 1996; Tooby & Cosmides, 1992). Since we are, in evolutionary terms, simply another product of that process, it is accepted increasingly that we carry within us certain evolutionarily more “primitive” although originally adaptive predispositions to behave in certain ways at certain times and in certain circumstances. However, unlike “lower” order species whose activities may be determined almost exclusively by stimulus-evoked, “all or nothing,” instinctual patterns, our species is characterized by a remarkable capacity, consequent to the development of our expanded frontal cerebral cortex (Innocenti & Kaas, 1995), to reflect upon and modify such patterns and to be influenced by socio-cultural formation and context. In addition, our evolutionary development has given us the potential to acquire a capacity for intersubjectivity and an extraordinary ability, acquired through the process of socially meaningful, joint, and recip-

­The Evolution of Cognitive Capacities and of Cultur  51

rocal interactions, to “read” or “be in” the minds of others. It has been suggested that this ability enabled our ancestors to exist effectively and advantageously in large groups, which have, for some time, been our “Environment of Evolutionary Adaptedness” (see Evans and Zarate; Buss, 2005; Dunbar and Barrett, 2007). It is suggested that the ability to understand each other’s minds and motives has been and continues to be of critical importance for our species and is reflected in our preoccupation with social intercourse and communication— including our predilection for gossip! More seriously, this also implies that whatever meaning or fulfillment there is in our lives is fundamentally social, an understanding, in our view, with important implications for both psychotherapy and politics. Most evolutionary psychologists, however, in common with even more recent psychodynamic theorists, propose an understanding of mind and self that is characterized by a cognitive, or at best an intersubjective, monadism. In this formulation, interpersonal experience is seen as “mapped” or “represented” within fundamentally individual, pre-existing mental structures. Curiously, this very Western view of the self would almost certainly be incomprehensible to most members of traditional or “primitive” societies. In this respect, the CAT model may well have something important to contribute to a dialog with evolutionary psychology. These various features of our evolutionary inheritance, in particular our capacity to be shaped by developmental experience and the internalization of social meanings and cultural values, have largely contributed to the historic conceptual conflict between the protagonists of the effects of “nature” and “nurture” or of genes versus environment. This “for or against” ­argument should, by now, be essentially redundant. As Plomin (1994) has remarked, the “nature–­nurture” debate is centered nowadays around the hyphen and around its developmental, synthetic interactions. And as we (AR) have previously noted, notwithstanding our various predispositions, “humans are above all biologically predisposed to be social formed.”

­The Evolution of Cognitive Capacities and of Culture In the view proposed here, although humans retain their biological characteristics, the sources of their evolutionary success are to be found in the ways in which they are ­radically unlike other animals. These include notably: (a) the enormously enlarged brains which enabled our ancestors to replace stereotypic and predetermined techniques with flexible, intelligent solutions in the struggle to wrest a living from nature; and (b) the development of faculties, eventually speech, which enhanced their ability to work together and to pass on knowledge from one generation to the next. As a result of these changes, cultural evolution became a dominant factor in how humankind evolved biologically. As new social forms radically altered the behaviors and qualities of individuals likely to aid survival of the group, individuals evolved who could learn the skills and values of the particular group they were born into, that is, people whose nature it was to be formed by nurture. There is also direct biological evidence for the social formation of mind, namely the shaping of neural pathways which occur during early development. To quote a classic review of the field by Eisenberg (1995): “Major brain pathways are specified by the genome; detailed connections are fashioned by, and consequently reflect, socially mediated experience in the world.” How evolution led to the remarkably flexible and capable mind of modern humans will now be considered in more detail. Much of this is well articulated by Donald, on whose

52

The CAT Model of Development of the Self

work the following account is drawn (Donald, 1991, 2001). Adding understandings drawn from cognitive psychology to the traditional sources in archeological, anthropological, and biological studies, offers, in our view, a convincing and fascinating reconstruction of the main stages in the evolution of the modern mind. Four million years ago, our ancestors the australopithecines already shared food and labor and formed nuclear family structures. One and a half million years ago, Homo erectus, blessed with a much larger brain, managed to build shelters, use fire, and develop better tools. Over the following period the size of the brain compared to that of other mammals continued to increase markedly, with a last period of rapid growth occurring 0.3 million years ago. These changes were accompanied by another significant anatomical development: the evolution of the human vocal tract, with its capacity for the rapid generation of differentiated sounds allowing speech. Donald describes how contemporary chimpanzees are capable of flexible and nonstereotypical ways of thinking and relating and how their social organization is dependent on their capacity to remember “large numbers of distinctly individual learned dyadic relationships.” The development of the human brain from an equivalent level went through a number of intermediate stages, each conveying greater cognitive and social advantages. During the first of these (the Mimetic culture), non-linguistic skills in representing, differentiating, rehearsing, and communicating were elaborated. Knowledge could now be contained and communicated using metaphoric activities; both tool-using and sign-using were established. This allowed the greater cohesion of social groups, which developed complex structures sustained by group rituals. The semantic and social structures that developed over the million or more years of this phase were accompanied by developments in the brain which prepared the way for the addition of symbolic language, but it appears that this developed independently, existing alongside the mimetic modes which persisted and are still a powerful aspect of human communication. The evolution of the larynx and the acquisition of language in the Mythic age provided the individual with the basis for the conscious mobilization of mental capacities. It also enormously enhanced the cohesion and purposefulness of human society by linking, in stories and myths, the guiding values and meanings of the group. The power of oral transmission is illustrated by the account of Australian Aboriginal myth which incorporates accurate descriptions of a terrain, recently identified, which has been under the sea for the past 8,000 years (Tudge, 1996). Another example is provided by the Maori of New Zealand–Aotearoa whose ancestors arrived in a small number of boats. Traditional accounts trace their ancestry of different groups to one or other of these boats and genetic studies have provided confirmation of the groupings. Speech is now the dominant mental function because, with it, both memories of events and descriptions of the skills and sequences which can be conveyed mimetically can be described and communicated in abstract, generalized forms (see Maturana, Mpodozis, & Letelier, 1995). Language opened the way for the theoretic culture we now inhabit, where we are capable of analytic, de-contextualized forms of thinking which the earlier systems could not sustain. These functions were sustained in turn by the manufacture of pictorial or sculpted artifacts, perhaps initially serving mythic functions, and the development of external, physical mnemonic devices such as notched sticks, indicators of astronomical events, maps, and eventually, 8,000 years ago, writing. The development of written records greatly increased the accumulation and transmission of information. External symbolic

­Evolutionarily Pre-Programmed Psychological Tendencie  53

storage, vaster than any single mind could conceivably hold, has now become a dominant factor in human thought. Just as the development of tools and machines enormously extended people’s physical capacity to change material objects, so the brain developed the capacity to extend enormously the power of thought. Some philosophers have gone as far as to suggest that the human brain should now be considered simply as a functional part of its socio-cultural context (Clark & Chalmers, 1998).

­Evolutionarily Pre-Programmed Psychological Tendencies Many authors (reviewed in Gilbert, 1992; McGuire & Troisi, 1998; Stevens & Price, 1996) suggest that pre-programmed patterns, analogous to those triggered by the “innate releasing mechanisms” described by ethologists, may underlie our tendency to think and act in certain ways in certain circumstances. The Jungian concept of archetypes can be seen similarly. While requiring careful attention as partial, possible determinants of human behavior, we consider that to exaggerate their importance can be as reductive and misleading as some of the attempts by earlier socio-biologists to explain culture in terms of the enactment of “hard-wired” biological tendencies. However, according to these writers, there are highly stereotyped, ritual behaviors seen throughout the animal kingdom associated with, for example, aggression, status-seeking, mating, or care-eliciting and care-giving. The power and apparent “irrationality” of such responses is well exemplified by the experience of falling in love or the dedicated preoccupation of a nursing mother with her baby. Gilbert (1992) has described the predisposition to enact such phylogenetically evolved “biosocial goals” as “mentalities.” This concept combines affects, action tendencies, and cognitive and attentional structures. These are manifest in social life from early on and could be seen as analogous to or contributing to the formation of RRPs. The behavioral patterns (for example care- or proximity-seeking behavior) described by attachment theorists can also be seen to be subsumed within such repertoires. However, as pointed out by Gilbert (1992), they would be, phylogenetically, only one of many adaptive developmental behaviors. Attachment theorists (Bowlby, 1988) have also properly pointed to the life-long importance of negotiation of issues relating to attachment and loss. In  ­parallel, writers such as Stevens and Price (1996) have described the concept of “­frustration of archetypal intent,” by analogy with the ethological phenomenon of the “search for the object never known.” This could manifest, for example, in the case of someone who never had the experience of a good mother or father, as a life-long search for this never-experienced, perhaps idealized, relationship. This phenomenon can be recognized clinically and described in terms of role enactments and can be important to identify and work with. Primitive, stereotypic responses to highly stressful situations provide perhaps more definite examples of such pre-programmed predispositions. These would include fight, flight, or freezing responses to threat, the sensitivity to shame which we share with other social animals (Gilbert & Andrews, 1998), and the resort to dichotomous, “black and white” thinking derived in evolution from the critical need to distinguish friend from foe (including especially in the context of large groups), or safe from dangerous situations. Some of these responses, particularly dichotomous thinking, may be a focus of psychotherapy, as

54

The CAT Model of Development of the Self

may the stereotypic consequences of prolonged stress or trauma on the developing self (see Kalsched, 1998, 2013). Primitive responses such as these are most often elicited in those who have been subject to threat and abuse during their own upbringing and can manifest in social phenomena such as racism, aggressive nationalism, stigmatizing behavior, and overt violence (see Braten, 2013; Zulueta, 1993). Expression of these will also be determined by the history, power relations, and dominant ideology of different societies. By contrast, those who have been treated with love and respect tend to re-enact those roles and are capable of more considered and compassionate responses to stressful situations. It should be noted, despite the history of our past century, that the dominant tendencies enacted by our species have also included, and potentially remain, those of cooperation, creativity, and mutual interdependence.

55

4

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy S ­ ummary When people present with mental health problems, it is understood in Cognitive Analytic Therapy (CAT) that the psychological entity being addressed is the Self, as previously described. Abnormal development or damage to the Self is understood in CAT to result from the effects of adverse, possibly traumatic, relational experience, including socio-cultural experience. This is internalized in formative reciprocal roles (RRs), and generates dysfunctional, frequently symptomatic, coping pattern reciprocal role procedures (RRPs) and causes, in more serious cases, distressing failures or disruptions of integration of the Self and its processes. This is understood to occur in the context of possible genetic and temperamental vulnerability. In CAT, such damage and dysfunction of the Self is understood to occur on a spectrum of severity and complexity and to be likely, if more severe, to be accompanied by a range of problems, or so-called “co-morbidity.” This is implied in the CAT Multiple Self States Model (MSSM) of “personality disorder.” This offers a dimensional rather than a circumscribed, categorical approach to mental disorders such as tends, problematically, to prevail in many health care systems. The CAT understanding of the damaged Self also implies the need for a whole-person and contextual therapeutic approach. Given these understandings, the aims of therapy are seen, in large part, as reparative changes to these damaged and dysfunctional structures and processes of the Self. These changes include joint “recognition” and helpful “revision” of RRs, of distressing and often dysfunctional RRPs, and greater integration of the Self. Social rehabilitation, broadly understood, would be seen as an important implicit aim of therapeutic work, although this would depend on context. Given these understandings of the Self, the work of therapy is seen in CAT as necessarily based on a genuinely collaborative, but explicitly timelimited, therapeutic relationship. It is understood and hoped that this new relationship and its “voice” (initially a “situational” RR) will gradually be internalized to some extent. Within this benign relationship, the work of therapy can proceed. Therapy assists in making narrative sense (“meaning making”) of historic and current difficulties in living and will usually involve trying out new and alternative RRPs (“exits” or “aims”), and identifying and challenging “Self–Self” enactment of RRs and RRPs (including internalized dialogical “voices”). The later phases of therapy may also require use of complementary techniques to work through and

Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, Second Edition. Anthony Ryle and Ian B. Kerr. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

56

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

process current or historic experience, including use of “no-send” letters, behavioral experiments, empty chair work, creative or body therapies, or more formal trauma processing work. For a more damaged Self this work would also aim to identify a tendency to dissociate into Self states, and by implication would aim at improved integration, self-reflection, executive function, and relations with others. Treatment may be powerfully complemented or consolidated by some form of group or social therapy experience. These understandings of the damaged Self imply that patients may at times enact extreme and desperate roles and (coping) role procedures, both outside of and within therapy. The latter may challenge the therapist personally and threaten the treatment alliance. They imply a need to map and anticipate these potential reciprocal enactments, ideally from the initial encounter, as in the “map and talk” approach, and not simply when a formal diagram is created. Those occurring within the therapy relationship can be described as a form of “transference,” and of “reciprocating” and “identifying” counter-transference. Having some means of resolving such episodes (so-called “rupture and repair”) is recognized as critical for the therapeutic alliance and for the outcome of any therapy. Given that it is implicit that we all have our own diagrams or maps, CAT implies an ongoing need to be open to and engage with supervision and/or reflective practice at all times, but especially when working with more damaged and challenging patients such as are frequently encountered in public health services. Ideally, all mental health workers, and others working with troubled individuals or systems, should be offered at least a brief training and therapy experience to facilitate such insights, and to support working in a non-collusive, relational manner, given that such dynamics in and around the Self and others are fundamental to mental health and well-being. Psychotherapists aim to help their patients change how they experience, make sense of, and manage their lives, seeking to free them from maladaptive, damaging, or restrictive Self processes. Psychotherapy is concerned principally, although by no means exclusively, with changing the consequences of early developmental experience. Different therapies acknowledge this to differing extents and have different understandings of these consequences and of how therapy may influence them. We aim in this chapter to outline the CAT understanding of abnormal development of the Self and its important implications for therapy. The more detailed applications of the approach in various conditions and contexts will be reviewed in later chapters.

­Abnormal Development of Self and Its Consequences Adverse, possibly overtly traumatic, early relational experience may affect development of the Self in various ways. It may occur through the internalization of negative or maladaptive reciprocal roles (RRs) and the emergence of reciprocal role procedures (RRPs), which may be restrictive or symptomatic, and through the anxiety or trauma-induced dissociation of Self processes and structure. This damaging process is depicted diagrammatically in Figure 4.1 where all levels of potential damage are shown. A tendency to dissociate into different Self states is indicated by broken lines. All three forms or levels of damage are found in overt Borderline Personality Disorder (BPD) type disorders (see Chapter 10) and to varying extents in other disorders, both “neurotic” and psychotic, where the internalization of

­Abnormal Development of Self and Its Consequence  57 Healthy intergenerational cycle

Intergenerational transmission – “cycles of abuse”

Treatment

Inconsistent, depriving, abusive enactment of reciprocal roles

Treatment or forensic outcome?

Further adverse life events Damaged Self with poorly integrated maladaptive repertoire of RRs and RRPs and impaired capacity for empathy, self-reflection, and executive function

Figure 4.1  CAT-based diagrammatic sketch of damaging and abnormal development of the Self.

abusive and neglecting role relationships is frequently manifest in neglect and possibly abuse of Self and others. In addition, the metaprocedures that normally link and mobilize appropriately the individual’s reciprocal role repertoire are disrupted or undeveloped with the result that separate, unconnected (partially dissociated) reciprocal role patterns persist. Furthermore, deficient parenting or care-giving, marked by little or no concern with the child’s emotional experience (as opposed to obedience or appearance for example), offers no source from which a self-caring role might be internalized. This, combined with the disruptions of self-reflection accompanying switches between states, results in an impaired capacity for self-reflection and hence an impaired ability to take responsibility for damaging behavior or to learn from experience. Some of the abnormal neuro-biology and neuro-psychology implicated in these processes is gradually being described and is noted later in this chapter. Although it is important to appreciate these neuroscientific abnormalities in broad terms, given their damaging effects, and to consider their possible impact on therapy, they cannot however, by definition, fully “explain” or “account for” apparent mental disorder (see below).

58

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

Persistent Negative Role Patterns In less severe disruptions, where the scaffolding provided by caretakers was authoritarian or neglectful, a wide range of individual problems may be created but the main legacy will be concerned with issues of control and care. Thus, the child of a parent offering critical, conditional care may be critical of Self and expecting of criticism from others, possibly manifest in perfectionist striving or placation and depression, and may also be critical of others. It is the overall pattern, not the detailed manifestations, that persists through to adult life, and should be noted and mapped in reformulations. Such patterns persist because they are the only ones known and constitute a part of personal identity, and because apparently confirmatory reciprocations can usually be elicited or “provoked” from others. These patterns may be involved in various forms of “neurotic” disorder such as anxiety, depression, or anorexia as well as in psychotic disorders (see Chapters 9 and 10).

Avoidant, Defensive, and Symptomatic Role Replacements or “Coping Strategies” Role procedures which are experienced by the child as dangerous or forbidden may be replaced by avoidant, restrictive, or symptomatic procedures. Classical psychoanalytic theory emphasizes the role of fantasy—for example, the Oedipal castration threat—but in clinical practice the “actual shape of interpersonal reality,” as experienced in the pre-verbal and later phases, offers a more parsimonious and plausible explanation, although it remains true that such experience may be amplified, distorted, or misinterpreted. The actual shape of experience may reflect direct parental prohibitions on acts or feelings, the persistence of which may further provoke guilt. Or the consistent failure to name evident facts—for example around sexuality—may mean that the child has no way of thinking about the area and may again feel unease or guilt. A depressed mother may be unable to offer the appropriate affirmations of the child’s explorations and energy, an anxious parent may convey mistrust in the child’s capacity and in the world, an emotionally needy parent may discourage independence in the child, an obsessional parent may inhibit all signs of spontaneity in the child, and a parent themself deprived and abused in childhood may over-protect the child, may envy the care the child receives, and may react abusively to the child’s anger, which may be felt to be abusive. In all these cases the child is likely to feel irrationally guilty, as if the abuse or deprivation was “deserved.” In general, young children will internalize an assumption that they are somehow “to blame,” or it is “my fault,” or “I am unworthy of care,” in the face of adverse experience; such “core beliefs” are frequently to be found within formative RRs and as such may be helpfully noted and mapped. Symptoms (affecting mood or somatic functions) and avoidant procedures can be located in the role procedures governing self-management and relationships, serving either to replace, avoid, or punish acts or feelings sensed as forbidden (“primary gain” in psychoanalytic terms), or they may serve to control others (“secondary gain”). All role procedures are, in some sense, compromise formations between the desired, the possible, and the culturally and parentally provided definitions of the permissible. The ego defenses of classical psychoanalysis are conceptualized here as aspects of RRPs in which the avoidance of feeling and memory and the editing out of certain behaviors—frequently linked to anger and

­Abnormal Development of Self and Its Consequence  59

Table 4.1  List of Some Typical (Formative) Reciprocal Role Patterns and Some Possible Consequent Reciprocal Role Procedures, all Possibly Characterized by Implicit Dialogic Voices. Parent/culture derived role

Child derived role

Possible reciprocal role procedure(s)

“Good enough” care

“Well enough” cared for

Care for self and others, cope well

“Ideal” care giving

“Ideally” cared for/ dependent

Seeking/expecting ideal care

Conditionally loving/ accepting

Conditionally loved/ accepted

Striving/placating

Over-involved

Over-dependent, suffocated

Seek over-involvement, or rebel

Critical

Criticized, not good enough

Placate, people-please, criticize self

Controlling

Controlled

Placate and submit, or control and/ or rebel

Incomplete care, unreliable

Anxious, fragile

Prematurely autonomous, interact warily

Needy, dependent, uncaring

Depended on, uncared for

Caring, “parental” child, neglect self

Abusing/exploiting

Abused/exploited

Expect abuse, self-harm, or retaliate angrily

sexuality—are linked to patterns of relating to others or in experiencing and managing the Self. A list of some typical formative RRs and RRP patterns encountered in clinical practice (and elsewhere) is given in Table 4.1.

Dissociation A third legacy of negative childhood experience, one in which inherited vulnerability to dissociation may play a part, is the failure to achieve adequate integration of Self processes. While most of us are aware of being made up of many component parts, we normally have a fairly clear sense of a central identity, are able to acknowledge all aspects of this, and can usually flexibly mobilize the aspect or enactment appropriate to the context. These features are partial or absent in so-called BPD and also certain psychotic states. In severe personality disorder, genetic predisposition—possibly involving a tendency to dissociate and/or impaired impulse control—and abuse and neglect appear to have disrupted or impaired the development of an integrating central Self (see Gunderson, Herpertz, Skodol, Torgersen, & Zanarini, 2018; Reichborn-Kjennerud et al., 2015). Much of the clinical phenomenology of BPD appears to be the result of the presence of a number of partially dissociated Self states (each characterized by a RR) which are narrowly defined and often extreme, and of rapid, confusing switches between states. These switches are understood to occur in the face of experiences of overwhelming stress and anxiety compounded by an inability to respond to these in a self-reflective, calm, and adaptive manner. When this occurs, patients will frequently put powerful pressures on therapists and others, seeking reciprocation to these extreme and unstable states. These understandings of severe disturbance and degrees of damage to the Self also offer, importantly, a dimensional approach to severity and complexity that is “transdiagnostic”

60

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

and more clinically meaningful and congruent, particularly in relation to presentations of so-called “co-morbidity.” Seen from the Multiple Self States Model (MSSM) a multiplicity of problems and symptoms would be anticipated in severe and complex damage of the Self and its processes. This approach contrasts with the “diagnostic list” clinical perspective based on measurement of overt symptoms, traits, and behaviors largely characteristic of current classification systems and, problematically, of most Westernized health care systems. Implications of Relational Adversity, Stress, and Trauma for the Developing Self

All of these structures and processes of the Self, as described in Chapter  3, may be disrupted and damaged profoundly by, especially early, experience of emotional neglect, stress, abuse, and relational trauma (Adolphs & Anderson, 2018; Corrigan & Hull, 2018; Cozolino, 2014; Damasio, 2012; Glover, 2011, 2015; Meares, 2012; Moffit & The KlausGrawe Think Tank, 2013; O’Connor, Monk, & Burke, 2016; Panksepp & Biven, 2012; Schore, 2012; Siegel, 2012; Teicher & Samson, 2016; Toth & Cicchetti, 1998), and the effects of what more recently have been described broadly as “Adverse Childhood Experiences” (see Anda et  al., 2006; Choi, DiNitto, Marti, & Choi, 2017; Danese & McEwen, 2012). Psychological trauma is now seen by most authorities to result in wide-ranging disturbances and frequently in dissociation (Corrigan & Hull, 2018; D’Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012; Hermann, 1992; Howell, 2013; Knox, 2010; Lyons-Ruth, 2008; Meares, 2012; Nijenhuis & Van der Hart, 2011; Ryle, 1997a; Van der Hart, Nijenhuis, & Steele, 2006). This has damaging effects in itself, especially if chronic and long term, and may result in damage at different levels, for example to the “core” Self, depending on the timing and extent of relational adversity and trauma. Trauma and stress is likely to have life-long (Choi et al., 2017; Teicher & Samson, 2016; Verhulst, 2017), multisystemic (e.g., neuro-endocrine) and transgenerational effects on mental and physical health. Some of these are apparently mediated by epigenetic effects (see Adolphs & Anderson, 2018; James, 2018; Plomin, 2018; Roth & David Sweatt, 2011) resulting in possibly heritable changes in mechanisms controlling levels of gene expression (as in “re-setting a thermostat”). These various changes may evidently lead to a multiplicity of clinical presentations and syndromes such as depression, anxiety, complex post-traumatic stress disorder (PTSD), and personality-type disorders, and are increasingly thought also to play a role in psychotic disorders (Howes & Murray, 2014; Trotta, Murray, & Fisher, 2015; Varese et al., 2012). It is now well known that the first few years of life (including intrauterine life) are a period of particular neural plasticity when processes of neurological development and maturation are still occurring. Hence, this is a period of particular vulnerability to stress and relational trauma (Corrigan & Hull, 2018; Cozolino, 2014; Damasio, 2012; Eisenberg, 1995; Fox, Calkins, & Bell, 1994; Meares, 2012; Moffit & The Klaus-Grawe Think Tank, 2013; Panksepp & Biven, 2012; Schore, 2012; Siegel, 2012). It has been documented in increasing detail in both animal experiments and in humans that early experiences of deprivation, stress, and trauma can have profound and long-lasting neuro-biological effects. It is not yet clear how far such neuro-biological abnormalities are reversible or modifiable by treatment, whether psychological or pharmacological, although it is now recognized (see Robertson, 2000) that the brain, even at later stages of life, may remain more plastic than at first thought. In one early classic study, abnormalities in the orbitofrontal cortex seen on functional brain scanning in obsessive–compulsive disorder or “OCD” (which may have

­Abnormal Development of Self and Its Consequence  61

been a result of the disorder) diminished following successful treatment of whatever modality (Baxter, Schwartz, Bergmann, et al., 1992). On the other hand, it has recently been shown that enduring reduction in hippocampal volume (whatever the cause) is associated with poorer outcomes following (drug) treatment (Colle et al., 2016). Some more recent evidence from, for example, survivors of Romanian orphanages a generation ago, also suggests some infants (around 20%) may be more resilient and capable of psychological catch up and “repair” following such deprivation than assumed, although the majority, especially following longer term deprivation, suffer considerable life-long damage to their physical and mental health care (Kumstaa et  al., 2017; Sonuga-Barke et  al., 2017; Verhulst, 2017). Damaged relationship patterns have also been reported in socially deprived primates and some other mammals, whose social and cognitive development is then severely impaired and in whom apparently permanent abnormalities of neurotransmitter function are seen (Schneider, Clarke, Kraemer, et al., 1998; McEwen, 2012). In general, therefore, developmental experience of relational adversity and trauma will in turn distort or restrict the internalization and subsequent enactment of the RRs and RRPs central to the CAT model of development of the Self even if they do not fully account for their subtlety and complexity. But importantly, the role enactments encountered in therapeutic and other situations may be determined in part by such neuro-biological damage. A large number of neuro-biological and neuro-psychological abnormalities have by now been documented in relation to developmental stress, relational adversity, and trauma, many of which are non-specific. They also relate possibly to genetic, or other, vulnerability to trauma, although the extent of this is debated (James, 2018; Plomin, 2018). These occur in a range of clinical disorders such as anxiety and depression and especially in more severe BPD-type disorders (see reviews by Cohodes & Gee, 2017; Dean & Keshavan, 2017; Lima-Ojeda, Rupprecht, & Baghai, 2018 and Chapter 10). These findings include volumetric abnormalities of structures such as the hippocampus, amygdala, anterior cingulate cortex (ACC), pre-frontal cortex (PFC), disturbances in neuro-plasticity, neuro-endocrine disturbance of the hypothalamo–pituitary–adrenal (HPA) axis (possibly through a stress-induced increase to the body’s “allostatic load” (McEwen, 2012), and disturbances of neuro-transmitters, such as various monoamines, and of neuroimmunological systems. Certain genetic polymorphisms may predispose to disorder especially following stress (Moffit & The Klaus-Grawe Think Tank, 2013). In experimental animals, post-natal or intrauterine stress has been observed to lead to lifetime vulnerability to states of anxiety and hyper-arousal (Glover, 2011, 2015; O’Connor et al., 2016). Chronic stress may generate permanent homeostatic abnormalities in the developing HPA system in part, as noted previously, through epigenetic mechanisms, and so adversely affect neuro-development. In the case of PTSD in humans, gross neuro-anatomical abnormalities (“scarring”) of the hippocampus were among the first findings reported (Bremner, Randall, Scott, et al., 1995). These changes are apparently mediated by the toxic effects of elevated levels of glucocorticoid hormones and of various neurotransmitters. These also have powerful effects on emotional memory and also on the reexperiencing and re-enactment of traumatic situations when triggered (see Marek et al., 2018). Life events research also clearly demonstrates a correlation between adversity and subsequent clinically evident social anxiety and phobia (Marteinsdottir, Svensson, Svedberg, Anderberg, & von Knorring, 2007).

62

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

Further neuro-psychological abnormalities following developmental stress and trauma occur in nearly all neuro-cognitive domains (De Bellis, Woolley, & Hooper, 2013). These include poorer language and memory functions, impaired visuo-constructive abilities, and include reduced academic achievement and IQ. More generally, they include findings such as increased emotional reactivity and sensitivity, hypervigilance, and paranoia. Some of these are reviewed by Bungert et al. (2015) in the context of BPD-type disorders. Findings from developmental neuro-physiology and the emerging field of “social neuroscience” (Decety & Ickes, 2009; Gantt & Badenoch, 2013) have also demonstrated the importance of neuro-hormones involved in empathy, trust, affiliation, and bonding (such as oxytocin, vasopressin, and dopamine), and also of networks of so-called “mirror neurones” (Ammaniti & Gallese, 2014; Iacoboni, 2008; Rizzolatti & Sinigaglia, 2007; Trevarthen, 2017) in the normal development of relationality and prosocial behavior. All of these may be liable to disruption and disturbance possibly as a result of developmental trauma and adversity and/or genetic predisposition. Neuro-physiologically, greatly increased so-called P3a evoked potentials in BPD-type disorders have been observed, implying a deficiency in higher order inhibition in the right hemisphere. This is adduced as support for the idea that BPD is due in part to a maturational deficit as a result of relational trauma (Meares, 2012). This may conceivably also result in impairments in, for example, affect regulation, theory of mind and mentalization, impulse control, self-reflective and executive function, as well as disordered interpersonal relations. Temperamental abnormalities, including some that are possibly gender-related (see Herpertz et al., 2017a), may also play a greater than hitherto suspected role in the occurrence or presentation of mental health problems and disorders. These may include those with overt or subclinical so-called “autistic spectrum” disorders (see Greenberg, Warrier, Allison, & Simon Baron-Cohen, 2018). The contribution of these factors to mental disorder presenting in psychiatric and psychotherapeutic practice, and the challenges they pose, are at present undoubtedly not fully appreciated (see discussion in Happe & Frith, 2014).

Broader Implications of a Relational Adversity and Trauma (“Deficit”) Based Model of Psychopathology Many of the above findings are still individually of uncertain significance and, unsurprisingly, occur in many “disorders.” Establishing the direction of causality and disentangling those abnormalities due to pre-existing vulnerability factors from those due to developmental adversity, and how they interact, is an important challenge for the future for all forms of mental disorder and for treatment. However, they demonstrate the importance of understanding the impact of possible underlying trait vulnerability as well as developmental adversity on mental function and on the nervous system. All this raises the possibility that defining some of these disturbances and abnormalities (of the Self) may ultimately guide and inform more personalized or tailored, or “bespoke” treatment programs. These may well be of differing modalities, or combinations of modalities. These abnormalities may also be potentially reversible to some extent as a consequence of successful treatment given the likelihood that, as well as neuro-biological damage occurring through psychological causes such as stress or emotional deprivation, conversely, neurological changes may be brought about by psychological treatments. This is

­Abnormal Development of Self and Its Consequence  63

a further argument against any mutually exclusive biological or psychological models of mental disorder (see also Gabbard, 2000). Most researchers do stress the etiological role of developmental stress and adversity in most mental health problems and disorders, although many leading psychiatric researchers proceed to interpret these resultant disorders as essentially biological illnesses, with clear implications for treatment modality. Interpreting these findings is, however, also problematic given that the effects of, for example relational adversity, trauma, and deprivation are multiple (they are “pleomorphic”). In turn, they interact with further environmental experience and demonstrably contribute to many forms of mental disorder. Conversely, mental “disorders” are all multiply determined (with rare exceptions such as Huntingdon’s disease due to one dominant gene defect), with variable mixes of, undoubtedly interacting, causes ranging from the genetic, to the psycho-developmental, to the social and existential. But it should be remembered that “mind,” even conceived as representing the “function of the brain,” cannot be reduced to physical descriptions of the central nervous system, notwithstanding that the structure and function of the brain system will significantly influence the “operations” of the mind (see Kerr et al., 2015; Lock & Palsson, 2016; McGinn, 1989; Midgley, 2014; Northoff, 2014; Rose & Rose, 2016). Although still argued by some to varying extents (see e.g., Lewis, 1966; Metzinger, 2003; Prescott, 2015; Solms & Turnbull, 2002), it is currently inconceivable and untenable that the attempt to describe completely and account for higher mental functions solely in physico-chemical terms, as proposed in banal “mind-brain identity theory” type approaches, could be successful (see Fuchs, 2007; Gantt & Badenoch, 2013; Kerr et al., 2015; McGinn, 1989; Midgley, 2014; Nagel, 1974; Rose & Rose, 2016). This was of course Freud’s great aspiration a century ago as described in his “Project for a Scientific Psychology.” But this attempt is based on the fallacious belief that highly complex systems and their “emergent properties” can be understood by assembling models of, and describing, their component parts. In reality, when new properties emerge, new totalizing paradigms are required. Attempts to account for mental functions in terms of disordered biology by describing abnormal molecules, anatomical structures, or functional brain scans has been described as simply “referential connectionism” (McGuire & Troisi, 1998). The limits of this project are further determined by the fact that essential aspects of higher mental functions represent also the internalization of socio-cultural values and beliefs and relate to issues of meaning and purpose. The “emergent property” that is mind or the structure that is the Self, characterized by “consciousness” or self-awareness, a subjective sense of self, agency (Knox, 2010), and the experience of free will and for many of “spirit” (Kalsched, 2013; Marsh & Low, 2006; Samuels, 1985) points to the need for understandings beyond those based on physico-chemical laws. Such understandings we see as implicit in the aims of psychotherapy. It is clear that a major part of the presentation of any mental disorder of whatever severity represents the internalization of interpersonal and socio-cultural experience and their meanings. The challenge, as noted previously, is to attempt to integrate and understand these various findings meaningfully within an over-arching paradigm. From a CAT perspective (see above), we have offered a conception of “Self” as such an “organizing construct” and as the most effective and meaningful means to aspire to this. However, it will be important for psychotherapists to appreciate that some aspects of the clinical disorders

64

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

they encounter may be at least partly due to neuro-biological damage or abnormalities (whatever their origin) which may well be refractory and unresponsive to conventional talking therapies. This may include those based on conscious recall and imaginal work with retrievable memories (such as trauma-focused CBT or Eye Movement Desensitization Reprocessing (EMDR)) (see Corrigan & Hull, 2018). They may require alternative or complementary, for example trauma-processing or pharmacological, treatment approaches such as somato-sensory processing (Ogden & Fisher, 2015; Ogden, Minton, & Pain, 2006), “Havening” (Ruden, 2011), “Brainspotting” (Grand, 2013), or Comprehensive Resource Management (CRM) (Schwarz, Corrigan, Hull, & Raju, 2017), possibly creative or body therapies, or newer approaches such as psychotropic drug-assisted therapeutic processing, for example using MDMA, Ketamine Psilocybin, and LSD (see Mithoefer, Grob, & Brewerton, 2016; Schenberg, 2018). Some of these challenges are discussed further in Chapter 9. However, most commentators stress the need for all such work to be embedded within or “nested” within a secure relational framework and a number of CAT therapists have been successfully undertaking this type of work within a CAT framework (see review by Shea, 2018). The clinical implications of some of these issues are discussed further in Chapter 9. The emerging body of evidence noted above, combined with sociological evidence, dating back to the pioneering work of Brown and Harris on the social origins of depression, and that of Bowlby within attachment theory, clearly indicates that the principal cause of common mental disorders is actual experience of psychological trauma, relational and social adversity, and abuse or emotional deprivation (Bowlby, 1988; Brown & Harris, 1978; Harris, 2001; Weich & Lewis, 1998; and see James, 2018; Weich, Patterson, Shaw, & StewartBrown, 2009; Wilkinson & Pickett, 2009). Historically, this also supports the hypotheses of various writers in, broadly speaking, the “deficit” tradition of theories of psychopathology (see discussion in Bateman & Holmes, 1995; James, 2018; Schwartz, 1999). This would include historic figures such as Ferenczi (see Stanton, 1990), discredited at the time for holding such views on the importance of real life trauma and on the reparative aspects of psychotherapy; Sullivan (1953), with his emphasis on the damaging effects of stress and anxiety on development; and some of the British object-relations school such as Guntrip, Winnicott, Sutherland (see review by Sutherland, 1980), and Khan (1973) with his theory of subtle, “cumulative” trauma. Bowlby (1988) and the attachment theory tradition he engendered produced important evidence on the developmental significance of neglect, adversity, and trauma. Kohut’s (1977) self psychology model also departed radically from classical psychoanalytic theory in stressing the importance of empathic care-giving in development and therapy. Recent findings in the field of infant observation have also confirmed the damaging developmental effects of early deprivations (e.g., through maternal depression) (see above). A fully centered, integrated Self is, however, a rare achievement, as famously noted by Fairbairn (1952). Through the course of adult life, the repertoire of formative RRs and the inner conversation comes to include roles and voices from all stages of life, embodying feared, hated, admired, and loved others, each capable of representing systems of value and belief. “I” may relate to, or be constituted by, all or any of these. This implies that the therapist’s task is to identify and help to challenge the restrictive and damaging RRs and associated voices and to encourage the emergence of a more reflective, independent, superordinate,

­Common Therapeutic Factor  65

and complex “I.” To indicate this, CAT therapists often include in the diagram an image of an “observing eye” of the patient which is outside the system: the eye which becomes an “I” (see further discussion in Marx & Marx, 2012). This underlines the emphasis in CAT on extending and equipping conscious, self-reflective thought through a benign, new relationship in order to enable change. In addition to the overt effects of early deprivation and trauma in damaging the Self and on mental health, more subtle, damaging effects on general health and well-being have also been demonstrated as a result of psychological “attitudes” acquired during an upbringing in low status socio-economic groups (Bosma, Dike van de Mheen, & Mackenbach, 1999) or in indigenous or deprived and “marginalized” “communities,” possibly of minority status (Kirmayer, 2005; Kirmayer, Gomez-Carrillo, & Veissière, 2017; Kirmayer & Ryder, 2016; Kirmayer, Simpson, & Cargo, 2003; Kopua, Kopua, & Bracken, 2019; Mills, 2014). These “attitudes” can well be understood in terms of internalized reciprocal roles and their enactments. Such a model of psychopathology or of disorder and damage to the Self also highlights the need for strategies to identify developmental trauma and deprivation as it happens and to undertake preventative action. This has important social and political implications and has been in recent years an area of increasing interest in studies of child development and psychiatric epidemiology. Increasingly sophisticated analyses of populations at various degrees of risk are being undertaken, along with definition of possible types of intervention that might reduce it (Albee, 1998; Mrazek & Haggerty, 1994). Some of these will be social rather than psychological. Apart from direct intervention with children, psychotherapy may, however, also play an important role in, for example, treatment of parents who may be at risk of damaging their children through their own disorders. Such models of developmental psychopathology may also play an important role in suggesting what sort of interventions, social or psychological, may be helpful. An innovative, CAT-based, early intervention service for youngsters at high risk of developing borderline personality disorder, or features of it, has been developed in Australia with encouraging results (see review of such approaches by Chanen & Thompson, 2014 and Chapter 10)

­Common Therapeutic Factors Change in psychotherapy, or change to the structure and processes of the Self, is in part the result of those factors common to the majority of approaches, namely the experience of a relationship with a recognized expert who offers close attention and respect and provides some new framework of understanding—all of which serves to restore morale. The early negotiation of a definition of the problem in a language shared by patient and therapist is also helpful (Frank, 1961). CAT would aim to address all of these factors. As an individual therapy, it fulfills all of the criteria for effective therapies acknowledged in standard therapy texts and treatment guidelines (see Castonguay & Beutler, 2006; Gabbard, Beck, & Holmes, 2005; Greenberg, 1991; Kazdin, 2009; Lambert, 2013; Norcross, 2011; Roth & Fonagy, 1996; Wampold & Imel, 2015; Westen, Novotny, & Thompson-Brenner, 2004). Such treatments should be well structured, have a clear focus, devote effort to enhancing collaboration and compliance, be theoretically coherent to both therapist and patient,

66

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

encourage a powerful attachment relationship, and be well integrated with other services. These are all features of the current CAT model, which in addition, arguably uniquely, offers a clear, structured relational framework from within which to understand complex and challenging disorders, and to undertake a range of therapeutic activities. The recognition of the importance of intersubjectivity has, in some psychoanalytic circles, altered the traditional interpretive stance. The description of “implicit relational knowledge” and of its modification through the “shared implicit relationship of therapy” by the Process of Change Study Group (Beebe, 1998; Lyons-Ruth, 1998; Stern et al., 1998; Tronick, 1998) has some parallels with the CAT model of RRs and RRPs and their modification in therapy. Implicit relational knowledge is described by this group as procedural and is distinguished from what is conscious and from what is dynamically repressed. The recognition of this kind of knowledge in the development of CAT was first based on the experience of feeding back repertory grid analyses to patients (Ryle, 1975). Implicit relational knowledge is seen to create an intersubjective field which includes reasonably accurate sensings of each person’s ways of being with others, a process described in CAT as the enactment of reciprocal role procedures (Ryle, 1985). Description of this process has, of course, become fundamental to CAT theory and practice. In the “dyadic expansion of consciousness” hypothesis, Tronick (1998), with reference to mother–child and therapist– patient interaction, suggests that each self-organizing system can be expanded into more coherent and complex states in collaboration with another. These are described as “moments of meeting” and are considered a crucial aspect of therapeutic change. Here, too, some convergence with the dialogic model of CAT is apparent. However, it is not clear from these accounts what modifications to traditional analytic practice are being suggested. This would be important given that, in our view, many aspects of traditional psychoanalytic practice are actually antithetical to the joint recognition, acknowledgment, and changing of roles and procedures (Ryle, 2003).

­ amaged or Abnormal Development of the Self and the CAT D Model of Therapeutic Change Many therapies, including some derived from the psychoanalytic tradition, see parallels between the process of childhood learning and therapy. Whereas in some forms of psychoanalysis this has meant that “deep” change is seen to depend upon a process of regression and recapitulation, in CAT the emphasis is on working with the adult prospectively to enlarge the capacity for conscious self-awareness, and enable potential changes to the structures and processes of the Self, through the reformulation process. Reformulation makes recognition possible and recognition opens the way for revision. It is based on description rather than interpretation. Understanding and control are derived from this joint work of therapy in which the therapist offers a reparative scaffolding designed to allow the maximum opportunity for the patient’s own initiative by working together to create and use carefully developed conceptual tools. In most cases, direct attempts to modify defensive and symptomatic procedures are not needed; they fade from view as the agenda shifts to the revision of the associated or avoided role relationships determining self-care and interactions with others.

­Damaged or Abnormal Development of the Self and the CAT Model of Therapeutic Chang  67

In the course of reformulation and with the help of symptom monitoring, most somatic and mood disorders can be identified as accompanying defined RRPs, either those that are continuations of early damaging patterns or those that have replaced the more effective modes which were disallowed by others or by an internalized voice derived from others. An internal prohibition on anger, for example, is likely to be accompanied by submissive behavior to others and by guilt and anxiety if anger is experienced; depression and somatic symptoms are common accompaniments. Reformulation will focus attention on the procedure rather than the symptom. As patients begin to apply their new understandings, as they experience the reality of the therapist’s concern, and as the expressions of their problematic procedures in the therapy relationship are described and not reciprocated, symptoms and negative moods usually fade without direct attention. Practitioners who use both CBT and CAT usually use CBT with more cooperative and less disturbed patients. It is our impression, however, that even in such patients the CAT “top down” focus on high level self processes (which can incorporate more focal attention to lower level issues if this is indicated) is as effective and quite possibly quicker than CBT in controlling symptoms, while also dealing with interpersonal and self-managing procedures and avoiding its possibly diminishing (or “Magistral”) assumptions. Some therapists from a CBT background, or indeed many other health care backgrounds, may feel a need to be busy and helpful, and can find the less active, relational, and reflective CAT mode difficult. With more disturbed patients, the understanding and use made of the difficult therapeutic relationship in CAT is a boon to both patients and therapists and can be extended, in some situations, to other members of a treating team or ambient system (Clinkscales, Tan, & Jones, 2018; Jones, Annesley, & Gilley, 2012; Kerr, 1999; Kemp, Bickerdike, & Bingham, 2017; Kerr, Dent-Brown, & Parry, 2007). Vygotskian ideas of relevance to therapy are those which are derived from the understanding of the formation of Self processes. They indicate the need for the therapist to: (a) “scaffold” learning in the patient’s zone of proximal development (ZPD) (perhaps alternatively labeled here the zone of proximal personality development, ZPPD); (b) provide a significant, empathic relationship; in which (c) appropriate mediating “tools” are created. The relevance of this fertile concept of scaffolding to therapy was noted in Ryle (1982) and had some influence on the later development of CAT; through this, the object relations ideas in CAT were modified in a way emphasizing actual experience. In their exploration of the world, children constantly encounter a reality which is imbued with the meanings conveyed by others. Through the early joint, and the later, increasingly sign-mediated, activity of the mother–infant dyad (Leiman, 1994b), children learn both the meanings of reality and the definitions of self and other. The “learning” involved in personality development differs from intellectual learning in many ways. Formal rules of conduct and explicit social norms have a small and late impact compared to the indirect transmission of values and assumptions about the world and the self through the child’s joint activities with others in the early years. These formative experiences are the source of most of the issues addressed in psychotherapy. What is learned through them is, to a greater or lesser degree, unreflected upon. This is not to say that later life experiences of deprivation, adversity, or frank abuse and trauma may not also have profound or catastrophic effects on mental health. The child’s sense of self and emergent repertoire of reciprocal roles will largely reflect the style in which the scaffolding for early learning is supplied. For example, this may be

68

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

sensitive, over-controlling, inconsistent, abusive, or deficient, and will determine how small or large a range of possibility was conveyed and how much support and how much space for initiative seems to have been offered to the child. The values and procedures governing the sense of self and of others will be shaped and limited in these ways. Therapists need to work with their patients through identifying these restrictions and distortions by offering a different, respecting, and accurate scaffolding in the patient’s ZPPD. The use of these metaphors of scaffolding and of the ZPD (or “ZPPD”) offer crucial insights into the process of therapy and will recur throughout this book. They must be used with caution in one respect: the zone is not a place and the scaffolding is not a structure and neither is static; as development and therapy proceed, both undergo continual revision. With change from therapy or from important others (such as a teacher, mentor, partner), the extent of the zone may be extended and new forms of scaffolding may be called for.

­ nderstandings of “Transference” and “Counter-Transference” U and Avoiding Collusion In every relationship, people bring from their developmental past their own repertoire of RRs and RRPs and expect or attempt to engage with others in terms of one or other of their familiar patterns. They (we) will usually unconsciously seek out others who have, or whom they believe to have, a matching repertoire, with shared or reciprocal features. If they do not get the expected and desired reciprocations, they may attempt to extract them forcibly or they may give up. In close, emotionally significant relationships the reciprocal roles will usually repeat patterns evolved in early personality development and reflect basic assumptions about trust, acknowledgment, care, and power. From a CAT perspective, transference and counter-transference are understood as the enactments of particular sets of such RRs and RRPs within the context of the therapy relationship (and see Ryle 1997c). A major contribution of Freud’s early work was his recognition that, when his patients demonstrated feelings and behaviors which he felt were inappropriate to the situation, they were manifesting assumptions originating in childhood. This “transference,” first thought of as an obstacle, was soon seen to present a direct opportunity to address the patient’s problems by recognizing, interpreting, and not responding in the ways expected or wished for by the patient. The origins of psychoanalysis in hypnosis, with the patient recumbent and (in Freud’s case) with the analyst being out of sight, combined with the classical analyst’s principled denial of ordinary conversational responses, means that a particular form of transference is liable to be elicited. This is typically one in which initial dependent idealization is followed by anger and a regression to more childish modes. This supposedly “neutral” stance of the analyst was claimed to be the necessary way of achieving an understanding of unconscious processes, and over the course of the last century many influential schools of psychoanalytic practice have proposed an increasingly exclusive and intensive attention to the regressed relationship evoked by the technique (see Bateman & Holmes, 1995; Schwartz, 1999). However, the traditional assertion that cure may be effected through interpretation alone of such a transference neurosis (representing in any case only one enactment from a patient’s repertoire of RRs) has not been substantiated. Indeed, there is evidence that the therapeutic outcome may be inversely related to frequency of transference interpretations

­Understandings of “Transference” and “Counter-Transference” and Avoiding Collusio  69

(Piper, Hassan, Joyce, & McCallum, 1991). Recently, more attention has been paid by some to the limits of classical psychoanalysis, and Stern et  al. (1998) propose that “something more than interpretation” is needed, notably attending to the importance of procedural learning and of “implicit relational knowledge.” These ideas were influenced by the important infant observational research outlined Chapter 3, some of them by the authors of the paper. However, Trevarthen (2017) offers a somewhat different view of the therapeutic implications of the findings of recent decades of research in infant psychology. There are obvious convergences with CAT in the position of Stern et al., but many theoretical obscurities remain, and the revisions of psychoanalytic theory are not clearly translated into helpful revisions of practice. In particular, from a CAT prospective, as also noted above, we have cautioned that—for more damaged and disturbed patients especially—explicit, empathic, collaborative reformulation of presenting problems and their relational origins may also be required, as well as more proactive work on changing and revising unhelpful patterns of coping and of relating (Ryle, 2003). Having a therapist whom one likes and respects is effective in assisting change in patients with mild or moderate levels of disturbance, and in these cases psychotherapy “technique” is of limited importance, provided it does not damage the quality of the relationship. In more disordered patients, however, the maintaining of a good relationship and the provision within it of useful understandings is often problematic as patients disrupt or distort it, just as they do their everyday relationships. In these cases, the specific CAT techniques and understandings play a key role in establishing and maintaining a working relationship; without them, therapists are likely to be drawn into inadvertent collusion which will reinforce problem procedures or lead to the end of the therapy. The most problematic collusions are those which are justified by the system belief guiding the therapist, especially when these prescribe withholding or controlling attitudes which commonly echo the patient’s childhood experiences (although becoming over-involved and excessively sympathetic to a patient can be just as unhelpful). Only an accurate and sensitive awareness of the evolving therapy relationship, aided by supervision, can allow the establishment of a therapeutic relationship which is emotionally intense, honest and thoughtful, and which generates well-focused mediating conceptual tools which can be internalized as a corrective to, or replacement of, the previous damaging and restricting patterns. In summary, the CAT understanding of therapeutic change requires the following: 1) The creation and maintenance of a non-collusive, empathic, and respecting relationship with the patient. 2) Making meaning and “validating” a patient’s often confusing and distressing story, aided by the collaborative creation of mediating tools (descriptions, diagrams). These make the patient’s specific problematic procedures and structures available for conscious reflection. In most cases the “ZPPD” is seen to include the high level “strategic” procedures operating in relationships with others and in self-management. More focal and limited issues may be addressed within this overall procedural understanding. 3) Movement through the stages of reformulation, practice in recognition, and the process of revision or replacement of problematic procedures. The process is not a simple linear one as the safety established through reformulation may allow access to previously avoided affects and memories that need to be addressed and worked on.

70

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

4) “Ending well”—aided by the time limit and the use of concrete, collaboratively constructed conceptual tools including the goodbye letter—encourages the internalization of what has been experienced and learned in therapy. This will include the new benign experience of the therapeutic relationship itself. It aims to encourage and support a patient to move on, and also to enable the therapist to avoid the temptation of an “interminable” long-term relationship, possibly characterized by dependency and/or mutual narcissistic gratification, which may be quite unhelpful.

­Use of Personal and Elicited Counter-transference From a CAT perspective, it can be helpful to distinguish two sources of counter-transference. One, which may be called personal counter-transference, will reflect the therapist’s particular range of role procedures. These may include unhelpful vulnerabilities such as an undue wish to be depended on or to control, or a tendency to avoid anger, or trivial personal quirks like a dislike of fat people. Whatever they are, patients will seem to be remarkably skilled at eliciting them. Trainee therapists need to use supervision to become aware of their particular tendencies; in due course one can learn to recognize the “temptation” to collude and use it as evidence about the patient’s procedures. This recognition may point to personal issues that can be explored in the personal experience of CAT that is now mandatory for practitioner level trainees. Such personal counter-transference is not totally distinct from the specific reactions evoked by the particular patient, which can be called the elicited counter-transference, for the individual threshold for different feelings and behaviors is bound to vary. The important thing overall to bear in mind is that we all bring our own “maps” to the work of therapy, as well as to life in general.

­Identifying and Reciprocating Counter-transference Within elicited counter-transference reactions there is another useful distinction to bear in mind: that between identifying counter-transference and reciprocating counter-transference. This distinction bears some similarity to the historic concepts of concordant and complementary counter-transferences described by Racker (1968). This distinction in CAT stems logically from the model of the relational and dialogic Self. A person enacting one pole of a RR may either (a) convey the feelings associated with the role to others, in whom corresponding empathic feelings may be elicited; or (b) seek to elicit the reciprocating response of the other. These processes may involve direct speech and action but are often powerfully conveyed non-verbally by tone, posture, and expression.

­Self-Esteem Many descriptions of psychiatric syndromes refer to the level of “self-esteem.” It is, for example, allegedly low in depression and excessively high in hypomania. The term is used more often than it is defined and is sometimes taken to represent a stable character trait.

­The “False Self  71

It may be helpful to assess not only the level of self-esteem but to work out what maintains it. Any maladaptive procedure, as listed in the Psychotherapy File, if persistently enacted might result in low self-esteem. Arguably one of the most fundamental and defining procedures contributing to low self-esteem would be one based on historical experience of criticism and/or neglect (leading to an assumption of worthlessness) and of experience that leads to an assumption that “whatever one does, nothing will ever work out.” The result of the latter may be that one gives up trying with the consequence that nothing changes or improves, so perpetuating the original assumption. Low “levels” of self-esteem may reflect (a) external realities such as unemployment, poverty, and social powerlessness (see Hagan & Smail, 1997); (b) restrictive procedures such as the traps listed in the Psychotherapy File, dilemmas such “as if either a brutal success or a nice failure,” or snags whereby success is felt to be undeserved or forbidden; (c) dominant patterns of reciprocal role relationship, for example having a “critical/conditionally accepting or loving” to “conditionally loved and guilty/striving” pattern which is manifest in unreasonable, idiosyncratic, and extreme conditions for self-acceptance and in the taking on of submissive or humiliating roles in relationships. Understood in these terms, recognizing low selfesteem is only the first step; the range of underlying maladaptive RRs and procedures needs to be identified and accurately described. The Personal Sources Questionnaire, described in Ryle (1990, pp. 249–252), can help the systematic exploration of individual sources of self-esteem.

­The “False Self” This somewhat loosely used term suggests a person whose sense of self is anxiously overdependent on the responses of others, who may enact defensive, for example striving, placatory RRPs, and is therefore in some sense out of touch with or defended against “authentic,” possibly painful, feelings. In CAT theory, where conscious experience is seen to be mediated by signs created with others, what is the basis for a distinction between a “true” and a “false” self? Both the development of the Self and restrictions upon its development are determined by the form and content of the scaffolding provided or imposed by parents and society. While the shaping of personality in terms compatible with the society is a necessary and inevitable process, there are some societies, or some sections within societies, and some families, and maybe some therapies, in which compliance to social norms leaves little room for individual exploration. Their scaffolding imposes narrow solutions and fails to provide the materials for personal learning. Seen in this way the concept of the “false self” implies a restricted sense of self and, given our quintessentially social character, a consequent sense of inauthenticity or not being “in dialog.” It suggests that the concept of the ‘false self’ may be seen as a shorthand for a certain group of RRPs (for example “striving to please,” “putting up a front,” “seeking to be treated as special”) which result in the features described above. These would also importantly result in being “out of dialog” with self and others. Such a presentation would be very common in Narcissistic Personality-type disorders (see Chapter 10). This conception also implies an extensive ZPPD within which personal development might occur provided that therapy can offer a reparative, constructive experience and a meaningful dialog through which change may occur.

72

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

­Who Does the Therapist Speak for? Every family and every culture will determine and set some limit on what may or may not be said and done; the dominant range of social values and attitudes will be made evident by what is celebrated, what is acknowledged, what is discouraged, and what is ignored and by how power and privilege are distributed. In this way every individual’s internal regime (including the psychoanalytic “unconscious”) will contain the voices of the external social and political reality as refracted by parents and teachers. Therapists have themselves ­usually, although by no means always, been formed in the same society as their patients but, in many cases, are seeking to offer a different perspective in order to remedy the effects of harsh external social realities and of forms of control which have been internalized by their patients. So, who is the “super-addressee” in therapeutic dialog? To what social agency or what value system does the therapist refer in his or her comments? We seek to extend awareness, choice, and control, but we inevitably convey some more specific social values for, although procedural descriptions can be understood in utilitarian terms as simply pointing out the unwanted consequences of current behaviors, most therapists do not conceal their ethical concerns. Thus, most, when considering damaging relationship patterns, will favor revisions toward more mutual and respecting modes and all will vote with varying force against murder, child abuse, wife beating, and racism. In less extreme ways, many personal restrictions or deformations, while socially congruent and adaptive, seem to contradict the therapist’s broader definitions of human values and needs. In these circumstances the neutral therapist is a myth; tacitly he or she is either challenging or identifying with current social power. If a patient holds views which the therapist cannot stomach it may be impossible to work effectively, but assuming or imposing normative ethical values should be done with extreme caution (and see Chapter 9). One should remember that many therapists have argued (and some still do) that homosexuality should be “cured” and that working class or illiterate patients cannot use therapy. As psychotherapists, a heightened self-awareness of our tacit social assumptions is every bit as important as the forms of self-knowledge which may be acquired through personal therapy. We do want to have influence in order to help our patients change but we do not want to impose compliance with our personal views. Whether we identify ­ourselves as agents or as critics of society, we should be explicit when we voice or convey an opinion and should emphasize that our aim is to extend conscious choice not to impose solutions. To this end, we should encourage a therapeutic relationship that is argumentative as well as collaborative. We need also to avoid too literal an understanding of the ­stories patients tell. While the origins of the internal conversation may usually be directly linked to historical experiences, it is of course the case that children may misjudge and misremember their experience (Offer, Kaiz, Howard, & Bennett, 2000) and the extent of their own responsibility and the meanings and intentions of others. The range of ­characters and behaviors described in fairy tales are often extreme in the degree of their wickedness or their perfection; but apparently they still appeal to children whose life experiences have been relatively benign and mild, serving as concrete representations of their fantasies and misinterpretations.

­Implications of Our Evolutionary Past for Psychotherap  73

­Implications of Our Evolutionary Past for Psychotherapy Human personality is determined by the interaction between individual variations in the human genome and the practices, beliefs, and language of the culture into which the individual is born. The scope for individual differentiation is huge, allowing genetically similar infants to grow into all the diverse contemporary and historical cultures. However, these cultural influences and social realities do not always prepare individuals well for the world into which they are born, and psychotherapists are largely engaged in trying to correct the resulting deformations. This may also involve them in identifying some of the requirements of the culture as damaging; the aim of therapy cannot be adaptation to every kind of political system. The relationship of psychotherapy theory to the dominant beliefs and values of our contemporary societies is an area with political and moral implications that deserve more attention. The biological versus cultural debate is related to this: while psychotherapists need to accept the power of those biological factors that cannot be influenced by therapy, whether due to genetic or organic factors, theories which exaggerate biological and minimize cultural influences generate forms of treatment which in reality impose or justify a diminished status for the patient. Most therapies rely heavily on speech, but few make much use of the concrete semiotic artifacts which, in evolutionary history, played so important a part in intellectual development. CAT makes use of writing and diagrams (as “psychological tools”) in the reformulation process, just as our ancestors 10,000 years ago used their mnemonic devices, because the availability of these for re-reading and repeated application to events provides a much more powerful input than do purely verbal comments. They also constitute a concrete expression of shared meaning-making and support (analogous to “transitional objects”). One main purpose of reformulation is to make explicit, and therefore available to ­reflection, the patient’s unreflected-upon interpersonal and internalized RRs and RRPs. Through joint, descriptive reformulation, CAT opens these early learned patterns in humans to discussion, reflection, and action. The use of words and symbolic devices does not mean that other forms of communication are left out; however, much of the “chemistry” of an established therapeutic relationship depends on “mimetic” communication. What are often described by dynamic therapists as intuitive responses to “the unconscious” are more probably reactions to unidentified mimetic communications, especially those not congruent with what is said, of which the patient may or may not be aware. The use of words or diagrams to explore and describe these can help bring them into full awareness and into the therapeutic conversation. The evolutionary story also suggests some ways in which psychotherapy in general and also CAT practice might be extended. For some people, as group therapists are aware, group experiences, with their capacity to mobilize parallel mimetic communications, in addition to explicit sharing and appreciation of stories and of support, have powerful alternative or additional effects to the dominantly verbal interchanges of individual therapy. For others, drawing and painting may provide a more powerful form of externalization and symbolization than language or the abstract diagrams of CAT; some CAT therapists do in fact combine the

74

The CAT Model of Abnormal Development of the Self and Its Implications for Psychotherapy

more “conventional” tools with these methods. Role play and psychodrama, with their ritual components, combine the use of mimetic communication with the permitted expression of inhibited or forbidden affects. More active bodily involvement through dance, rhythmic exercises, and music-making, which are essentially mimetic modes, have a long history as healing rituals in “less developed” societies but are much less used in ours (see discussion in ComptonDickinson & Haakvoort, 2017; Wigram, Nygaard Pedersen, & Bonde, 2002). In treating psychological distress accompanied by somatic symptoms, the fuller integration of physical treatments might be of value. These would address what in CAT terms would be seen as the incorporation and enactment of RRs and RRPs in body states and “language.” This would also constitute a recognition of the way in which somatic symptoms may be understood as signs. The most widely applied methods in current use are those seeking to ease the secondary somatic effects of anxiety through relaxation, a procedure at once bringing ease and restoring some sense of control to the patient. Forms of meditation usually include physical relaxation as a means of diminishing symbolic mode thinking. These various procedures, it should be noted, are normally provided in therapeutic contexts which convey permission, acceptance, or membership and serve to ease the demands and remedy the psychologically toxic isolation experienced by many and certainly in our individualistic Western cultures.

­Concluding Remarks Given the above considerations, to be doing CAT, a therapist must, at a minimum, engage with the patient in an empathic process of meaning-making and descriptive reformulation, itself a powerfully alliance-generating activity, and must aim to use the descriptions and the therapy relationship to help modify the identified problematic enactments, including especially those at play within the therapy relationship. This basic practice involves even unrepentant Cartesians in a form of relational and dialogical understanding and exchange. However, the detailed application and the further development of the model require that practice is rooted in an empathic, relational, and dialogic theoretical understanding. Knowledge, memory, meaning, affect, and action, although to some extent differently ­processed in the brain, are joined in life and are considered together in procedural descriptions. They are formed and maintained in relation to past and present others. This understanding involves the linking of a developmental and socio-cultural history with current Self structures and current relationships and requires the description of: (a) internal and enacted reciprocal patterns of relationship and dialog; (b) procedural sequences; and (c) structure. The latter involves: (a) hierarchy (how tactical procedures are determined by  strategic ones); and (b) coherence and continuity of the Self whereby a system of ­metaprocedures can organize and mobilize procedures and enable a sense of agency and relatedness. Therapy represents the modification and development over time (which may often be much less than traditionally postulated) of the patient’s Self system by conscious, collaborative sharing of these understandings and by narrative meaning-making, and by the deeply felt, sometimes relationally challenging, mutual therapy experience.

75

5

The Practice of CAT Selection and Assessment of Patients for Therapy S ­ ummary Cognitive Analytic Therapy (CAT) is applicable to a wide range of disorders of varying severity and in a range of contexts. It is important nonetheless to undertake a thorough assessment with prospective patients in order to establish the nature of their problems, the presence of any risk factors, and their particular suitability or wish for this form of therapy. The experience of an assessment interview should give patients an impression of the style of CAT and contribute to their motivation and “psychological mindedness.” In CAT, these are not seen as “all or ­nothing” phenomena nor prerequisites for therapy but rather as something that therapy may cultivate and expand. Some problems may require other or additional forms of treatment, ranging possibly from pharmacotherapy to social therapy. There may be reasons not to undertake therapy at a given time due to, for example, active substance abuse, threat of violence, or active psychotic disorder. Assessment may be assisted by use of the “Psychotherapy File,” the Personality Structure Questionnaire (PSQ), and, for example, the generic “CORE” ­questionnaire. These issues are illustrated by several brief case illustrations.

R ­ eferral CAT offers a general model of psychotherapy applicable to a wide range of disorders and severity, but each patient needs to be considered in relation to both their problems and the treatment context. In some settings there may be a range of therapy options available, in others there will be little choice. In long-established out-patient departments in health service settings referrers will hopefully have learned which patients are suitable, but there will still be inappropriate referrals. Where psychotherapy is carried out in the possibly more psychologically hostile environments offered by some psychiatric services, inappropriate referrals may represent the “dumping” of difficult cases, most often personality-type disorders or somatizing patients, or examples of the “treat that if you dare” referral of “hopeless” cases. Whatever the referral route, therapists have to make their own decisions about which patients to accept for treatment, albeit ideally in the context of some form of case discussion

Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, Second Edition. Anthony Ryle and Ian B. Kerr. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

76

The Practice of CAT

forum or supervision. Therapists working privately and with essentially self-referred patients will need to be particularly alert to the presence of more severe psychiatric disorder and to the assessment of potential risk from more distressed and disturbed patients.

­Assessment Information CAT adopts a highly inclusive approach to offering therapy to many patients who would, for various reasons, be deemed unsuitable for therapy within many other models. It can achieve considerable success with many such patients given its prospective, proactive, and empathic style and its collaborative focus on engagement and alliance building. However, some people may still be unsuitable for psychotherapy, at least at the time of assessment. These include those with acute psychotic disorders, active and continuous substance abuse (who may nonetheless be able to engage with concurrent or prior assistance with such problems), or serious, acute physical disorders. Patients who are receiving large doses of a number, possibly a large number, of prescribed psychotropic drugs may likewise be unable to engage with therapy given the effects of medication. Those individuals who pose an active risk of violence based on either past history or present behavior should be taken on only with due circumspection and regard for safety and level of potential support. Depending on the context and referral route, a proportion of patients will be unsuitable for psychotherapy and may need to be referred for psychiatric assessment and management. Therapists should be alert to, and able to identify or refer for a further opinion, conditions such as severe depression (particularly if an individual describes serious self-harm intentions), bipolar affective disorder (“manic-depression”), “schizophrenia”-type and delusional or paranoid disorders, early dementia, and other organic, especially neurological, disorders which may present as psychological impairment. Many of these disorders may still be partly amenable to and helped by psychological treatment, but will require particular consideration, caution, and usually collaboration with other health professionals. It is always wise for psychotherapists to enquire routinely about drug use, whether illicit or prescribed. Basic teaching on these topics should normally be offered on any psychotherapy training and these conditions are described in any basic psychiatric textbook (see Harrison, Cowen, Burns, & Fazel, 2018; Sadock, Sadock, & Ruiz, 2014). Even in cases apparently suitable for therapy, the following questions should also be addressed. Might other modalities of treatment such as group, couple, or family therapy be indicated rather than individual work? Are there contraindications (possibly amenable to prior treatment) in the form of severe psychiatric disorder or substance abuse? Is the patient’s current social and personal situation sufficiently stable to allow therapeutic work? Is there an unacceptable risk of violence (assessed in relation to the treatment context), or of suicide? If any such risk is evident, are supportive or psychiatric facilities available if needed? Some more distressed and disturbed patients with, for example, personality-type difficulties may well be better treated, if possible, by a multidisciplinary team, which may be CAT-informed or trained. This can offer broader treatment options and containment, and minimize the stress on an individual therapist as well as the risks of collusion. In addition to considering these background factors, the assessor, when responding to the patient’s story or commenting on the way the interview has been coped with, will propose

­The Conduct of the Assessment Intervie  77

tentative explanations and links, including possibly in relation to “transference” and “counter-transference” reciprocal role (RR) enactments. This will give some idea to the patient of what is being offered and give some idea to the assessor of the “motivation” and “psychological mindedness” of the patient. Concerns in relation to these would include patients who, despite attempts at reflection and joint discussion, persistently and rigidly “externalize” their problems and ascribe them to outside factors or persons. These might include extremely fixed beliefs about the somatic, “biological,” or possibly spiritual nature of their problems, the role of current social adversity, or rigid religious beliefs and practices The latter should not be a rigid exclusion criterion given that such issues can be worked with productively in therapy in the context of a respectful, culturally sensitive, joint exploration of meaning. This should in any case be routine across various different cultural contexts and countries, a challenge for which the approach of CAT is appearing to be broadly helpful (see discussion in Chapter 9). The style of the interview should already provide an experience of an empathic, collaborative, “doing with” approach. How patients engage in this and interact will provide some idea of their ability to make use of therapy but this does not imply that CAT requires patients to be already “psychologically minded.” It is their response to appropriate therapeutic activity and explanations that determines “treatability.” Greater psychological mindedness can be one outcome of the assessment interview, and assessment interviews often initiate the therapeutic work. In rare instances this may in itself constitute a “good enough” therapeutic experience. The early sessions of therapy are likely to include further assessment procedures such as symptom monitoring and diary keeping focusing on particular relational problems or dysfunctional patterns.

­The Conduct of the Assessment Interview Before meeting with the patient, the therapist should read any referral letter and any other relevant clinical notes and questionnaire results. These may convey important information such as suicidal preoccupations or abuse histories about which patients may be reluctant to speak. Patients should be told what information has been received, but in general should be invited to give a broad impression of how life is at present and to retell their story in their own words. Any reluctance to speak at this stage should be noted but accepted. The purpose and duration of the assessment meeting and the role of the assessor should be made clear, as should the issue of what will be recorded and how much detail would be communicated and to whom (e.g., to a referrer). Most CAT therapists nowadays would routinely wish to include the patient in any correspondence that is undertaken, other than possibly in rare circumstances such as, for example, those involving apparent serious risk to others. In our view it is important to be transparent, respectful, and collaborative in these matters from the very onset. Sadly, this may be a new experience for some patients who have been treated within formal psychiatric services. Thereafter the interview should be largely unstructured, because what the patient chooses to say and how it is said may convey as much as the content. However the therapist needs to be aware of his or her implicit agenda and may use prompts or direct questions to open up important issues which are not volunteered and to explore the feelings and meanings associated with issues that may be under-reported and left unexplored by clinicians,

78

The Practice of CAT

such as a possible history of trauma or childhood sexual abuse. With regard to the latter, authorities in the field note that the majority of clinicians avoid asking about abuse and propose that first assessment interviews should routinely include such inquiry. They suggest that this needs to be introduced with care and suggest a progression, for example from “tell me a bit about your childhood” through “what was the best and worst things about it,” “how did you get on with your Mum and Dad,” and “how was discipline dealt with,” before asking direct questions about physical violence, disturbing sexualization, or overt abuse (Read, Hammersley, & Rudegeair, 2007). Toward the end of the interview, the assessor should rehearse the main “headlines” of the story as they have understood them, and propose possible links and patterns between reported events and experiences, possibly already mapping them out in a tentative fashion (see Potter, 2017, 2020; and Chapter 6). He or she should offer provisional descriptions of the main issues and should seek the patient’s comments. Any ways in which the patient’s problematic RRs and reciprocal role procedures (RRPs) have been evident “in the room” during the interview should be noted, including in the assessor’s counter-transference. Feelings experienced by assessors or therapists often represent a reaction to the patient’s story or demeanor (reciprocating counter-transference) or an identification with the patient (empathic counter-transference). Important communications are very often conveyed non-verbally and may not be experienced or acknowledged by the patient, or indeed by the therapist. In some cases, it can be helpful to discuss tentatively and non-judgmentally what these counter-transference feelings (RR enactments) may mean and may convey about the patient. They should also be raised and discussed if need be in some form of supervision or case review setting. This recapitulation and linking show the patient that the story has been attended to and acknowledged and provide a sample of what therapy can offer. It also allows the therapist to gauge how far the patient can make use of such comments. The patient’s own understanding about the nature of his or her problems and expectations of therapy should be clarified and any response to the interview should be invited. An outline of the CAT therapy model explaining the time limit, the reformulation process, and the expectation of some homework, and indicating broadly how the patient’s particular problems might be helped, should be given. The nature of the therapy relationship and the ways in which the patient’s reciprocal roles and procedures will almost inevitably be enacted and may affect it are stressed and explained. Given the pessimism or despair with which many patients present it is often worth stressing, without being blandly optimistic, that therapy can help considerably and enable significant life changes. However, it is also important to stress that therapy (unlike, e.g., surgery) requires active participation and that they must feel, at least in some part, “up for it.” Alternative treatments, if available, should be described so the patient can make an informed choice. Practical arrangements and an account of what is to happen next should be clarified at the end of the meeting. It is usually helpful to offer patients the chance to go away and “think about it,” and also to consider if they might rather work with a different therapist (e.g., male or female, or of different ethnicity), lest they feel pressurized unhelpfully into therapy, thereby possibly setting up an unhelpful “reluctant” or “resistant” role procedure. However, many are very clear by this point that they want to engage and get on with it. Assessment interviews are challenging, including relationally, and are not technical exercises. They call for the full range of therapy skills and for an ability to respond

­The Conduct of the Assessment Intervie  79

thoughtfully and empathically to individual patients and to enable them to reveal significant aspects of their lives, emotions, and problems, even if they had had no prior idea about what to expect. What is learned in the course of the interview can often be related to aspects of the CAT conceptual model such as problem RRs or unrevised dysfunctional RRPs and fed back to the patient (including by means of a copy of an assessment report) in a way that contributes to the establishment of a shared language. Such comments need to be tentative and the patient’s understanding and comments sought and considered, exemplifying the collaborative nature of the therapy. Areas where knowledge and understanding remain incomplete should be noted, and occasionally a second assessment meeting may be needed. In cases of doubt on the part of either patient or therapist, or possibly both, a decision about proceeding with a formal course of therapy may be deferred until reformulations have been created and the situation then reviewed. Very occasionally this may in itself be a helpful or adequate of experience of therapy, or provide a basis for further work; for example, with a community team or GP (see, e.g., Carradice, 2013, and Chapters 9 and 11). In writing up assessment interviews it can be a valuable, although time-consuming, exercise for trainees to describe in detail the evolving process of the meeting. It is even more accurate and more revealing to audiotape and replay the session and during training it is helpful, and now often mandatory, to do this with at least one patient. For experienced assessors it is enough to record the main content and themes, the feel and process of the meeting, and the assessor’s judgments and counter-transference. The account can then be re-cast in this suggested, but not definitive, order: 1) Referred by whom and reason for referral. 2) Main presenting problems and why they have led to coming at this time, along with some account of current life situation. Attention should be paid to possibly dissociative experiences occurring as a result of psychological trauma. 3) Any formal medical or psychiatric history. 4) Early history, other life events and experiences, relationships, and socio-cultural background. This should not take the form of a detailed biography simply detailing “what happened when”; rather, the aim should be to identify and describe key themes and formative relational experiences. This would include exploration of the occurrence of overt psychological trauma and abuse, if relevant. 5) Some description of current mental state which may be more or less formal depending on context. 6) Process of session and impression or counter-transference. 7) A possible formal ICD/DSM type diagnosis of any psychiatric disorder if assessment is occurring in a formal health service setting and depending on the background of the assessor. The danger of treating diagnosis as a definitive “entity” that implies certain treatment pathways should be borne in mind (see discussion in Chapter 9), as well as the fact that such a diagnosis would represent only one aspect of the whole person that CAT would aim to understand and treat. 8) A provisional formulation of how present problems are derived from RRPs developed in coping with past events and formative RRs. The formulation would aim to describe how these RRs and procedures may contribute to and influence how current life difficulties and other issues, such as unresolved mourning or psychological trauma, are coped with.

80

The Practice of CAT

It would also note whether these may constitute a risk of any sort (e.g., self-harm or, possibly, antisocial behavior) at present or possibly in the future. It would also note how these RRs and RRPs may have been played out or evident in the interview. 9) A treatment plan which would include an offer or otherwise of formal therapy and a suggestion for how long. This would normally be discussed and agreed with the patient. In team situations, final decisions about the treatment plan might be made by at a team meeting, a procedure which should guard against the influence of unrecognized mutual enactments of reciprocal roles and procedures (including “counter-transference”) on decisions. However, decisions may also be influenced increasingly by managerial and political pressure on “through-puts” and “outputs” in increasingly commercialized public health care systems. Therapists working independently may not be subject to such pressures, but other issues may prevail. These include availability of complementary treatments, or level of support in working with more challenging patients. This formal account of assessment procedures cannot convey the density and complexity of a satisfactory meeting or how much powerful feeling may be evoked by the often horrific life experiences and often admirable efforts at survival reported by patients. A more live impression may be given by the following selection of vignettes of assessments carried out (by AR) in an out-patient CAT clinic. As with all case material, these will be modified and “de-identified” to avoid recognition. The provisional identification of key RRs and RRPs given in these summaries would suggest issues to pursue and clarify in therapy and would not be considered in any way final. The cases will be summarized broadly under the headings suggested above and a brief retrospective comment on the issues illustrated by the case will be added.

Nora 1) A 28-year-old London West Indian referred by an experienced GP counselor whom she had consulted on account of her inability to show affection and her increasingly aggressive feelings toward her daughter. 2) She appears as intelligent, articulate, and insightful and her survival of a very difficult life is impressive. 3) She is increasingly concerned with how she treats, and sometimes beats, her 9-year-old child. She knows it is in part because she is like her father and in part because “she is too much like me.” The child was by the first of three relationships, the last of which she has recently ended. In all three she was clearly dominant, refusing any hint of being controlled or abused but also intolerant of her partner’s displays of affection and at times being “vicious and revengeful.” 4) She was raised in a chaotic family, the only reliable figure being one older sister (out of a total of “about 15” offspring of her mother, father, and step-father). She indicated that there were experiences she did not feel ready to talk about at this interview. Despite this background, she did well at school and attended a Further Education College until her first pregnancy. She is now working part-time and attending further education classes. 5) Apart from the older sister’s care she seems to have derived from childhood a coping RRP of defiant coping in relation to a formative RR of neglect and abuse in relation to neglected and abused. To her distress, she sometimes enacts the abusing role to her

­The Conduct of the Assessment Intervie  81

daughter. She expresses contempt for most others, especially men, although she has one intimate woman friend. Under her tough coping mode there is probably a degree of self-contempt. 6) Despite this history she was frank and open in the interview and I believe she will work hard in therapy to understand herself better but, as her main coping mode has been to avoid emotional exposure, she will find it difficult to risk contacting her childhood pain and may well be dismissive of the therapist. Comment: Admiration for this woman’s evident strength needed to be tempered with a realization of how hurt and angry she was. Therapy, if she became involved, would mean contacting and expressing powerful feelings of anger and deprivation and losing the safety her emotional distancing provides. The therapist would need to be ready for a rough ride and should anticipate this in the reformulation; survival of this could be the most important aspect of non-collusion. The time limit may make risking this exposure tolerable to her, however. The GP and practice counselor were aware of her anger with the child and at this time there seemed no need to involve Social Services.

David 1) David, aged 27, was seen at the request of his psychiatrist. He was an in-patient, detained under the Mental Health Act, having been brought in by the police after threatening to jump off a Thames bridge. 2) He struck me as a compliant, anxious young man, saying he wanted to have therapy, but it was difficult to get a strong impression of who he was. 3) He had been depressed since early adolescence, and had had two hospital admissions at the ages of 18 and 20. Since that time there had been phases during which he drank heavily and I gathered from the notes that he had also used a lot of cannabis. The recent depression was associated with the end of a 3-year-long gay relationship, an ending provoked by his drinking. He had also recently lost his clerical job due to poor time keeping. 4) He described his father as a very authoritarian man; for much of his early life his maternal grandfather was his main support. This was especially the case after he was upset and felt rejected following the birth of his sister when he was aged 6. His grandfather was also the only one in the family who accepted his announcement of his homosexuality. 5) A main thread in his life would seem to be his wish not to resemble his father in any way. He understands that this makes him over-placatory and that the ensuing resentment leads to depression and drinking. The basic RRP of something like resentful placation apparently derived from a RR of harshly controlling in relation to harshly controlled experienced in his relationship with father. The suicidal acts seem to have followed sudden and extreme mood changes, perhaps better described as state shifts, representing a switch from depressed placation and resentment to angry defiance, and there remains some risk of this anger leading to an impulsive suicide. He is currently on antidepressants and will remain under psychiatric supervision. 6) Contraindications to therapy include my feeling that he was compliant rather than frank in the interview and the incompletely declared history of substance abuse.

82

The Practice of CAT

Therapy should be conditional on controlling this. It might be wise to offer a provisional four to six sessions before committing to a full course. On the positive side he has a reasonable work record and did sustain a relationship for 3 years and his grandfather provided some real care which he still remembers. If he can engage in therapy, he might be best referred on to group therapy after 8–12 sessions of individual CAT. Comment: There were a number of doubts about how far this patient could be engaged in therapy. It might have been wiser to have suggested a prior period of out-patient support to see if he could remain substance free. On the other hand, starting therapy at a moment of crisis can often promote rapid engagement at the level of underlying self processes and can allow fundamental change rather than the restoration of defensive or coping compromises. In this case, it seemed important to offer treatment while accepting that there was an above average likelihood of him not completing the course.

Nick 1) Nick, a 31-year-old lecturer, was referred by his GP on account of a longstanding lowgrade depression (with no “biological” features) and episodes of loss-of-control anger. 2) He was close to tears during the interview and seemed highly motivated to make better sense of his life. 3) He described an increasing sense of dissatisfaction with his life, feeling that others saw him as a resource but never remained as friends. His second marriage had recently been under strain when he felt ignored by his wife, but they are now on better terms again. He gets unreasonably angry. 4) Nick is the eldest of two children from a working-class family in Scotland. Following the birth of his sister when he was 5, his mother became psychiatrically ill and she remained unstable thereafter. Father was impatient with her and devoted himself to his daughter and Nick became his mother’s main practical and emotional support. He did well academically and went to university where he met and married his first wife. She was described as clingingly dependent and he left after 2 years. His present wife, in contrast, is a strong, independent woman. He manages his working relationships and enjoys the performance of lecturing but feels others to be bewilderingly inconstant. He could agree with my suggestion that maybe he was inconstant in how he saw them. He described how, in addition to the performance mode, he had three distinct states, one the thoughtful one he was in today, one a state of maudlin self-pity, and one a state of being out of control. 5) It seemed that his mother had been dependent on him and his father had been unavailable to him as a support or model (a RR of needy and neglected in relation to unsupporting and neglecting). His first marriage had been a repetition of his relationship with his mother, suggesting a RRP pattern such as needy, unsupported, care-taking. His second marriage avoided a repetition of this, but he acknowledged that he sometimes resented his wife’s admired strength and social ease. He was clearly anxious to understand better his own contribution to his difficulties. He gave a clear description of differentiated states and state shifts. He did not meet full borderline personality-type disorder diagnostic criteria.

­The Conduct of the Assessment Intervie  83

6) He clearly has real strengths and should make good use of therapy. I suggested he should discuss with his wife whether a session together might be helpful at some stage. Comment: This man made the decision to seek therapy on the basis of unhappiness and the realization that he was at least in part the author of his misfortunes; this suggests that he is likely to be a rewarding patient. Essentially, he was someone who had been trapped in the caretaking role he had acquired in childhood and had repeated in his first marriage. No longer having to be the dutiful caretaker he is now, it seems, more aware of being the neglected one, and he elicited from me a concerned, fatherly counter-transference. He is now suffering from the distance he creates between himself and most people and from intrusions of the unhappy and angry feelings he had never expressed in the family situation. Therapy can give him a chance to mourn what he never had in the way of care and to free himself from the historically rooted anger, while experiencing focused care and manageable disappointment.

Debby 1) Debby, aged 26, was referred from the Accident and Emergency (A&E) department where she had been psychiatrically assessed after overdosing on paracetamol. 2) She told her story with clarity and some urgency and made me anxious. This was mitigated to some extent by the use she had made of her recent meeting with the referring psychiatrist and the use she seemed to make of this session. 3) Her overdose followed a row with her current boyfriend. They have lived together for a year and she recognizes a negative spiral in which her possessiveness and threats provoke him to increasingly rejecting behaviors. She had recently opened a window and threatened to jump; he had pulled her back angrily and this had provoked the overdose. 4) Her father had shot himself when she was 6. Since then until last year she had lived with her mother and older sister. Unlike her sister she said she had no clear memories or feelings about her father, knowing only what she was told by her mother, from which it seemed he had been unstable and quarrelsome. However, in telling me how her mother broke the news of his violent suicide to her and her sister, she cried. After a number of transient relationships, Debby fell desperately in love at the age of 19. A year later her boyfriend confessed to an infidelity; her response was to threaten to jump from the window. He dragged her from the window sill and phoned her mother “who came and took her away to cool things off.” Two days later she was contacted and told that he himself had jumped to his death from a high building. She was unable to face going to his funeral and had remained deeply obsessed with his memory for the next 3 years. She was quite aware of the spiral of possessiveness provoking rejection which had characterized that relationship and was evident in her current one, but she felt she really could not bear to be left. I tried to explore how one might understand her story, linking the history of two relationships with men marked by intense possessiveness and the terror at abandonment with her apparent absence of memory or feeling about her father’s death. This link with her father was something she seemed not to have thought of before.

84

The Practice of CAT

5) Since the recent crisis she has stayed in close touch with her mother and is continuing to work in her civil service job. It did not seem that there was an immediate threat of suicide—a view shared by the psychiatrist who had interviewed her in the A&E department. The underlying dilemma could be simply summarized: “it is as if, if I am deeply involved with a man, then he is bound to leave me.” A more explanatory description might be a reciprocal role procedure derived from the unmourned loss of her father, for instance desperately seeking love but fearing abandonment and therefore quickly angry arising from a RR of apparently loving but inevitably abandoning in relation to apparently loved but inevitably abandoned. 6) I urged her not to have the means of self-harm to hand and to make use of the A&E department (in which she had confidence) if the impulse to self-harm returned. She would like therapy and it will be set up as soon as possible. Comment: The history of at least toying with a violent means of suicide was certainly ­anxiety provoking, particularly given that her first boyfriend and father had both chosen violent methods of killing themselves. It was as if the only safe relationship was one of fusion and the only coin available to deal with its loss was a lethal one. Despite the somewhat macabre feel to the story, there was no indication for compulsory treatment and I felt that she was relieved to have discussed the situation with the psychiatrist in the A&E department and to have committed herself to therapy in order to understand better the origins of her behavior.

Evelyn 1) Evelyn was a graphics designer aged 32 referred by her GP. She had requested the referral following a year in which she had experienced many disturbing feelings and intrusive memories after taking “ecstasy.” She had taken no drugs since that time. 2) She arrived breathless and late and for the first part of the session was speaking under great pressure and somewhat incoherently. By the end I felt I had built up a fairly clear but incomplete picture of what she was wanting from therapy. 3 and 4)  The effects of the drug had been to open her to periods of intense feelings associated with childhood. These centered on her relationship with her mother who, she felt, “had been over-involved with me emotionally and unable to set any realistic boundaries.” Evelyn began to use alcohol and drugs in early adolescence, preferring cannabis because it calmed her. A brief unsatisfactory sexual relationship with a man at 17 was followed by an intense but confusing relationship with a woman. Since that time, she had had a number of short-term sexual relationships with men, “preferably boring ones with whom she could avoid emotional closeness”; she also referred to elaborate forms of sexual fantasy which we did not discuss. In her work life she has set up and run successfully her own business. Two previous attempts at therapy (in early adolescence and in her mid-20s) had not been helpful. 5) Her fear of emotional closeness can clearly be associated with her mother’s overinvolvement and lack of boundaries and was probably reinforced by her intense, confusing lesbian relationship. This suggests a formative reciprocal role pattern something like overwhelming and neglecting in relation to overwhelmed but with own needs neglected

­The Conduct of the Assessment Intervie  85

leading to a RRP of becoming invasively overinvolved. Men are still felt to be safer than women and she emphatically requested a male therapist. The possible advantage of therapy from a woman—the more feared gender—was discussed, but it seemed that initial engagement might be too difficult, and her request was agreed to. Her main coping strategies have involved hyperactivity and the avoidance of closeness. 6) She now wants to know herself better and has clearly been flooded with memories of childhood which point to the source of her difficulties. Therapy will confront her right away with the urge to avoid feeling involved but I feel there is a real chance that she will be able to use it. Comment: The success of therapy will depend on establishing a manageable working relationship which can be sustained as she faces the fears and angers associated with closeness. As these are clarified the nature and significance of her undisclosed sexual fantasies may become apparent. CAT is particularly appropriate because of the containing effect of reformulation and the clear time limit.

Diana 1) Diana, aged 33, was referred by a social worker attached to her GP’s surgery with an 8-month history of nightmares, depression, and fits of uncontrollable weeping. 2) She told her painful history in a way which was dignified and intensely moving. 3 and 4)  She was clear that her present state dated back to her 5-year-old adopted ­daughter starting at school. This had brought back intense recollections of how, at that age, her parents had separated and she had been put in care. She had stayed in a very large, harsh institution until she was 13. No emotional closeness between the children was  permitted; she had had a brief relationship with an older caring girl which was forbidden. The dormitories were locked with no access to toilets and wetting the bed was punished by being paraded in the wet sheet. Leaving there aged 13, she was rejected in turn by her mother and by her father and step-mother. From 15 she had managed on her own and trained in dressmaking. At the age of 24 she married an inarticulate but reliable man in whom she has little sexual or emotional interest, especially since she was found, after extensive investigations, to be infertile. She is intensely loving of her adopted daughter and expressed the fear that, from fear of hurting her, she may not set appropriate limits. 5) The story and its telling put me in mind of Winnicott’s notion of how adults may need to have the breakdown that they could not experience in childhood; Diana’s grief and nightmares were appropriate expressions of what she had been too unsupported to bear to experience fully as a child. Given that her early life could be summarized as involving little more than the RRP pattern of lonely coping deriving from a formative RR of depriving, abandoning, and hurting, in relation to deprived, abandoned, and hurt, it was an achievement to have found her way to a job and a relationship and to have survived the disappointment of her infertility. Her adopted daughter’s starting school was both a separation from her most loved other and a reminder of her own deprivation. She shows concern for the child in the middle of her own pain (and no evidence of the destructive envy certain object relations theorists might insist on interpreting).

86

The Practice of CAT

6) I was moved and impressed by her ability to have survived a bleak life and by her ability now to experience and communicate her released feelings. I think she will make very good use of CAT and might be particularly helped by a mature female therapist, given the absence of any maternal figures in her past. Comment: Diana exemplifies those patients who seem to have found the strength to survive with very little help from others and who can make very good use of what help they are given.

The Six Cases No two stories are alike, and no simple classificatory system can group patients in ways relevant to psychotherapy, but the six case vignettes together illustrate many of the issues which need to be considered in the assessment interview. All six were considered to have psychological problems potentially amenable to CAT. Only David had a significant, associated, formal psychiatric condition— depression and a history of alcohol dependency—for which he was receiving medication. None met the full criteria for borderline personalitytype disorders, but all had longstanding evidence of damaging patterns of self-management and of relating to others. Provisional reformulation of the underlying reciprocal role patterns suggested that current disturbed patterns often combined repetitions of childhood patterns (as in the uncontrolled anger in Nora and Nick and the uncontrolled mood variations in Evelyn) with enduring alternative coping or symptomatic procedures in the form of emotional distancing (in Nora, Nick, and Evelyn) and of substance abuse (in the case of David and Evelyn). Possible contraindications to therapy included David’s recent substance abuse and the risk of suicide in David and Debby. Evidence of at least one valued, emotionally significant relationship in childhood is often taken as an indication of a possible positive therapy relationship. In this respect Nora had her caring sister and one friend, David had his grandfather and one 3-year relationship, Nick had his second marriage, which represented an escape from the childhood compulsive caring role, and Diane had one brief supportive relationship in the children’s home. Evelyn was basically still avoiding repetition of the smothering closeness experienced with her mother. Debby seemed to have a reasonable relationship with her mother; she presented an unusually violent consequence of an unresolved mourning reaction, but early instability in the parents’ marriage and the unremembered attachment to her father may have generated the reciprocal role pattern described above. The fact that all six had fairly stable work histories is a good prognostic sign in that those who can cope with employment are more likely to cope with the work of therapy.

­Other Considerations In contrast to most time-limited models, the use of CAT is by no means restricted to less severe disorders and change in the deeper structure and processes of the Self is the common aim. Both more common problems and disorders as well as more severe and complex, personality-type disorders may be amenable. But there are important distinctions to be made, with implications for assessment and, correspondingly, treatment between these

­Other Consideration  87

types of presentation. It is also the case that personality-type disorders (see Chapter 10) identified by standard diagnostic criteria are hardly ever found in isolation. Patients frequently meet criteria for more than one of them and they are virtually always accompanied by other “disorders” such as depression, anxiety, or substance abuse. The concept of “comorbidity” is of little value. It seems better to think in terms of the range and intensity of symptoms and of the degree to which the structure and processes of the Self are distorted and poorly integrated. Current diagnostic procedures evaluate simply symptoms, traits and  behaviors with, in general, little meaningful attempt to conceptualize or describe underlying psychological structures and processes, far less the whole person in their ­developmental and social context. Psychotherapists will encounter many patients who could be diagnosed in “Cluster B” of the DSM5 classification (American Psychiatric Association, 2013). Those with Borderline Personality Disorder (BPD), Antisocial, and especially Narcissistic Personality Disorder (NPD) although demanding, can be rewarding to treat. Undertaking an assessment and establishing a working therapeutic relationship is difficult because such patients tend to repeat their (understandable) general tendency to mistrust, disrupt, or idealize their relationships with their therapists, and all too easily provoke collusive reciprocations in the form of offers of ideal care or rejection. These interactive patterns, and abrupt switches between them, may occur during the assessment interview as the patient may experience the assessor alternately as, for example, intrusive, unconcerned, critical, or rescuing. Such events need to be identified as early as possible. It can be helpful to draw provisional part diagrams mapping out how such enactments may have been inadvertently provoked during the assessment interview. The recognition of some structural and procedural problems within the Self at a single assessment meeting may not be easy as many patients have developed socially acceptable modes of coping and of self-presentation (RRPs) which can make them seem relatively integrated. For this reason, the routine use of screening questionnaires is recommended. The Psychotherapy File (Appendix 1) is usually introduced early on and can be usefully given at the first assessment or therapy meeting. Completing the user-friendly (i.e., personally “experience-close” and non-judgmental) Personality Structure Questionnaire (PSQ) (Appendix 3) will also be helpful. Assessment based on meetings with other close (e.g., family) informants recorded through, for example, the SAP (Moran, Leese, Lee, & Walters, 2003) may also be helpful, if feasible. Most therapists in the UK will also use a broader generic measure of distress, disorder, and risk such as CORE (Barkham, Gilbert, Connell, Marshall, & Twigg, 2005). CAT is directed at the understanding of and changes in the structure and processes of the Self and of repetitive, general “high level” processes concerned with its management. Most common behavioral and symptomatic problems are understood to be specific or “low level” manifestations of more general patterns. For less severe distress or disturbance, any respectful therapeutic input can be helpful, through the influences common to all approaches as discussed by Frank (1961) and more recently (e.g., Castonguay & Beutler, 2006; Gabbard, Beck, & Holmes, 2005; Greenberg, 1991; Lambert, 2013; Norcross, 2011; Roth & Fonagy, 1996; Wampold & Imel, 2015). However, we would naturally argue that the proactive, empathic, and collaborative nature of CAT should lead to better engagement and retention in therapy and to more rapid change, and outcome studies generally support this view

88

The Practice of CAT

(Calvert & Kellett, 2014). In more difficult cases with borderline features, the assessment and reformulation methods of CAT offer particular advantages, contributing to the more rapid establishment of an active collaborative therapeutic alliance, rather than a collusive, superficial, or even rejecting relationship. Preliminary verbal or diagrammatic understandings suggested during the assessment session(s) can help identify, anticipate, and manage those procedural enactments which may be otherwise likely to lead to dropping out. The assessment and treatment of personality disorder-type presentations (including NPD) is considered in Chapter  10. The assessment and treatment of other “personality disorders” with CAT apart from BPD has not so far been systematically studied, although encouraging results are being obtained in individual and systemic work; for example, in forensic settings with a range of personality disorder-type patients (see Clinkscales, Tan, & Jones, 2018; Kemp, Bickerdike, & Bingham, 2017; Kerr, Ramm, & Simpson, In Press). But it appears that the basic approach, which allows considerable flexibility, may be of value in a wide range of “difficult” patients both as a therapy and as an aid to team work (see also Chapter 11). As noted above, in cases where there is doubt about the capacity of the patient to engage, a three to four session contract aiming to arrive at a provisional reformulation and to see how far the patient can make use of the understandings and relationship offered will usually make it clear whether CAT or some other treatment is indicated, or not.

­Assessing Motivation It is not a requirement in CAT that patients for therapy should have an already evident willingness or ability to engage in and stick with therapy, nor to think about and reflect on their own, possibly self-sabotaging, roles and procedures. Indeed, such an ability would be seen in CAT as an aim or outcome of successful therapy. In many more distressed and disturbed patients there may be little obvious capacity for this. However, the development of increased self-reflection or “psychological mindedness,” and correspondingly development of some hope of change through therapy, through a new type of relationship, and through the joint work of developing and using the conceptual tools created during reformulation, can be surprisingly rapid and profound. This being so, there is no call or rationale for a separate program of “motivational enhancement”; in many ways, the early phase of CAT can be seen as a form of “motivational interviewing.” Motivation is not a separate merely technical faculty, it does not depend on some “motor” being wound up, and it is not something that can be simply taught. People will proceed to involve themselves in an activity when it makes sense to them through some encouraging and helpful relational experience. The early sessions of CAT can assist motivation because they can help induce or enlarge self-understanding and the capacity for self-reflection, and also, in parallel, a sense of hope. Patients who actively “resist” participation in the process are commonly manifesting a procedure that is inevitably of significance in other settings, such as the pattern described in the Psychotherapy File as “If I must then I won’t,” or a more general pattern, for example, of reciprocating any perceived demands with refusal or rebellion. These patterns are usually important aspects of the problems for which therapy is sought and one initial first therapeutic task is to try, non-judgmentally, to describe and jointly address them. The few patients who cannot be recruited to the work of therapy in the course of assessment and

­Assessing the Risk of Self-Harm and Suicid  89

early exploratory sessions may be better served by approaches more limited to and focused on work on problematic symptoms and behaviors. It is important to recognize, including for the well-being of therapists, that some people may not be able to engage in treatment at that point in time, or possibly not at all.

­Combining CAT with Other Treatment Modes Nearly all psychotherapy patients suffer from some degree of anxiety, depression, and ­associated physical symptoms, as is witnessed by their scores on symptom inventories. While many symptoms recede and disappear as a result of therapy through identifying and modifying the problematic RRs and RRPs generating and maintaining the symptoms, there may be some (e.g., substance abuse or eating disorder) that require treatment in their own right. This may be either because of their direct impact or because they may make patients inaccessible to psychological treatment. In these cases, prior or concurrent treatment by other means may be indicated. It is important and helpful to make sense of the significance and impact of other specific treatments (including medication) by considering them in relation to the patient’s “map.” A number of such problem presentations are discussed in Chapter  9. The predominant biomedical assumptions of many mental health services and the pressures of the pharmaceutical industry tend to mean that psychologically maintained problems (often portrayed as “disorders” in themselves) are all too easily regarded and treated as equivalent to somatic illnesses. It also often means that their relational and social origins, and perpetuating factors, are ignored. One of the values of symptom monitoring during the early phases of treatment is that it helps patients become aware of the way formative relational experiences, habitual coping patterns, and current situations, thoughts, behaviors, and feelings contribute to and are associated with the symptom, and it is often appropriate to initiate such monitoring at the assessment interview.

­Assessing the Risk of Self-Harm and Suicide Many patients referred for psychotherapy, especially in public health services, will have a history of deliberate self-harm or attempted suicide. Nowadays such services will usually, and in part understandably, require staff to undertake separate formal, but often defensively motivated, “risk assessments.” However, these are often unhelpfully limited by their “tick box” nature and the absence of any meaningful psychological formulation. Self-harm may be an important feature of presentations, such in the cases of David and Debby described above. Such patients, especially where there have been multiple episodes, have an above average risk of successful suicide. Self-harm can involve a range of behaviors from superficial scratching to dangerous deep cutting, and from taking a few extra tablets to potentially lethal overdosing. The meaning and significance of such enactments need to be jointly explored and understood (or “mapped”). Such enactments can represent, variously, attempts to relieve intense distress, to communicate a need for help, vengefully to give others a hard time, or actually be an attempt to end a life. Self-harm always needs to be assessed,

90

The Practice of CAT

therefore, in relation to a full understanding of the patient’s RRs and RRPs and current life situation. For these reasons, simple standardized approaches or treatment guidelines for “self-harm” as if it were a discrete “disorder” are likely to be inadequate and ultimately ineffective. An in-depth psychotherapeutic case formulation is called for, addressing formative relational experiences and their consequences, coping mechanisms or procedures, and current personal support and social context. Cowmeadow (1995) and Sheard, Evans, Cash, et al. (2000) described approaches based on CAT, and. Ougrin, Boege, Stahl, Banarsee, and Taylor (2013) describe an approach to the therapeutic assessment and engagement of young people presenting with self-harm that draws explicitly on CAT while also taking account of a number of theoretical models. CAT-based assessment and treatment for borderline-type disorder, where self-harm may be a prominent feature, is described in more detail in Chapter 10. Patients reporting an untreated, deepening depression, frequently associated with severe anxiety, with heightened self-blame and marked physiological symptoms affecting sleep, energy, and concentration, and patients reporting detailed plans for suicide may need urgent psychiatric treatment (e.g., admission and medication) and may not be initially accessible to therapy. Apart from such presentations, assessors should be prepared to take on patients for CAT who have a history of attempted suicide or current suicidal preoccupations. However, this decision may depend on professional context and the availability of, for example, team support in a public health service. In doing so therapists need to be clear in their own minds, and make it clear to their patients, the limits of the therapist’s availability and of their tolerance for anxiety. Realistically, individual therapists who are not working in a specialist team context cannot be continually available in person or by telephone, and in any case to attempt to provide such care could feed idealization (and in due course disillusion), and undermine the patient’s autonomy, notwithstanding that many patients do need and deserve high levels of support. The risk of suicide is greater in patients who have not had, or have no, close relationships, or whose key relationships are deeply disturbed, and who feel a deep sense of hopelessness about life. If a patient is determined to die, nobody can stop them, and making this clear establishes that therapists cannot be controlled by threats. Patients who fear that they cannot control self-harming impulses should be encouraged to keep a list of, and be prepared to use, available resources such as their family doctor, local A&E departments, a community nurse, telephone contact with friends, or with the Samaritans (in the UK) and any other sources they may have already identified. If, at assessment (or later during therapy), the threat of suicide seems active, and if the therapist is not working in a Community Mental Health Centre or other professional setting, it may be advisable to arrange to share management with psychiatric services from the beginning. Despite the fact that therapy often involves accessing very painful memories and feelings, and despite the rapidity with which this may happen in time-limited CAT with deeply disturbed patients, serious self-harm or suicidal incidents in the course of therapy are, fortunately, extremely rare. It is probably the case that reformulation and the early bonding of the therapy relationship creates some hopefulness and provides a safe containment through meaning-making. Within this most patients will access feelings and memories only when they feel safe enough to do so.

­“Paper and Pencil” Devices and Questionnaire  91

­Assessing the Potential for Violence The assessment of potential violence is not easy. It is of course a major preoccupation of specialist (especially forensic) mental health services. The most robust predictor is usually a history of past violence, but episodes of uncontrolled anger (such as were reported by Nora and Nick) are common, especially in patients with so-called borderline and antisocial personality disorders, and in many patients these may have involved inflicting serious injury on others. In forensic practice there may well be a history of murder or the infliction of grievous bodily harm. Classical psychopathic individuals who possibly suffer from some genetic predisposition, showing no remorse, and professional killers are unlikely to seek or be referred for therapy. However, many treatable “Cluster B” type patients have escaped inflicting serious or lethal harm during outbursts of “out of control but justified” rage, or involvement with the law, more by luck than judgment. Part of the decision about offering treatment to potentially violent patients must depend on the setting. Some such patients should only be seen in institutional settings with the agreement of and support of other staff members and appropriate safety arrangements. Therapists need to include a direct consideration of violence and its possible enactment in the reformulation letter and sequential diagrams (maps) will aim to trace helpfully antecedents and triggers. Therapy will, of course, be conditional on the control of threatening behavior. Accessing possibly traumatic memories of victimization and abuse in childhood in the course of therapy, especially if they have involved shame and humiliation, can sometimes provoke dangerous anger in such patients, sometimes associated with switching into dissociated states in which the therapist is confused with past abusers. It is important in assessment and treatment planning with such patients to be aware that there is a mortality rate among therapists and others who are drawn into working intensively with violent patients especially without adequate supervision and a supportive context.

­“Paper and Pencil” Devices and Questionnaires Self-report inventories can be taken as approximate indications of patient problems and there are strong arguments for including them as a part of the initial assessment. They provide baseline data on which to compare different patient samples and changes between pre- and post-therapy measures can contribute to the clinical audit of the performance of a service or of outcome for therapists working independently. The 8-item PSQ (see Appendix 3) can be completed and scored in a few minutes in the course of the assessment interview and provides a reliable indication of the presence of structural dissociation such as characterizes BPD. Moreover, it introduces the idea of states and state shifts which can be further explored in the session. It was designed on the basis of the CAT “Multiple Self States Model” of BPD with the particular aim of identifying patients’ awareness of having distinct Self states. It is reproduced in Appendix 3 and its use is described in Chapter 10. It yields an overall score which correlates with the diagnosis of BPD and with measures of dissociation. Patients scoring 28+ (“caseness”) should be asked to elaborate on their experiences; in most cases it is possible to identify the natures of the states between which they switch

92

The Practice of CAT

(see Bedford, Davies, & Tibbles, 2009; Pollock, Broadbent, Clarke, Dorrian, & Ryle, 2001). Bedford et al. reported the scores of a large sample of patients referred for psychological treatment. Mean scores were intermediate between normal and BPD samples suggesting that variable degrees of incomplete “personality” or Self integration are a factor across the whole range of psychological problems. The now widely used, openly available (“copyleft”), CORE battery (Barkham et al., 1998 and 2005) offers a broad generic measure of a range of psychological difficulties and risk. It also usefully scores co-terminously with standard measures of depression. Shorter (e.g., 10 item) versions are also available. It would be ideal practice to use the full or shorter versions regularly throughout therapy, helpfully providing information on change and also possible issues arising in therapy. This can inform the course of therapy and is also useful if a patient drops out before completing an end of therapy assessment. Further specialist assessment measures in specialist settings, such as for symptoms of Obsessive–Compulsive Disorder (OCD), traumatic imagery, eating disorder, and substance abuse, may clearly also be useful. The CORE Battery, the PSQ, and any other tests administered should ideally be briefly reviewed before the assessment session as some patients acknowledge symptoms of importance which they do not easily report at interview. Acknowledging a patient’s statements can be helpfully validating and can also be a useful topic for discussion.

­Treatment “Contracts” It is important to be clear with a patient about the likely demands and expectations of therapy, especially as they may appear very different from those previously experienced; for example, attending a GP or routine psychiatric out-patient services. Joint clarity about aims and objectives and ways of working is well-recognized as a predictor of more successful therapies. These arrangements or informal “contracts” include understanding and agreement about length of sessions, proposed initial duration of therapy, (although it should be made clear that this would usually be subject to review), and about responses to non-arranged missed sessions. These latter sessions would normally be lost, although they would be subject to, sometimes invaluable, discussion and exploration, rather than simply admonition or being ignored. Non-attendance will often represent an enactment of RRs and RRPs. The same would apply to other so-called “therapy interfering behaviors,” such as substance abuse or self-harm incidents. These would therefore not necessarily be a prompt for discharge as may occur with some other approaches or services. However, simply not turning up for several sessions and not responding to communications on the part of the patient would likely prompt a discharge letter (possibly negotiable depending on any patient response) by most CAT therapists, at that time at least. These arrangements may sometimes be helpfully summarized in a formal treatment contract. This can ensure that issues such as those noted above, the possible use of audiotaping, or the ethical limits of confidentiality should risk issues (to self or others) become apparent, are unambiguously spelled out. Failures to stick to the contract by the patient (or the therapist!) can be used to explore therapy-related issues if a clear statement of this sort is available.

­Concluding Remark  93

­Concluding Remarks An assessment interview can be challenging for both patient and the interviewer. The main aims are to get to know enough about the patient and their “map” to make sensible decisions about therapy and to give the patient an experience that provides some idea of what therapy would involve, possibly with that therapist with whom it should aid engagement. It should involve a respectful and empathic, conversational enquiry rather than a subjecting of the patient to a structured battery of questions and answers. As Michael Balint famously stated, “if you ask questions all you get is answers.” The use of supplementary standard questionnaires, such as the PSQ and the CORE battery, along with others depending on (e.g., trauma-related) symptoms that can be repeated at intervals may be of considerable value to both patients and clinicians. An assessment conducted along the lines described above constitutes an important first step in the therapy process in CAT and may contribute significantly to a successful outcome.

95

6

The Practice of CAT The Early Reformulation Sessions S ­ ummary The early sessions in Cognitive Analytic Theory (CAT) include further exploration of the patient’s story and the joint creation of written and diagrammatic descriptive reformulations of a patient’s overall picture of distress and dysfunction and its developmental origins, in the context of a collaborative, empathic therapeutic relationship. These reformulations normally become central to the subsequent work of therapy. They focus principally on the historic ­internalization and current enactment of (formative) reciprocal roles (RRs), including ­associated dialogic voices, and on reciprocal role procedures (RRPs), and how these may result in problematic and distressing emotions, behaviors, and symptoms. Reformulation aims to elucidate and demonstrate how problematic RRPs, with their various patterns and outcomes, typically reinforce the formative RRs underlying them, usually in “vicious circle”‐type loops. Reformulations constructed with patents with more “severe and complex” and borderline‐type disorders will need to include description of patterns of dissociation or “switches” into ­different, often highly distressing, Self states and their consequences. After a few sessions a written, ­narrative, reformulation letter is usually followed by a diagrammatic reformulation (or “map”), although this is flexible. In order to help more damaged or disturbed patients it can be productive to attempt jointly a rudimentary or partial diagrammatic reformulation (“map”) as early as possible. This can facilitate engagement with any patient by communicating, in a non‐judgmental manner, that the origins of their difficulties, often traumatic, have been understood and acknowledged. Preferably at a slightly later stage, formal “exits” or “aims” will also be articulated and added to the reformulations, although it can be helpful at an ­earlier stage to flag up that these will be addressed and worked on. These represent alternative ways of being and doing (new RRs and RRPs) for the patient and represent an important aspect of therapy (“revision”) along with a new, collaborative, meaning‐making, relational experience. These documents serve as psychological “tools” that promote a powerful therapeutic alliance by providing a means of understanding and mapping an integrated picture of often personally unhelpful and maladaptive RR and RRP enactments, (part of “recognition”), especially those which may constitute potential threats to the therapeutic alliance. Revision of these inevitably provisional documents may well be required during the subsequent course of therapy, possibly in the light of further background information, patient responses, or Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, Second Edition. Anthony Ryle and Ian B. Kerr. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

96

The Practice of CAT

enactments in relation to them. Constructing a reformulation is a clinical skill that requires practice, supervision initially, and an ability to remain empathic toward the patient while also thinking procedurally and reciprocally. With increasing therapist expertise and confidence this activity becomes, ideally, seamlessly incorporated into the dialog of therapy from the first meeting. These principles are detailed and illustrated with clinical examples. This chapter describes a core activity of the CAT therapist. To those unfamiliar with the approach it should repay careful reading, particularly in relation to the work of therapy. The activity of reformulation also illustrates and embodies the theoretical constructs underlying the model, including its genuinely collaborative therapeutic stance.

­Case Formulation and CAT Reformulation Psychotherapists of all persuasions construct case formulations for their patients. This process involves the selection and arranging of information according to their theoretical understandings of the issues understood to be important in therapy. In CAT, reformulation aspires to be a joint activity. Its aim is to generate generalized descriptions of the structures and processes maintaining dysfunctional procedures, and their underlying (internalized) relational and developmental origins. While most patients will usually be able to give full, if often disorganized and personally bewildering, accounts of the diverse aspects of these problems and experiences, they will almost inevitably need therapeutic assistance to enable work on the recognition of patterns and their origins and triggers. Therapists need to pay particular attention to accounts of formative childhood experiences as these are likely to have shaped current procedures. This shaping may be manifest in beliefs, values, attitudes, and behaviors which resemble those described from childhood, or in further coping, defensive, or symptomatic procedures that have replaced them. In CAT, reformulation will seek to identify the personal and cultural meanings accorded to their experience by patients, incorporated in RRs and RRPs, and possibly also evident in poor integration of the structure and meta‐processes of the Self. The non‐blaming linking of past and present is usually unfamiliar and valuable to the patient and is recorded in the reformulation letter. The recognition of recurring dysfunctional patterns and devising generalized descriptions of them may be helped by the patient’s use of the Psychotherapy File but, as with the historical linking, all descriptions should be offered provisionally for the patient’s consideration. The patterns initially recognized by patients in the File frequently highlight more generally pervasive issues. With experience, assessors and therapists become good at recognizing patterns and “voices.” Very often the stories told, and the attitudes and expectations conveyed in the first session, convey the key issues with which therapy will be concerned. This is in part a reflection of the fact that underlying all the details, patients are usually concerned with a limited number of themes concerned with, for example, dependency and care, control, submission, or abuse. The accuracy of generalizations from particular incidents can be tested out in session. Therapists should avoid being too quick to propose links and patterns which they may, with experience, quickly perceive, even if they are careful to invite comments on their suggestions. It can help to avoid the danger of seeming magically understanding or omniscient if serial rough drafts of preliminary verbal and diagrammatic reformulation are

­The Process of Reformulatio  97

discussed and sketched out during sessions. Even when therapists may quickly see a ­pattern and its likely origins it is of fundamental importance for patients to have the opportunity to live through the emotional experience of telling their story—and the experience of having it sympathetically heard, explored, and acknowledged, often for the first time. Despite inevitable overlaps in theory and practice with various other models of therapy, CAT differs from most in a number of respects: 1) Therapists aim to work collaboratively and relationally with the patient from the start. This involves patients being encouraged to tell their stories and to reflect together on them, and activities such as self‐monitoring and reading the Psychotherapy File. It involves therapists in openly sharing their provisional understandings, and possibly counter‐transference responses, with their patients and inviting their comments, responses, and modifications. This activity is also likely to contribute to the development of a strong therapeutic alliance. 2) Therapists make use of writing and diagrams (“maps”) to make their understandings explicit and “portable,” allowing patients time to test out their meaningfulness, accuracy, and usefulness, and to contribute to their revision and to therapeutic change. 3) In order to demonstrate how problems have been formed and maintained, therapists offer both a “narrative reconstruction” and summary of the patient’s story, in the form of a letter tracing the links between past relational experience and current procedures, and a diagrammatic depiction of the patient’s current personally unhelpful and dysfunctional role procedures (Target Problem Procedures - “TPPs” or “key issues”) and possibly presenting problems (“target problems”). In this way, reformulation in CAT offers a “whole person,” “trans‐diagnostic” approach aiming at not only at an understanding of apparent presenting difficulties or “diagnoses,” but also, importantly, of their developmental origins and self‐reinforcing dynamics. 4) By the close of the assessment phase the reformulations will have been recorded formally in written and diagrammatic form and agreed upon. These provide a common agenda or “route map” for the work of therapy, and a conceptual, “psychological” tool of use to both patient and therapist. Importantly they offer a non‐judgmental, previously agreed, externalized means of making sense of and helping resolve patient role enactments (and therapist counter‐transferential reactions) that may constitute threats to, or ruptures of, the therapy alliance. Extended (contextual) reformulations may also help whole teams and systems working around “hard to help” or “difficult” patients (see Chapter 11). Reformulation in CAT offers a global, “top down” perspective, setting the range of symptoms and costly behaviors in the context of a preliminary understanding of formative relational experiences and key repetitive coping patterns, and overall of the patient as a particular whole person living a life in particular social and cultural circumstances.

­The Process of Reformulation Reformulation, which may have started in the assessment meeting, is usually completed, at least provisionally, by the fourth or fifth session. Delay in doing this will usually represent some form of, possibly mutual, collusive role enactment within therapy and should ideally

98

The Practice of CAT

be discussed and reflected on in supervision. There can, inevitably, be good reasons to defer creating a formal reformulation for some; for example, extremely wary, narcissistically “defended,” or traumatized patients. In some unusual instances, for example more reflective patients presenting with less severe and more focal problems, a therapy may be conducted without actually creating a formal reformulation. However, some “virtual” version would always be created in the head of the therapist as part of the CAT approach overall. It is certainly advisable to follow the normal structure of (any) therapy during training and therefore to routinely undertake reformulations as described. Clinical experience certainly suggests that in practice they are almost always helpful—including to the therapist! However explicit reformulations are only “tools.” Therapists explain that the aim will be to achieve a tentative, agreed, joint understanding that will be ideally read aloud and then presented in writing at that session. This will be largely from the point of view of the therapist (which may be usefully stated in the letter), but based on information from and interactions with the patient; not, however, on any “deep” but unverifiable interpretations. The sessions leading up to the presentation of a provisional reformulation are devoted to largely unstructured but purposeful discussion combined usually with the use of the Psychotherapy File. Symptom monitoring, diary keeping, the construction of family trees, and other tasks to be completed between the sessions may also be suggested. For more unreflective or emotionally distressed and disorganized patients (and for insecure therapists) the File, and subsequently reformulations, provide a reassuring framework and therapeutic focus and shift attention from symptoms and behaviors to underlying processes. They also encourage the practice of applying thought to feelings. Passively “resistant” patients may enact this by non‐completion of agreed tasks, thus alerting therapists to a procedure that is likely to have a considerable impact on therapy. For patients who are more reserved or “defended,” the need may be to explore the felt meanings or emotional distress behind their more factual accounts. Throughout these sessions, the therapist should be alert not only to the content of what is said but also to the form in which it is said, and to attitudes, “voices,” or behaviors expressed directly or indirectly. It is important to distinguish idealization from cooperation, cooperation from compliance, reasonable criticism from contemptuous dismissal, fear of exposure from control, and so on. The aim through all this is to get to know the patient, to attempt to achieve a sympathetic understanding of what this patient has experienced, done, and learned in the course of his or her life. The aim is also to demonstrate a genuine and accurate empathy, to engage the patient in active, more hopeful, collaboration, and to offer preliminary new ways of understanding and doing life. If issues arise later in, or as a result of, the therapy that cannot be linked to the verbal descriptions of RRs and target problem procedures (TPPs), or cannot be located on the diagram, the reformulation would be revised. The experience of being empathically attended to by a thoughtful other, and the preliminary glimpse of how new understandings may be helpful, is often unique and powerfully moving, especially for emotionally deprived or abused patients. In nearly every case the process serves to raise the patient’s morale and strengthen a working alliance. The understandings themselves, even before they are fully grasped and integrated, are often containing, relieving confusions and uncertainties, and reduce the need for anxiety‐ or guilt‐avoiding procedures. This may allow greater access to memories (although some important, disturbing, or traumatic memories may be deeply unconscious) and increased awareness of emotion. Symptoms begin

­The Reformulation Lette  99

to be understood and may become less preoccupying. The creation of a meaningful story out of incoherent accounts of distress contributes to the extension of personal meanings, which is an essential element in the achievement of psychological well‐being. And for the therapist the explicit understandings serve to make collusive reciprocations to problem role procedures more avoidable or remediable and assist overall therapeutic orientation. The different elements of the reformulation are commonly carried out over the same time period. The reformulation letter is often presented first, serving to establish the therapist’s grasp of what it has been, and is, like to be the patient. For more disturbed patients, recognizing the damaging reciprocal roles and procedures may need to start in the first session if inadvertent collusion (including rejection) is to be avoided. These may be listed or represented in partial and provisional diagrams for discussion with the patient, an activity which may be a good way, with any patient, to demonstrate what therapy can offer. It is important in undertaking both written and diagrammatic reformulations to stress from the beginning that the main aim of therapy is change, and that for each TPP or “key issue” focused aims or exits will ultimately also be worked on. Describing these formally is normally, although not invariably, best deferred until after the work of reformulation in order not to detract from the important business of recognition and from its emotional impact and the initial processing of this usually powerful experience. Describing and beginning work on aims or exits represents something of a change of therapeutic “gear.” However, many aims will already be implicit (e.g., watching out for, and trying not to embark on, problematic RRPs), or may be helpfully discussed during the early reformulation sessions. In some cases, it can be helpful to incorporate them into the initial letter especially if this appears to aid therapeutic containment and possibly promote some hopefulness about the future. For the purposes of this chapter the reformulation letter will be discussed first, followed by a description of sequential diagrammatic reformulation (SDR) or mapping. The latter will include a preliminary consideration of the reformulation of partially dissociated borderline‐type patients but a fuller consideration of this will be postponed to Chapter 10.

­The Reformulation Letter This section will begin with an example—another was given in Chapter 2 and extracts from others will be offered elsewhere—and will then summarize the principles on the basis of which letters are constructed. Case Example (TR) Beatrice, aged 28, was referred by a psychiatrist after 14 months treatment of depression; she was currently taking tricyclic antidepressant medication, which had improved her sleep to some degree. At the interview she gave a clear account of herself. She looked tired and unhappy and wept on three or four occasions but was also able to respond with smiles and even a laugh. Beatrice was the youngest by 5 years in a family of four children. Her father had left her mother when she was aged 6 months and there had been no contact since. She saw her mother as resenting her, describing her as cold

100

The Practice of CAT

and concerned only with appearances. She was sent to boarding school aged 9 where she became a rebel and was finally expelled aged 12. Nobody seemed concerned with the reasons for her behavior. At the age of 16 she was sent to visit her oldest sister in Canada; a letter followed from her mother asking the sister to keep her, but she refused to stay. She left school and took a secretarial training and at 18 set off alone around world, paying her way by typing as she went. She finally settled for 6 years in Japan, learning the language and making friends. While there she started her first deeply passionate sexual relationship with an Englishman. When he returned to the UK she followed him, but within a few months he backed off, leaving her desolate. This had led to her seeking help. Beatrice completed the Psychotherapy File after the first session, identifying the following items as applying to her: traps: 

Depressed thinking; trying to please; avoidance. Either trying to be perfect and angry and depressed or not trying and being guilty and dissatisfied. Either I get what I want I feel childish and guilty, or I do not and I feel frustrated and angry. Either involved and likely to get hurt or not involved, in control but lonely. snag:  I sabotage good things as if I do not deserve them. dilemmas: 

At the second session Beatrice discussed a number of painful details from her past and she reported a dream of seeing herself wrapped in plastic among the frozen ­chickens in a supermarket. At the third session the following draft reformulation letter was read out (comments on it are written in square brackets: Dear Beatrice, Here is the letter I promised you; it is my attempt to understand your past life and how it has affected you now. I hope we will be able to discuss it and you should feel free to alter any aspects which are wrong or do not make sense. [It is important to stress the provisional nature of the letter, to discourage passive acceptance and to ensure that the final version will be “owned” by the patient.] You had a very desolate early life. You were much younger than your sisters and were ­probably not a planned pregnancy, and your mother was faced with your father’s desertion soon after your birth. Because of that (and perhaps for other reasons we have not discussed) you remember her as a remote and unaffectionate figure. You felt she was concerned with appearances but not with your feelings. [This is a bald summary of what had been discussed, naming clearly what seemed to have been the impact of formative childhood experiences. While it is important to avoid accepting patients’ accounts as objective history—hence “you remember” and “you felt,” or “it seems like,” or “it sounds as if”—it is also important to fully acknowledge their ­subjective experience.] Boarding school provoked your first rebellion but your expulsion did not seem to make ­anybody concerned about how you were. At 18 you set off alone and ended up making a ­success of work in Japan and making two or three good woman friends.

­The Reformulation Lette  101

[This is perhaps an inadequate acknowledgment of the patient’s strengths, a risk due to the focus in CAT on problems and problem procedures.] Your first powerful (almost overwhelming) attachment to a man was with Richard; for the first time ever you felt securely loved. When he returned to the UK you followed, only to be rejected after a few months, leaving you desperately unhappy. Your depression stems from that time; although recently you have struggled to return to work and go to your evening classes; you find life exhausting and joyless. [Having summarized the story the letter goes on to propose some ways of linking the past with her present state. These links will have been explored verbally but often they are more clearly described in the letter.] It seems to me that very early on you learned to expect little from others and that it was safer to manage on your own. But, as you indicated when completing the File, you still find yourself trying to please others in the hope of getting acceptance, only to be used by them, which makes you hate yourself. Richard was the first person with whom you experienced the depth of your need for affection. Maybe what you hoped for was unrealistic or maybe, ­meeting abroad, it was difficult to judge what was possible. Or perhaps he was just not ready for commitment. Whatever the reason, his leaving was a terrible blow, and since then you have experienced the abandoned and uncared feelings which, I suspect, you had learned to put aside in your early life. [The letter now considers what has been learned in the first sessions. The inclusion of the patient’s own metaphors or images in the letter anchors the reformulation in personal experience while extending and making explicit the understandings which they contain.] After our first meeting you had the distressing dream you told me about, seeing yourself wrapped in a plastic bag among the frozen chickens in a supermarket. This disturbing image seemed to me to stand for the feelings of the forlorn child you have always carried within you, despite your achievements and strengths. In therapy we will be trying to thaw the chicken, to go through and beyond your hopelessness and the negative feelings you have about yourself (the target problems). To do this we will need to work on the patterns of thinking and acting which continue to make you vulnerable. [Descriptions of the target problem role procedures will now be proposed, bringing the focus of therapy onto current patterns, described, if helpful, as traps, dilemmas, and snags.] You recognized in the File how, feeling uncertain of your worth or your rights, you try to do what others want and as a result feel used and resentful and still more uncertain about yourself. I also think that your mother’s seeming indifference to your emotional needs left you with the belief that you must either be totally self-sufficient or emotionally involved and doomed to be abandoned. Having managed your life without deep involvements, the experience with Richard seemed to brutally confirm the truth of this dilemma. I also wonder how far you may have felt you deserved the difficulties of your childhood and whether this and the brief rebellion at school may be the source of your irrational guilt. I certainly have the impression that you often act as if you were guilty and ought not to be happy so you sabotage things that do go well. [The work of therapy is now described and the possible effects of the patient’s procedures on the therapeutic relationship are spelled out, possibly also through disclosing, judiciously, and even humorously, some aspects of therapist counter-transference.]

102

The Practice of CAT

During therapy I think it will be helpful for us to work on recognizing and controlling these negative patterns as they recur in daily life. We will also need to be alert to how they may arise in your relationship with me. For example, you may feel you need to please me to be accepted—and hence you may feel angry with yourself and with me because of that. You may feel that being exposed and vulnerable is too dangerous to risk. The time limit means you will certainly be “abandoned” at the end of our 12 further weeks. This may leave you feeling reluctant to be involved, which would also protect you from feeling overwhelmed by dependency. Your irrational guilt and the critical “voice” that we identified, may make it hard for you to accept the help that you need. Hopefully we will be able to face and resolve these feelings if they arise. No therapy and no relationship can make up for the lacks you experienced as a child but I believe that working together for the next three months will give you enough support for you to revise the apparently unhelpful and damaging ways you have relied on up to now. It can give new understandings and a manageable loss and by building on your strengths can free you to find the good that is available in others and in yourself.

General Principles of Writing Reformulation Letters Most letters can follow the form of the above example, drawing upon (but often saying more clearly) what has been already discussed. The following points should be borne in mind: Aiming to talk in terms of “we” is helpful, as is trying to relate a subjective story illustrated by examples. Simply listing events or achievements, as if in a school end‐of‐term report, that “you did this,” or “this then happened to you,” is less helpful. 1) Make it clear that the letter is a provisional one, open to revision by the patient. 2) Give an outline account of what brought the patient to therapy and how they seemed then, and a summary of the significant points in the life history. The aim is not simply to rehearse the whole story nor simply to list a chronology of biographical details. 3) Show how the patterns (RRPs) evident in the present were derived from this past history and its formative relational experiences (RRs). These might represent repetitions of these early relational experiences and/or attempts to cope or manage in ways that were restrictive or unhelpful. However, it should also be stressed and acknowledged, non‐ judgmentally, that these represented the patient’s attempts “to do their best and cope in the circumstances.” It can also be helpful to note the frequently positive and commendable things a patient has achieved despite often very difficult circumstances 4) Provide a summary account of the present presenting problems (target problems or TPs) if helpful and of the current damaging role procedures (TPPs), possibly in terms of traps, dilemmas, and snags, or simply as problematic reciprocal role procedures together with their underlying RRs. It should be noted that specific TPs (e.g., substance abuse, or loneliness) may arise from various TPPs, and also that a single given TPP or “key issue” (e.g., “criticizing–criticized” leading to “coping by putting up a front and people‐pleasing”) may give rise to various different TPs (e.g., substance abuse or loneliness). 5) Consider and anticipate (possibly using some gentle humor if appropriate) how these may be manifest in the therapy.

­Diagrammatic Reformulation or Mappin  103

6) Offer a realistic, but not blandly optimistic, suggestion of what may be achieved. It is justifiable and can be very helpful (it can instill some hope) to state clearly that therapy can lead to important changes if the patient is prepared to try to engage actively with it, and is “up for it”—although of course it cannot be a “magical cure.” 7) When setting out to write a letter, and notwithstanding these formal considerations, the best advice is probably, in the end, to set all notes aside and write a draft directly from the heart. 8) A reformulation should ideally be checked out in supervision or with a colleague to ensure that nothing is said or contained in it that could possibly be construed as wounding or offensive. This may be an issue very occasionally with, for example, narcissistically damaged and hypersensitive patients, some of whom who may also be prone to litigation. It can be daunting to write such an account after only three or four hours’ conversation, even when this has been supplemented by various questionnaires and the patient’s use of the File and self‐monitoring. Trainees at first may need to spend a lot of time on the task and supervision is essential. Every reformulation letter will be unique although a certain repetitive structure or formula can be helpfully applied. In effect each letter should offer a micro‐cultural conceptualization of each person’s story and difficulties. Similarly, patient responses to letters and maps will vary considerably. These will in themselves be material for exploration in therapy. Some patients may wish to respond formally in writing ­themselves, which can be helpful. Despite the apparent difficulty of the task, in the great majority of cases therapists produce moving and accurate letters which are received by the patient with relief and emotion, which is sometimes profound. Patients commonly say, significantly in itself, that up to now “no one has ever really listened” to their story. Letters do not have to be exactly “right” for, by stating clearly what their understandings are, therapists offer their patients an opportunity to suggest changes where the account does not fit. In that sense being “wrong” can serve to clarify the story and can provide the experience of genuine collaboration. In practice, it is often best to read the letter out at one session for an immediate response and to give a written copy to the patient to be read through and brought back with amendments at the following session. After any necessary changes the final version is copied and retained by both therapist and patient. Creating reformulations in this way is hard work and requires deep thought and consideration. As we have previously pointed out, however, if the therapist does not do this work or behave in these ways, it is not clear how the patient would ever be able to arrive at such understandings or begin to engage in the process of change.

­Diagrammatic Reformulation or Mapping The reformulation letter contains within its developmental, historical account a verbal description of current problem RRs and RRPs and associated voices and, where relevant and helpful, presenting problematic symptoms, emotions, and behaviors (TPs) which these may variously lead to. They have, however, important limitations. Written descriptions of sequences and of relationships can become rather wordy and difficult to remember, and

104

The Practice of CAT

the interrelations between different identified RRs and RRPs problem procedures may not be fully clear. Here the complementary use of diagrams or maps is of particular value. The aim of both written and diagrammatic reformulation is to help patients reach deep, “joined up,” understandings and keep them in mind, aided by the process of jointly working on them. Some patients appear to respond more to pictures or maps than to words, and vice‐versa, in ways that are not always predictable.

General Principles of Creating Diagrams or Maps Diagrammatic reformulation or “mapping,” sets out firstly to describe the core reciprocal role repertoire, including associated dialogic voices, derived from formative relational experiences and the ways in which this is also now repeated in RR (including Self–Self) and RRP enactments in ways that are often distressing, costly, and symptomatic. This repertoire may be partly deduced by the therapist from the procedures or “patterns,” along with associated feelings, beliefs, and values that patients report and manifest, as well from their telling of the story of their subjective personal experiences. It is a theoretical construct, although a clinically useful one, not a literal, “concrete” account of experience. To avoid confusion, it is best to confine the use of the word “core” to the core of the diagram and to describe deep and postulated unaccessed feelings and memories as “unmanageable” or “hard to reach.” In time, these can usually be identified as concerned with unmet need or deep pain or rage. The description “core pain,” which was widely used earlier in the evolution of CAT, was broadly equivalent to James Mann’s (1973) concept of “chronically endured pain.” But as well as being liable to be confused with the core of the diagram, the concept of “core pain” may easily be accompanied by an under‐emphasis or neglect of the potential enactment of the other pole of a reciprocal role of, for example, “hurting” or “abandoning.” The patient may have experienced such RRs in the past and may then “perceive” them in the therapist or, through role reversal, the patient may also enact them. Focus on core pain may also lead to neglect of the frequently highly “addictive” and “resistant” nature of unhelpful RRPs. With these caveats, it can nonetheless be helpful therapeutically, for both patient and therapist, to name and identify such a “core” part of the diagram. The diagram’s core is essentially an explanatory, theoretical, partly heuristic, device. The central repertoire of reciprocal roles or the consequences of maladaptive RRPs may be deduced partly from interactions with the patient and also from the range of reported experiences and manifest relationship patterns. Describing these patterns in general terms provides a basis for identifying the same patterns as they present in different particular ways and contexts, including in the therapy relationship. In the diagram, enacted and experienced RRPs, which may also involve situational role enactments with current others, are drawn as loops generated from the central repertoire of formative reciprocal roles, and are traced out so as to demonstrate their outcomes. In the case of problematic RRPs, these outcomes will almost inevitably reinforce the basic RR repertoire. This is indicated by drawing the loop as returning to the core of the diagram This, incidentally, always reinforces a whole internalized RR relationship—not simply one pole of it. This may be helpfully described as a “vicious circle”—a term most patients can recognize and identify with. Such a simple loop can also be seen as a form of “trap.” For example, a formative RR of “critical to criticized” may lead to a role procedure (characterized by a “criticizing” voice) of “striving to please.” This may be reinforced by hypersensitivity to any hint of criticism from others, or may generate perfectionist

­Diagrammatic Reformulation or Mappin  105

efforts which may lead to exhaustion and depression and real or perceived failure. This in turn may also re‐inforce the self‐critical “voice.” In another patient, a “controlling, blaming in relation to controlled, guilty, submissive” RR may generate a RRP of “placation with accompanying resentment.” This in turn may lead to ineffective outbursts that serve to increase the guilt and reinforce the pattern of guilty submission to self and others (see the case example of Dominic below). In constructing a complete SDR or map it is important to consider the procedures and “voices” in relation to both self and others that may arise from both poles of each reciprocal role. In some cases those (e.g., “Self to Self,” or “Self to other,” enactments) generated from the parental and culture‐derived formative RR (e.g., “demeaning and criticizing”) may be the most important to work with, although often less immediately apparent. These may be easily neglected, especially if a needy “victim” childhood RR pole (or “core pain”) is more immediately experienced and (understandably) responded to by the therapist. Focus and work on these former enactments represents an important and arguably distinctive part of the CAT approach. Diagrams constructed in this way should ideally embody clinically important, basic theoretical concepts in relatively clear and simple language, and also illustrate the model and how it works to the patient, and possibly others. They do this by: 1) Highlighting and acknowledging early relational experience and how it is internalized as a repertoire of formative RRs. 2) Showing how these play out, emphasizing, non‐judgmentally, the reciprocal nature of subsequent RRPs, often played out as current “situational” RRs with significant others, and also how they represent “best efforts” at coping. 3) Showing, therefore, how each role enactment is implicitly or explicitly directed to its anticipated reciprocal “other.” 4) Showing how a reciprocal role represents an internalized part of the Self. 5) Demonstrating how role enactments and associated voices may derive from either pole of a reciprocal role. 6) Showing how enactments of a repertoire of historic RRs and coping RRPs can inadvertently reinforce and perpetuate this repertoire, and how they may eventually lead to crises, breakdowns, and possibly formal clinical diagnoses (such as “depression”). 7) Showing that presenting diagnoses or clinical problems, although included ultimately somewhere on a CAT map, would not usually be placed as the central or starting point.

Historical Background: Simple “Flow Diagrams” The sequences described as traps, dilemmas, and snags that were central to the early practice of CAT can be expressed as simple flow diagrams. These would now be understood, as mentioned above, as the procedural expression of RRPs arising from underlying formative RRs. Correspondingly, diagrams based on and starting from formative RRs would now generally be advised in practice. Such part diagrams can, however, still helpfully be sketched out during sessions as a way of clarifying sequences and of gauging a patient’s current capacity to think diagrammatically. Such provisional part diagrams may lead on, for example, to more detailed self‐monitoring of sequences that are not fully understood, or may focus attention on the RRPs associated, for example, with self‐harm.

106

The Practice of CAT

Partial diagrams (see Figure 6.1), like the verbal descriptions in a letter, do not always, however, demonstrate easily or clearly the links between different problem procedures and underlying RRs.

Diagrammatic Reformulation or Mapping: Practical Considerations In constructing sequential diagrammatic reformulations (SDRs) or maps therapists are called upon to remain empathically “in tune” with the patient while thinking developmentally, sequentially, reciprocally, and structurally. Here, as in the whole of CAT practice, feeling and thinking should ideally complement each other. Patients will be involved in contributing, often in heart‐felt and moving ways, and in jointly noting and tracing particular formative experiences and subsequent sequences or patterns. But constructing the final integrated, paradoxically often simplified, diagram requires experience and will usually have to be led by the therapist. In undertaking this task, it can be helpful to adopt a “deliberately naive” I am bad and must not be angry

I feel guilty I give in or try to please I sulk or get angry

I get used or I feel out of control

A common trap

so my needs are ignored

I feel lonely uncared for

either be strong and care for them

I want to be close to others but it seems as if I must

so I feel out of control and break off

or give in to them to get care

A common dilemma

I feel a failure, unhappy

I want to succeed and enjoy life

so I undo or spoil things

things go well up to a point, but then

it is as if I am not allowed, must pay

A common snag

Figure 6.1  Part diagrams: sequences illustrating traps, dilemmas, and snags.

­Diagrammatic Reformulation or Mappin  107

c­ ollaborative position of inquiry, for example as to what the consequences of particular coping strategies might be. This might involve, for example, inquiring about or noting the position (likely the pole of a RR) someone starts from, or by venturing quizzically that “from what you say, you often feel put down and criticized,” then wondering aloud “I wonder how you usually try to manage, and, what ­typically would be the upshot of that”? Doing these exploratory sketch maps can be rather like “taking a line for walk” and seeing where we end up. Inevitably, this will be right back at the original formative RR. The construction, accuracy, and use of maps is therefore a joint activity, and may correspondingly lead to revisions or to the construction of simplified versions highlighting key therapy issues. The construction of the diagram can start in different ways. For some patients, it may be best to start with listing their key self‐descriptions to capture formative RRs. This may possibly take the form of an invitation to describe what it felt like during their formative childhood years, how it was for them, and their inner “subjective self,” and then to name and work out the reciprocal roles and role procedures they relate to. All the experiences, memories, expectations, actions, and symptoms described by the patient need to be understood as aspects of their RR and RRP repertoire. This repertoire and its relationship with the corresponding reciprocals as played by others, or by aspects of the Self, also needs to be elucidated and made clear. Another approach is to “think reciprocally” from the start, seeking to identify key reciprocal patterns from the experiences which were described as significant in childhood, from current patterns of self‐management or of relationships with others, from the patient’s responses to the Psychotherapy File, and from early transference– counter‐transference manifestations. It may be helpful to consult the list of common reciprocal patterns (see Chapter 4 Table 4.1) with the particular patient in mind. In CAT, however, descriptions of RRs are always negotiated with the patient and so are “personalised” or “bespoke,” and not “off the shelf.” Nor are they simply generated simply by filling in a questionnaire. Once the reciprocal role repertoire is listed and sketched out at the core of the diagram the key procedures generated from it will then be drawn as procedural loops that trace the consequences of the enactment. This should ideally be done tentatively with the patient as part of the dialog of therapy, checking out and negotiating the most fitting and evocative words to use. In some cases, partly depending on patient wishes, it can be helpful or necessary to start the diagram by noting down presenting problems or symptoms, and then working back to underlying issues. Symptoms and problematic behaviors may be located in the diagram as accompaniments or results of the enactment of particular procedures. For example, when a striving RRP arising from a “criticizing–criticized” RR is accompanied by “anxiety,” or may lead, for example, to “substance abuse” as a means of coping, or result in burn‐out and “depression.” Alternatively, symptoms may occur as substitutions, as when, for example, situations where assertion or anger might be appropriate are dealt with by submissive behavior accompanied by somatic symptoms and/or depression. A similar RR of “critically controlling to criticized/dependent” might lead to a RRP of angry criticism and rebellion, then suddenly switch to a RRP of “compliant trusted caretaker”—possibly in reaction to the reciprocation of a significant other or a therapist. It may also be due to the sudden intrusive experience of, for example, a “critically controlling” dialogic voice. Either way, connecting up symptoms and behaviors to underlying RRPs and RRs is fundamental, and arguably distinctive, to the CAT approach overall.

108

The Practice of CAT

When drawing out a map, procedural loops should aim to show the expected, perceived, or experienced consequences of enacting a role, including the elicited reciprocations. The RRs underlying a pattern of role procedures should usually be described in a box and/or highlighted (e.g., emboldened or color‐coded) in some way, thus representing the core of the diagram. Loops will trace the consequence of enacting procedures from either pole. Some will echo the core pattern by eliciting the expected reciprocations, some may represent role reversals of the core procedural pattern, some will be accompanied by symptoms (which may also have interpersonal effects). Patients find that descriptions of, broadly, “inner parent–inner child” reciprocal role ­patterns, based on recollections of childhood, are accessible, acceptable, and often helpful. But simple equivalences between these and current RRs and RRPs should not be assumed. Other significant sources, misinterpretations of experience, fantasy (although normally rooted in real experience), and the recognized limitations of formal explicit memory ­processes (including “false memory” syndrome) may all contribute to the final repertoire. It is a mistake to tie role descriptions in diagrams exclusively to the particular individuals in relation to whom they may have been formed. This this may limit generalization to other relationships and to self‐management, and may also result in a blaming attitude toward previous generations who may simply also have been doing the best they could in particular circumstances and culture. Coming to this mature realization, and possibly enabling some degree of forgiveness, may be for some patients a significant moment in therapy.

Single or Multiple Cores in Diagrams In general it is advisable and more effective to simplify and reduce the, sometimes quite subtle, variations in formative RRs together in a box, or “fuse” them, especially if they lead to very similar or the same RRPs (“lumping” rather than “splitting”). In the example of Beatrice (Figure 6.3), the problematic childhood pattern was condensed into a single formative RR description. In many cases a range of associated reciprocal roles, derived from one or both parents and possibly also involving the broader culture, or rivalry with, or care for or from, siblings, can be described within a single core box in the diagram. This indicates that the roles are compatible and that transitions between them are smooth and appropriate. In the case of Beatrice, the ideal RRP pattern was described on a different procedural loop because it referred to procedures enacted in different phases of life, and with only one person. In more severe and complex or borderline‐type cases, often involving serious emotional neglect or overt relational trauma, there may be a range of alternative, partially dissociated reciprocal role repertoires (“Self states”), only one of which is operating at a given time. A similar pattern may be evident in psychotic disorders. In such cases it will be important to separate out different RRs given their very different quality (e.g., “neglect” and/or “abuse”) and given that they will frequently lead to very different “coping” RRPs (e.g., ideal care seeking, substance abuse, vengeful anger, and so forth) along with associated states of mind. This is manifest in markedly discontinuous behaviors and variations in self‐awareness and sense of self‐coherence that can provoke powerful but confusing and contradictory counter‐transference feelings in the therapist. (The term “Self state” refers to the CAT Multiple Self State Model of more severe and complex damage or Borderline Personality Disorder (BPD), see Chapter 10.) These patients, because of their discontinuities,

­Diagrammatic Reformulation or Mappin  109

present their stories in a jumbled manner, showing what Holmes (1998) called “narrative incompetence.” For such patients especially, the reformulation letter and map, even if incomplete, can have a powerful impact in that they offer a preliminary sequential account in place of confusion, and can function as reassuring and remarkably containing concrete, or “transitional,” type objects. Many patients report holding onto these and carrying them around, and referring to them in when in states of distress or difficulty; for example, when feeling acutely panicky at night, or when tempted by self‐harming if feeling abandoned. Many patients can give clear and informative accounts of their shifting between states and the dialogic voices possibly associated with them, although these are often not volunteered as they may be felt to indicate “madness.” Indeed, they may still be unhelpfully regarded as an indication of psychotic disorder in some health services. The use of screening questionnaires, as described in Chapter 10, may be therefore helpful for reformulation. Once states and Self states are identified, self‐monitoring can trace the switches between them. When the presence of dissociated states is suspected, patients should be asked to record what they know about their states of mind and accompanying symptoms and behaviors and should monitor switches between them. Once states of mind are reliably identified, the reciprocal patterns need to be recognized. The therapist should try to help the patient to describe not only the dominant mood or behavior of each state but also the sense of Self and of others, and the degree to which feelings are accessed or cut off and the accompanying symptoms. A systematic investigation of a patient’s Self states can be carried out using a form of guided introspection, the States Description Procedure (SDP) (Ryle, 2007). The SDP was developed to clarify the features of the dissociated states of borderline patients but can be applied to the exploration of states in less dissociated patients where therapist responses may still be experienced as (inadvertently) collusive or provocative. In completing the SDP, patients identify from provided summary titles those states they recognize in themselves. They then characterize each state by identifying from provided descriptions the associated subjective symptoms and the patterns of relationship between self and others. Experienced therapists can obtain much of this information from interviewing, but it is recommended that trainees should read through the procedure and use the SDP with at least one patient as it serves to demonstrate the links between symptoms and reciprocal role patterns. The use of the SDP is further discussed in Chapter 10. Hubbock (personal communication) reported that the greater majority (90%) of 29 patients found the experience of completing and discussing the procedure useful, rating it as helpful or very helpful. In working with more severe and complex cases, therapists will need to bring together and map a range of information and understandings with the patient, locating each state as a state of mind associated with an aspect of a RR and identifying the reciprocal. It is often the case that both poles of the reciprocal role pattern will be described by the patient as subjectively experienced states, as when both an “abuser” and a “victim” state are recognized. In other cases, only one pole will have been recognized as experienced subjectively, perhaps because the reciprocal is always perceived in, or elicited from (or in psychoanalytic terms “projected into”), others. Dissociation between RRs is indicated diagrammatically by locating core repertoires in separate boxes which define the separate Self states. In a given Self state characterized by a particular reciprocal role pattern, the patient may enact either of the roles and will perceive

110

The Practice of CAT

or elicit the reciprocal in others. Abrupt state switches are a common feature of BPD, reflecting different types of instability which may be differentiated in the diagram: 1) Response shifts in relation to the same reciprocal, as in Beatrice’s switch from “trying to please” to “rebellious” in response to “critical rejection.” 2) Role reversals while in a given Self state, for example from “victim” to “abuser.” 3) Self state switches, for example Beatrice’s switch from the Self state comprising a formative RR of “critically rejected” and subsequent RRP of seeking ideal love and achieving (briefly) an “ideally loved to ideally loving” (situational) RR experience. This is then followed, however, after being let down, by a return to, and reinforcement of, the Self state characterized by her “critically rejecting–critically rejected” (formative) RR A further account and exploration of the issues arising in working with and reformulation with patients with “Self State” or borderline‐type difficulties will be found in Chapter 10. Various degrees of complexity may therefore be encountered in constructing the core, or cores, of diagrams (see Figure 6.2). The aim is to describe all major problematic RRs and RRPs in general terms as simply as possible. The decision about whether to list reciprocal role patterns in one, two, or several cores is a clinical and a practical one. Everybody has a range of ways of being. In that sense the self is a confederacy of states rather than a single nation, or a whole orchestra (with conductor) rather than one instrument. The pragmatic issue is to decide how best and how clinically most helpfully to describe their diversity and consequences and the level of their integration. The patterns illustrated in Figure 6.3 demonstrate the variety of ways in which the integration of the core repertoire may be displayed. The procedural loops are not described. In practice, simpler diagrams based around one key problematic formative RR, and one or a few RRPs, often suffices and this is to be preferred. Basic: A single reciprocal role pattern offers adequate understanding. The “French loaf” diagram: A number of reciprocal roles and reciprocal role procedures are listed within the core; these may be mobilized separately or together. “Split egg” diagrams may be satisfactory to a point but in most cases a more complete way of mapping borderline structures is needed. In these, the early abusing–abused pattern is shown to lead to some direct re‐enactments or experiences and to some defensive, coping procedures involving symptoms, avoidance, and so on; in either case the outcome may be to confront the individual with unmanageable levels of unmet need, sadness, or anger. These may be experienced as echoes or repetitions of the original abusive experiences which led to dissociation. This “flashpoint” or “crossroads” may be indicated on the diagram (as in the diagram of Rita (Figure 7.1) in Chapter 7), as the point at which switches to other Self states occur. At times this leads to the expression of primitive rage, leading to violence or self‐harm, and at times to dissociative symptoms such as perceptual distortions, depersonalization, and derealization. Most frequently it provokes a rapid switch to an established more manageable alternative Self state. This may be a “zombie” state, in which perceived threat or abandonment are responded to by emotional blankness (emotional withdrawal in relation to abandoning or threatening), to a state characterized by frenetic, highly focused but emotionally blank activity in relation to anxiety‐provoking threat, or to the search for an ideally caring to safely cared for state.

­Diagrammatic Reformulation or Mappin  111 BASIC: single RR

A B

“FRENCH LOAF”: RRs and RRPs co-exist, mobilized appropriately, smooth transitions A

C

E

B

D

F

“SPLIT EGG” AND SSSD: abrupt transitions, often inappropriate, some roles extreme “Self state sequential diagram”

“Split egg” A

C

A

C

E

G

B

D

B

D

F

H

DIALOGIC SEQUENCE ANALYSIS: traces rapid shifts between roles and RRPs A

B

C

A

D

B

A

D

B

C

Figure 6.2  Types of cores in sequential diagrams.

Figure 6.3  (a–c) Beatrice—Self states sequential diagram. (a) Initial depiction of formative reciprocal roles. (b) Mapping of key reciprocal role procedures leading to a similar state of “deep sadness.” One of these involves enactment of a situational RR of ideally loved to ideally loving (c) mapping the outcome of key reciprocal role procedures which reinforce original formative RRs and depicting also two Self states (SS 1 and SS 2) and highlighting a key dialogic voice using an asterisk.

(a) Beatrice – SSSD critical rejection

critically rejected

(b)

Beatrice – SSSD *critical rejection

critically rejected *disallow (Snag) guilty, striving, needy strive achieve* but

rebellious get rejected long for closeness but

strive to please

fear abandonment

get used

avoid closeness

*hate self

lonely

risk closeness idealise ideally loved

ideally loving

Profound sense of being worthwhile

needs unmet depressed

but abandoned deep sadness* ("the frozen chicken")

(c)

Beatrice – SSSD S.S.2

S.S.1 *critical rejection

critically rejected *disallow (Snag)

guilty, striving, needy

rebellious get rejected

strive achieve* but

long for closeness but strive to please

fear abandonment risk closeness

get used

avoid closeness

idealise

*hate self

lonely

ideally loved

needs unmet depressed

Profound sense of being worthwhile but abandoned

deep sadness* ("the frozen chicken")

Figure 6.3  (Continued)

ideally loving

­Diagrammatic Reformulation or Mappin  113

An important, overall distinction may be made between the processes (described as “ego” defenses in classical psychoanalysis) where emotional restriction is one aspect of limited role procedures, derived from the internalization of critical, controlling relationship patterns, and a Self structure marked by disorganization and discontinuities where no coherent or central pattern exists. Flexibility in making and revising diagrams is important and the above styles are not exclusive or mandatory. The diagram constructed with Beatrice described above does not exactly match the examples for, while there were two distinct Self states, these did not show the typical borderline features of frequent and abrupt alternations, since they were activated at different times in her life.

Example of Mapping To illustrate the process the construction of the diagram in the case of Beatrice (see above) will now be described. The information from Beatrice’s history and the reformulation letter given above were developed into a diagrammatic form. The initial and subsequent diagrams are reproduced in Figure 6.3a–c. It was developed with the aim of illustrating the sources of her current deep unhappiness and previous longstanding avoidance of emotional involvement. The dominant (formative) RR in the core of the diagram is critical rejection in relation to critically rejected leading to coping RRPs of either guilty striving and needy or rebellious. (Figure 6.3b). Striving led to achievement which she could not value and rebellion led to rejection and neither remedied her deprivation nor met her emotional needs. Striving to please led to being used and to self-rejection and this, combined with avoiding closeness for fear of abandonment, left her with her needs unmet. One other powerful RRP was exemplified uniquely by the relationship with Richard. Put simply, this was an example of a relationship seeming to offer all that was missing in childhood; it was described as ideally loved to ideally loving. This could be seen as an example of a (possibly archetypal) “seeking for the object never known.” The contrast between this relationship and all past experience, and the fact that it was unique and only mobilized with Richard, was described by locating this pattern separately. The link between the two cores was then traced; a longing for closeness linked with a fear of abandonment had led to placation followed by self-hate (critical rejection) or to the avoidance of emotional closeness (prior to meeting Richard). Taking the risk of involvement and his subsequent withdrawal had repeated the experience of being rejected, reinforcing the first core pattern and leaving her desolate. The final SDR (Figure 6.3c) for Beatrice showed how her seeking closeness had been constrained by her narrow range of options, as summarized in the procedural repertoire, how the experience of finding and then losing a deeply felt recent relationship had led to her current extreme unhappiness and “deep sadness,” and how these RRPs ultimately reinforced her formative RRs.

114

The Practice of CAT

Case Example: Dominic (Fictionalized) (IK) (This illustrates stages of mapping—including conflictual cross-cultural influences.) Dominic was a young psychology student who had been referred to a ­psychotherapy service because he was struggling with his course, although he had done well at school and was described as very bright and thoughtful. He had taken two overdoses in recent months, the second of which of had been serious and had only been discovered by a flat mate by chance. This had resulted in a hospital admission and referral for assessment. Dominic was of Chinese ethnic background but had been brought up in the UK by immigrant parents. At the first assessment meeting he sat looking at the floor and appeared withdrawn and uncommunicative. In response to a general enquiry about how things were now, he became quite angry about “having to go through all this again” and “anyway, what was the point”? However, he then looked up and around suddenly apologized, almost fearfully, for his outburst and added that there must be many other people who deserved help more than he did. After a few moments of silence, he did then confide in a quiet and rather resigned voice that he felt pretty fed up and exhausted and could not see a way of carrying on his course. He had been finding this disappointing because it was all so “technical” but he did not want to let his parents down by dropping out and “being a failure” and maybe he just “needed to try harder.” He agreed that he also felt very “alone” with all this. When discussing the implications of his constant feeling of needing to please his parents, he again became briefly angry at the attitudes of his Western fellow students who had “no respect for” and “did not care about” their elders. When exploring his social situation, it appeared he tended to keep himself to himself and tried to manage on his own. He also revealed that he was struggling with being gay which he felt guilty about, partly because it was simply not acceptable in his Chinese background culture, and was certainly not something he could ever discuss with his parents. He appeared, however, to appreciate that coping in this way overall was likely to be very exhausting and stressful. In discussing his view of the future he said he found it hard to see a way forward but agreed that a part of him did maybe have some hope that things might improve and that somehow he might find a way to complete his course and then maybe later explore the possibility of training as an educational or health care professional himself. In discussing his overdoses, he felt unsure why exactly he had taken them but agreed they might partly have been a way of communicating his distress. However, he said he had had really felt he “just wanted out of it all” the second time. During our initial assessment sessions we managed to roughly sketch out some of these issues (see Figure 6.4a–d), including especially the way in which he might “criticize” himself in a Self to Self enactment, and we ­d iscussed the idea of ultimately working on “exits” or “aims.” These might include coping in different ways depending on who he was dealing with, for example his parents (see below).

(a) Draft SDR – Dominic expecting to perform conditionally loving *criticising

expected to perform conditionally loved, criticised

(b)

Draft SDR – Dominic expecting to perform conditionally loving *criticising

led to overdoses feel hopeless, depressed

nothing improves

(confirms worst fears*)

expected to perform conditionally loved, criticised (“not good enough” “my fault”)

get exhausted, feel isolated, can’t cope

strive to perform and please, apologetic

works for a long time but ...

(c)

Draft SDR – Dominic expecting to perform conditionally loving *criticising

led to overdoses feel hopeless, depressed (confirms worst fears*)

nothing improves

apologise expected to perform conditionally loved, criticised (“not good enough” “my fault”)

get exhausted, feel isolated, can’t cope

not allowed, *self critical but ...

or works for a long time but ...

strive to perform and please, apologetic

briefly, rebellious, default.

Figure 6.4  (a) Depicts formative reciprocal roles; (b) mapping of most common coping procedure (effectively a “trap”); (c) further mapping of a “dilemma” leading to a briefly enacted RRP (effectively a “snag”) undermined by a critical voice; (d) depicting possible further RRP enactments (from the parental/culturally-derived pole of his formative RR) toward Self and/or others.

116

The Practice of CAT

(d)

? Draft SDR – Dominic expecting to perform conditionally loving *criticising

led to overdoses feel hopeless, depressed (confirms worst fears*)

apologise nothing improves

expected to perform conditionally loved, criticised (“not good enough” “my fault”)

get exhausted, feel isolated, can’t cope

or works for a long time but ...

*to self and others

Strive to perform and please, apologetic

not allowed, *self critical but ... briefly, rebellious, default.

Figure 6.4  (Continued)

Reformulation Letter to Dominic (Fictionalized) Dear Dominic, This is the letter I mentioned aiming to summarize the issues that brought you to therapy and what might lie behind them, and to reflect on where we are now and how we might move forward. This is only my impression of things and you should feel free to correct this or add to is as you see fit. When we first met it seemed you were feeling very fed up, worn out, and hopeless, both with the struggle you had been having to keep things going in life but also your experiences of ­various health services recently which seemed not to have been able to help you. However, it did seem as we discussed that it had felt also hard for you to ask for help feeling somehow that this represented a failure. In fact, you had got to such a stage that you just taken a very serious overdose which might have had disastrous consequences if someone had not found you. I remember very well when we met that you seemed at first very withdrawn and silent, although you then got quite grumpy and annoyed for a moment. However, as we have discussed since then, you pretty quickly apologized for getting angry at me—apparently because I was some sort of older authority figure. It does seem that being very personally assertive, given your particular background, was just not allowed. I think we have agreed that this seems to have been quite a key challenge for you growing up, especially in a very different culture in the West. In looking back, from what you say it seems your repeated experience in childhood was of being expected to perform and feeling criticized if you did not do well and it seems you began to develop a coping pattern of struggling on to please your “elders and betters” as you put it, managing everything on your own and not talking to anyone about things. This coping pattern is very hard to keep up and one consequence was recently that you got really very

­Diagrammatic Reformulation or Mappin  117

depressed and took the overdose, Just occasionally, like in our first meeting, it seems you might get so frustrated and annoyed that you do stand up for yourself and express some angry and ­emotional feelings. However, you then very quickly seem to repress these as if a “criticizing voice” sabotages them and stops them. From what you said about your childhood, although your parents cherished you in many ways, there were lots of times when you were judged simply on your performance. For example, you mentioned your progress at school was simply responded to in terms of the marks and reports rather than what they meant for you. It sounds like it felt very lonely and hard especially when your older brother seemed to be doing so much better so much more easily, had various girlfriends, and was as you put it “favoritized.” Again, this probably left you feeling somehow not good enough. In many ways it seems you did amazingly well to keep things going and get to university and also keep on helping your family. It sounds like a as child you also worried about your mother, who seemed also to experience similar criticism and repression at home and also the pressure to be there for others. It sounds like at times she also got low and exhausted, and it may be that this experience first nudged you toward thinking you might like to work in the health care professions—along with your apparently natural inclination to care about others. But we have also noted how the top of your “criticizing” formative reciprocal role is ­something that can apparently get enacted toward yourself, and sometimes in other situations, for example toward your fellow students and their attitudes to their parents and how in the West older people were as you put it “just dumped” into care homes. This role has also occasionally got enacted toward health services and myself, it seems as if you felt we were not maybe performing as we should. We talked also about the disturbed sleep and dreams you had been having of having to complete long and difficult tasks which kept slipping away from you. As we agreed these seemed very symbolic of the ongoing struggles you have been having. It seems significant that since starting work together you said that although you continue to have these troubled dreams overall your sleep has improved. Given all this I’ve been very impressed by the way you have stuck with coming to therapy and trying to open up about things even if this has seemed strange and new especially with an older authority figure. It seems despite your sometimes hopeless thoughts there is a part of you that would want to try to sort things out and move forward in a more productive way, and not just in order to please me as we have joked. This might involve moving on from what might seem like the insoluble dilemma between pleasing others and self-assertion that we mapped out on the diagram. This might, for example, involve exploring the possibility that it might be possible to discuss some of your difficulties with your family, even if not perhaps about being gay which seems a real no-go area for them, and maybe also to discuss with some of your friends how they cope with the course. You told me that so far this has really not turned out as you hoped as it seems to have been more technological than humanistic. You’ve clearly done a lot of thinking about these issues since we started therapy and have begun to see if you can begin to do try out maybe some of the little experiments we talked about. It does seem that talking about things in this way has been quite a new experience and has helped as you said a lot with your stresses and tension and the feeling that you

118

The Practice of CAT

have nowhere to go with it all. Perhaps this in itself is something to think about for the future. It does sound too as if the mindfulness classes you have started recently could be very helpful to you in managing things better in the future. I will add subsequently a couple of key aims or issues as we discussed and which we noted on the map, which will likely be around issues communicating to others, feeling it may be OK to stand for yourself within the limits of your family and their culture, and also thinking about that “criticizing” voice. We may also later on, as we discussed, try to do some work on emotionally processing some of your early formative experiences. I do think that if you can manage to stick with this process it will ultimately be helpful to you in moving forwards, although of course there will still be ups and downs and life outside will continue to be very hard for many people in many ways as we have discussed. I look forward to your response to this provisional letter and moving forward together the next couple of months. With best wishes TPPs/Key Issues and Aims for Dominic: 1) Because of your formative experience (RR) of being expected to perform and to be there for others, and of being criticized, you have tended to try to please people and cope on your own. This has led you to being exhausted and hopeless and to reinforcing those original experiences. Aim: Try to communicate some of how you feel and some of your own needs as appropriate to trusted people, as you have begun to do in therapy—and see what happens. 2) Because of your early experience of being and feeling constantly criticized you have acquired a “critical” inner voice that can get played out toward yourself, but also sometimes to others. Aim: Try to be aware of this voice and of its effects and consider, as we have begun to do, whether you need to accept it.

Exits and Aims In general, as previously noted, is best to leave the description of alternative coping strategies or the drawing in of alternative, more effective procedures (“exits” or “aims”) until the use of the map and letter has made them familiar and well understood, possibly after another few weeks. Recognition is the first, important task, and only when it is reliably achieved can patients normally begin to explore alternatives. The exception would be when symptoms or other procedures (e.g., substance abuse, anorexia) threaten the patient’s staying in therapy or where serious self‐harm is a possibility. In these cases, working on provisional exits located on incomplete diagrams may be an urgent priority, but always along with attempts to locate and together understand these in the context of their origins in formative RRs. However, it is helpful and important, despite the apparent intractable pessimism of some patient stories and “maps,” to flag up and stress from the beginning that therapy will also involve working on alternative ways forward and of “changing for the better” (McCormick, 2017). Likewise, it is helpful to stress positively how well in many cases patients have done in surviving and coping with often extremely difficult or traumatic life experiences.

­Formal Evaluation of the Impact of Reformulatio  119

­The Order and Process of Reformulation While general guiding principles have evolved around the process of reformulation, therefore, there are no absolute rules in this, except to find what appears through negotiation to work best for the patient. It is our conviction that thinking relationally and reciprocally from the start and incorporating this understanding in the reformulation process offers the best preparation for, and beginning of the work of, therapy (see also more recently Potter, 2020). Because of the dominance of monadic, individualistic assumptions in our culture, acquiring a more relational, reciprocal way of thinking and working can be a challenge for some therapists, especially perhaps those trained formally in individualistically based psychological or biomedical approaches. In current CAT practice, most experienced therapists will be more flexible about the order in which and how these various activities are undertaken, and also on the individual focus, for example, on historic RRs and voices, or the need for processing often powerful emotional memories, or addressing problematic symptoms and behaviors such as substance abuse, self‐harm, or angry outbursts in the “here and now.” As for any model of therapy, however, it is recognized as being helpful in training to stick at first to established structures and sequences.

­Formal Evaluation of the Impact of Reformulation The impact of reformulation letters has been formally investigated in several studies. Hamill, Reid, and Reynolds (2008) carried out semi‐structured interviews with eight patients and identified four main effects. Letters offered a tangible, lasting framework for the assimilation of a new perspective about themselves and their relationships, demonstrated the therapists’ commitment to the patients’ growth, taught patients something about the therapy process as an example of an interpersonal exchange, and helped them consider how they wished to share personal information. Shine and Westacott (2010) investigated the impact of the reformulation sessions on the therapeutic alliance in a study of five cases, using both quantitative measures of the therapy alliance and a qualitative analysis. The former showed no specific impact of the reformulation sessions, but the latter identified seven themes, namely: Feeling heard, Understanding patterns, Space to talk, Feeling accepted, Having something tangible, Working together, and Feeling exposed. They suggest that the impact of the reformulation process extends beyond the specific reformulation sessions. Clinical experience suggests that patients respond to their completed diagrams in three main ways. Some are relieved to have a new understanding of why it has been so hard to change. Others feel sad or appalled to realize how they have boxed themselves in and fear there will be no way out; this is a common enough response in any therapy at the point at which patients realize their own “contribution” to their problems. For them, it is important to emphasize that these are maps of problematic roles and procedures and not of the whole person, and important to emphasize that description is the first step, to be followed by recognition and change. A third, less common, response may be confusion. Therapists need to be careful not to impose over‐complex diagrams on their patients, even if they may need them themselves. Simplified maps leaving out many connections in the pursuit of readability are of more use than are brilliant constructions resembling the street map of some major city. In practice, full diagrams can often be replaced by simple

120

The Practice of CAT

working diagrams focusing on the most important roles and procedures. Inter‐therapist reliability and validity of the written formulation when the therapy audio‐tapes from several therapies were responded to by different therapists was demonstrated in a study by Welch (2010). Further challenging questions about the specific therapeutic effects of reformulation have been raised by a dismantling study by Kellett et al. (2018). The results of this possibly imply that the use of the overall CAT approach, including its conceptual framework and therefore use effectively of “virtual” reformulation, is likely to be the critical therapeutic factor whether or not formal tools such as reformulation are used. This would be consistent with an earlier qualitative study suggesting that the effect of reformulation related to its use within the overall context of a powerful (CAT) therapy experience (Rayner, Thompson, & Walsh, 2011). A further positive study of “service user” experiences of diagrams using “interpretative phenomenological analysis” suggested that diagrams facilitated understanding and reduced blame, and contributed to a sense of collaboration in therapy (Taplin, Greenhill, Seddon, & McGuire, 2018). Further discussion of the relation of reformulation to therapeutic competences is given in Chapter  8 and is extensively reviewed by Welch (2010).

Concluding Remarks In CAT, individuals are understood to be above all socially and relationally formed and motivated rather than being simply rational “information processors and decision makers”, or being simply at the mercy of endogenous disorders of chemicals or cognitions, or of unconscious destructive and conflictual forces. The role of reformulation is to illustrate and challenge the negative and “deforming” consequences of the individual’s particular psycho‐social formation and current context, and to support the patient in the recognition and revision of what has not gone well but was previously not recognized. Reformulations can help indicate, in a non‐judgmental and validating way, both how restrictions and distress were maintained and, importantly, how they may now be possibly overcome. They may also, by extending awareness of different aspects of the Self, contribute to integration and control. They evidently contribute powerfully to the collaborative ethos of CAT for both patient and therapist. Importantly, this occurs through, and in the context, of a thoughtful, empathic, therapeutic relationship.

121

7

The Practice of CAT Later Phases of Therapy, Working at Changing and Ending S ­ ummary During the later, more open, phase of therapy a range of activities may be undertaken, although these would always be related to previous reformulations. During this phase, further exploration and discussion of issues that the patient may bring to therapy is undertaken. These may include talking through difficult or painful experiences from the past or from the “here-and-now.” The former may include discussion and mourning of life possibilities that were never realized, whether due to real circumstances or perhaps due to enactment of unhelpful or self-sabotaging RRPs. Even during these phases, the work of Cognitive Analytic Therapy (CAT) involves continual, at least implicit, reference back to and focus on prior reformulations, which should describe and illuminate enactments of key reciprocal roles (RRs) and reciprocal role procedures (RRPs) both in the past and present, and within and outside of sessions. Active empathic engagement in therapy and monitoring and working on revising the enactment of such roles continues to demand high levels of concentration and hard work from both therapist and patient. Therapists aim, above all, to avoid reinforcing (colluding with) unhelpful or dysfunctional RRs and RRPs and should be alert to the Self state switches which may occur in more damaged and disturbed patients. Awareness of the likelihood of therapist counter-transferential RR enactments is especially important in avoiding collusion, particularly in working with more “difficult” or personality disorder-type patients. Dialogic “voices” associated with underlying RRs and sequences of RRPs may also be helpfully challenged and modified either by simply noting and “flagging up” their occurrence or, more formally, through the technique of “dialogical sequence analysis” developed by Leiman. Therapy may be assisted by aids such as rating sheets and, possibly, other forms of “homework” such as diary keeping, and may involve other techniques such as graded exposure, “behavioral experiments,” writing of “no send” letters, “empty chair” work, or use of creative or bodily-based therapy approaches. Active focus on and processing of traumatic memories implicit in some RRs may also be required at some point in some cases. The experience of a new benign, collaborative therapeutic relationship should also continue to be gradually internalized during this phase. Some patients may actually wish to note this new RR formally on their diagram. Focus throughout is maintained on the aim of “ending well.” Further challenging enactments and difficulties are to be anticipated toward termination and these will be explicitly addressed by both therapist and patient, partly through the writing of “goodbye letters.” Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, Second Edition. Anthony Ryle and Ian B. Kerr. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

122

The Practice of CAT

With the engagement of the patient in therapy, and the creation and revision of the ­written reformulation and diagram, the first phase of therapy is complete. The therapist has acknowledged and explored the patient’s experience and story, and together a new way of understanding has been negotiated and agreed. At this point there is a subtle change of pace, although these phases overlap considerably with each other. The style of therapy becomes rather more open and less directed, although the descriptive tools that have been created and recorded continue to be employed in working on change. This can be described as having two overlapping phases. The first involves the deliberate use of the tools to ­recognize each time enactments of a RR or of problematic patterns of behaving or thinking (RRP) recur. The second, partly achieved via recognition, is devoted to revising or changing them. In this chapter the main issues and techniques involved in these later phases will be ­considered. A more fine-grained consideration of the evaluation of therapist activities will be provided in the next chapter. It is important to recognize that, for all but the simplest problems, the work of therapy involves much more than the use of the reformulation tools under the didactic guidance of the therapist. It requires the skillful continuing development and use of the therapeutic relationship. The therapist’s focused attention and ­concerned curiosity will have been, for many patients, a new experience generating a new optimism. But change is not easy and old ways of being and old patterns tend to reassert themselves, especially under stressful conditions.

­Later Sessions—General Considerations During this phase, broader issues, some possibly already flagged up during earlier sessions, concerning the sense and purpose of Self, or relations with others, may be brought to the therapy relationship and may be addressed formally but also, and crucially, through the human quality of the relationship as it evolves and is thought about. The early clarifications offered by reformulation should encourage patients to think about changing but also serve to create an opportunity for explicit processing or mourning of past experiences including of losses, and reflection on possible missed opportunities and unfulfilled potential. Here, therapists need to be capable of attuned silences, possibly gentle humor as appropriate, and use of active exploratory and “processing” methods such as “no-send” letters, “empty chair” techniques, and, possibly, responding to and exploring a patient’s painting or imaginative writing. In these ways, while focusing on the recognition and revision of maladaptive roles and role procedures, therapists also convey a trust, gradually internalized, in the patient’s capacity for further growth and individuation in the ways also emphasized by more ­humanistic and Jungian type approaches (see Samuels, 1989), and by the “prospective” ­position espoused by theorists such as Vygotsky (see, e.g., Wertsch, 1985).

­Change and the Working Alliance in the “ZPPD” Vygotsky was describing the teaching of intellectual skills when he defined the zone of proximal development (ZPD) as the gap between current ability and the level of learning which the individual has the capacity to attain if provided with the support of a more

­Making Use of Transference and Counter-transference in Enabling Chang  123

c­ ompetent other. As discussed in Chapter 4, good teaching aims to operate in this zone and, by analogy, good therapy should aim to address what might be called the “zone of proximal personality development” (ZPPD), or perhaps “zone of proximal Self development” (ZPSD). Because the idea of self-reflection, in the sense of thinking about and reflecting on one’s own thought processes, is an unfamiliar activity for many people, one task of therapists is to provide concepts and experiences supporting the development of this capacity. Using the Psychotherapy File and taking part in the collaborative process of reformulation are ways in which CAT therapists are active in their patients’ ZPD, and many so-called “pre-contemplative” patients (Prochaska, Norcross, & DiClemente, 1994) are able to ­rapidly extend the scope of their self-reflection. In this sense, CAT constitutes a form of “motivational interviewing.” However, the wish to undertake therapy and change one’s life in some way does undoubtedly depend in some measure on an individual’s experience of a sense of personal crisis, whether specifically focal or at a more existential level. A major aim in CAT is to offer a more equal, exploratory, genuinely collaborative (Socratic) relationship that can generate a thoughtful, accurate, accepting, and generous internal conversation. Understood in this way, the creation and maintenance of a good working alliance requires the full range of interpersonal sensitivities and therapeutic skills. The tools and techniques of CAT are intended to support the therapist in maintaining such a generative relationship even in the face of all the ways in which patients may, unconsciously or unwittingly, find it hard to trust or may undermine change. The working alliance of therapy is therefore a special and unfamiliar form of relationship. It comprises not only agreement about aims and objectives, but also teaching and learning, combined with the provision of an arena for the manifestation and enactment of the patient’s RRs and RRPs. Experiencing, observing, and reflecting upon the relationship as it evolves in this arena allows a different kind of “learning.” The capacity to sustain ­relationships is developed by the therapist’s recognizing and not reciprocating unhelpful or destructive patterns and encouraging the patient to participate in a new way of relating. Therapeutic “technique” is aimed also at generating and living through an intense, reconstructive relationship.

­ aking Use of Transference and Counter-transference M in Enabling Change Patients can use the insights and understandings offered by therapy to recognize and change their everyday relationships and self-management procedures, and many do so, but learning is more immediate in the therapy relationship, where recognition can be linked to nonreciprocation and the exploration of alternatives. Failure to recognize unhelpful or negative procedures operating in the therapy relationship, whether hostile, avoidant, or idealizing, will inevitably block progress. Conversely, the use in CAT of these same concepts to reflect on the therapy relationship, and also the relationships of daily life, aids generalization of what is learned from the lived understanding of transference and counter-transference to daily life. The therapy relationship is not characterized by one single transference–countertransference relationship. Many changes may occur in the course of a therapy, or indeed of  a session, as different RR and RRPs are enacted. These “transferential” enactments

124

The Practice of CAT

(e.g., “rebellion,” “self-harm”) may also be played out between therapy sessions (so-called “acting out”), and will also need addressing. Early mapping and listing of the repertoire of RRs and RRPs, and continuing use of the diagram to trace what is happening during sessions, is one of the major, and arguably distinctive, contributions of CAT technique. It enables therapists to become skilled at recognizing the meanings of the range of feelings evoked during their time with and experience of each patient. Reformulation indicates the patient’s likely pressures and invitations to collude. It can be a useful exercise to trace how countertransference varies according to where the patient is located on the sequential diagram. For the therapist, it is always worth reflecting on “where they are” at any time in relation to their patient’s map. This should also be a regular question in supervision. In the case of borderline-type patients, the sort of events or remarks from the therapist which might provoke state switches, and likewise those states that present symptomatically, can only be identified and clarified by meticulous, empathic, and even possibly humorous use of the diagram. In the course of therapy, therapists, aided by supervision, can use their identifying counter-transference to explore feelings that the patient is conveying non-verbally but does not or cannot acknowledge or experience consciously. This does not need to be done mysteriously or omnipotently; it is enough to say something like: “in the last few minutes, while you have been talking, I have felt an undercurrent of anger (or sadness, or pain etc.); maybe it is your tone of voice or the way you are sitting. Am I picking something up from you?” Silences are often occasions when such indirect communications can be identified. As regards reciprocating counter-transference, the need is to recognize the pressures and to avoid reinforcing (collusive) responses. Here too quite straightforward comments can be made, such as: “As this is the third week you have not brought the diary you and I had agreed it would be helpful for you to keep, I wonder if you are needing to show me that you are in control or are angry in some way. What do you think?” Or: “Could your telling me how much help you had from your herbalist, your neighbor, and from the article in the color supplement and your dismissal of the Psychotherapy File as being too elementary to be of use be your way of telling me that you do not think much of this therapy and of me?” Therapists need to be aware of their own reactions to overt or covert attacks and aware of their personal vulnerabilities. It may be possible to explore with the patient which RR or RRP is being enacted. It may also be appropriate to acknowledge the possibility that the patient is reacting to an actual deficiency or error on the part of the therapist or of services. Either identifying or reciprocating counter-transference may identify feelings in the patient that contradict what is overtly said or done and may access feelings which the patient has not been able to acknowledge. Exploring these makes them available to the patient for reflection. To further add to the complexity of the therapist’s task, different forms of counter-transference may co-exist as, for example, when one feels distress on seeing or hearing of a patient’s self-harm or self-deprivation (empathic identification with the victim) and at the same time feels angry in response to what they have done to themselves (reciprocating anger evoked by their undermining of their lives and of the therapy). The most confusing patients are those with Borderline Personality-type disorders (BPD), because of their abrupt switches between states. This is particularly the case when anxiety provoked by touching on feared subjects leads to “whirlpooling,” a continuous process of rapid switching between states. When this happens, therapists need to impose a pause for

­Transference, Counter-transference, and the Working Relationship of Therap  125

thought which may be linked with getting the patient to try physical relaxation or use mindfulness techniques (see e.g. McCormick, 2017). The therapist then needs to examine one segment of the patient’s behavior or narrative at a time. A clearer understanding can also be assisted by noting or flagging up dialogic “voices” incorporated in RRs and RRPs on the patient’s map as they occur in session, or more formally by using the technique of dialogic sequence analysis (Leiman, 1997) (see example below).

­ ransference, Counter-transference, and the Working T Relationship of Therapy A therapist’s response to a patient is, of course, evoked by the full range of the patient’s characteristics, communications, and behaviors, not all of which are “transference” manifestations derived from childhood and not all of which are problematic. Some are evoked by the unfamiliar or perplexing way therapists (or possibly whole services) may appear to behave. This points to the need for therapists to be explicit about their role and to invite and respond accurately to questions and arguments about it. There is no reason to believe that opaque, vague, or emotionally blank therapists have a particular privileged access to transference enactments, for patients, like all of us, repeat their patterns wherever they go. Therapists doing CAT should be open about how they understand their role, preserving the right to limit their availability and to maintain their own privacy but able also, within the clear boundaries established through reformulation, to offer direct human responses. Therapist and patient roles are not symmetrical, and it can often be helpful to acknowledge this explicitly, but they are of equal value and the aim should be to base them on openness and mutual respect. CAT is a demanding model for therapists and patients. Because it involves a high level of participation from patients, a common transference response is one of initial commitment followed by withholding or disappointment. The successful holding on to the working relationship through these threats to the alliance is a key therapeutic task. Because it is intense and brief, dealing with loss and disappointment is a necessity, but one which, with the support of the reformulation tools and goodbye letter, allows the internalization of the work done together. In the discussion of technique which follows it is assumed that every kind of activity occurs in the context of, and has implications for, the developing therapy relationship. The working alliance is an alliance between the therapist and the patient that depends on the rapid extension of the patient’s ability to experience and feel and to think and reflect on the self. Jellema (2000), from an attachment theory perspective, suggests that patients whose tendency is to avoid accessing feeling need a different approach from those who have difficulty in thinking about themselves. But in many, if not most, patients both kinds of difficulty are met with, and the therapeutic response needs to address both, bearing in mind that it is often the “cognitive” aspects of CAT which provide the safety within which feelings can be accessed. Where patients have little faith in their capacity to reflect it may be important, once the scaffolding of the basic reformulation tools has been constructed, for therapists to avoid being too busy, so as to allow space for initiative and experimentation, and to remember that silence may be the appropriate form of activity at times, even in time-limited therapy.

126

The Practice of CAT

­Dialogic Sequence Analysis Case Example: Alistair Alistair was a 52-year-old solicitor who had recently been asked to resign from his firm after he had been involved in some shady financial dealings and had narrowly escaped prosecution. His Self states sequential diagram described two dissociated reciprocal role patterns, one “arrogant contempt A in relation to scum B” and the other “admiring C in relation to admired D.” This represents a typical narcissistic personality disorder pattern. This notation is used to trace the role reversals and Self state shifts as follows: Alistair arrived 10 min late for his sixth session, a little out of breath, and explained he had stopped to chat with an acquaintance near the hospital (Alistair A to therapist B) and adding that he had run up the stairs, which showed how superbly fit he was despite smoking and drinking too much (Alistair C to self D). He launched into an account of his holiday abroad; he had angered his wife by his arrogance (Alistair A to wife B) which he attributed to her failure to show concern for him (wife’s failure to be C to Alistair D) when he had been infuriated at the airport by the incompetent airline (Alistair A to airline B) and by the rude, idiotic French fellow passengers (Alistair A to French passengers B). Where they stayed the other English guests had been a dreary lot (Alistair A to the English B) but there were two charming Irishmen (the therapist was Irish; Alistair C to therapist D). They were very free in their behavior; doubtless the therapist had had numerous affairs? (Alistair A and C to therapist B and D.)

­Technical Procedures Following the completion of the reformulation phase the first (“honeymoon”) sessions are usually characterized by the patient’s active involvement, buoyed up by a new optimism and a developing understanding of the sources of their problems. This mood may include an element of magical hope or of idealization of the therapist who has brought them to this point, or may be expressed in compliant or placatory participation in the work. In the very short run, these enactments may serve to collect information and initiate new forms of diary keeping, but such procedures and their predictable, ultimately negative, outcomes should always be noted.

­Rating Progress When verbal descriptions of target problems and procedures are employed, change can be rated on visual analog scales the mid-point of which represents the state at the point that therapy starts (see Chapter 2 for an example). In the case of target problem procedures, ratings may initially be made of recognition rates and only when recognition is reliably present should ratings of change be made. Where diagrams are the main reformulation tool used, ratings can be made of the frequency or intensity with which particular procedural

­Recapitulating and Reviewing Session  127

loops are enacted. In BPD-type disorders the frequency with which problem RRs and RRPs are enacted and switches into distressing or negative Self states occur can be noted. The use of rating scales is disliked by a few patients and by rather more therapists and may have to be replaced by alternative methods. Regular review is, however, important. It has two functions: one is to build up the patient’s capacity for realistic self-evaluation, the other is to ensure that both patient and therapist keep in mind the whole array of problem RRs and RRPs and address those in which no change has occurred.

­Recognizing Enactments and Procedures as they Occur By the end of the reformulation phase, diary keeping and work in the sessions has begun to locate the place of symptoms, mood switches, and unwanted behaviors in the procedural structure. The patient’s attention has usually shifted from these once-automatic and apparently spontaneous experiences to the recognition of the newly identified problem procedures with which they are associated. In the case of borderline patients, the recognition of states and state switches will be the priority. Diagrams are the best basis for this monitoring and many patients keep them in their handbags or wallets or pinned over the bathroom mirror for ready consultation. The diagrams need to be as simple as possible and memorizing them may be helped if the core patterns and procedures are, for example, color-coded. Borderline-type patients commonly choose predictable colors for their states and procedural loops, such as pink for idealizing, black for depression, and red for rage. Simple diaries of significant events can be kept for each day and color coded by the patient; not infrequently the color becomes the mnemonic device; so, for example, a patient may report “I was feeling she was really wonderful—the kind of girl I had always hoped to meet. But then I realized that I hardly knew her … so I saw that yet again I was off into my pink state.” Such color coded “maps” are best left on the table between the patient and therapist during sessions and during supervision so that both events occurring during the session and the reports of the previous week can be located and placed in the context of the whole picture.

­Recapitulating and Reviewing Sessions It is a good idea, especially in the first half of therapy as a common understanding is being established, to set time aside at the end of each session, if possible and appropriate to the patient’s emotional state, to go over the main themes and feelings and to repeat (or now notice for the first time) their meanings. Often, the content may have dominated the discussion and the mood and important aspects of the process with transference implications may not have been noted. At this recapitulation, both reports and transference enactments need to be located in the procedural system by reference to the diagram, a process which establishes the diagram as part of the shared language and understanding. This review leads on naturally to the rating of change; this should be done by the patient but commented on by the therapist, especially where there are discrepancies between the rating and what has been reported in the session. This review also serves as the basis for the negotiation of homework. Where audio-taping of sessions is carried out by trainees, this recapitulation provides a useful focus for supervision.

128

The Practice of CAT

­Homework The term homework, taken over from cognitive-behavioral practice, has echoes of schooldays which may be liable to induce delinquency. But the idea of doing work between sessions can be very helpful in any brief therapy. The crucial thing is to devise with the patient an activity related to the themes and current preoccupations of the therapy. Learning to recognize problem RRs and RRPs as they are enacted is the essential task, as discussed above, but apart from this a variety of detailed homework tasks linked to the reformulation may be useful. Common examples would be: 1) Clarifying past history by constructing a life chart, completing family trees, or writing brief self-descriptions. 2) Writing assertive “no send” letters to hated, missed, or otherwise emotionally charged people, whether past or present or dead or alive. 3) Writing to, or carrying out some ritual acts on behalf of, incompletely mourned loved others. 4) Following simple behavioral programs such as graded exposure to feared situations or practicing alternatives to identified procedures; for example, practicing assertion in place of placation or passive anger. 5) Rehearsing ways of managing difficult emotional states. This may involve identifying misinterpretations of external events or getting their scale wrong through “catastrophizing” and overpersonalizing. 6) Rehearsing alternative thoughts and forms of self-talk. 7) Practicing physical relaxation or forms of meditation or mindfulness techniques. 8) Identifying and amplifying whatever forms of control the patient may have developed. This last may be particularly valuable where episodes of self-harm have occurred. Making a list of ways of coping, such as writing a letter to the therapist, contacting friends or telephone counseling services, or following some form of distraction, provides a readily available repertoire of active alternatives to self-harm. All these activities should be linked to the diagram so that when the patient recognizes an unhelpful procedure beginning to operate, an immediate rehearsed alternative is available. If homework is negotiated and agreed, then failure to carry it out is an example of a negative procedure in action which should be discussed and linked to the reformulation. Equally, therapists are responsible for following up and discussing what homework was done.

­Accessing Painful, Possibly Traumatic, Memories and Feelings In a therapy which is going well, it will be a matter of only a few weeks before patients can locate themselves reliably on the map and at this point they usually report less anxiety and more control, although occasionally some despondency at how repetitive they are. But this stage may also be marked by the emergence of painful feelings and memories which will amplify, but do not usually contradict, the understandings summarized in the diagram. The pace at which these are contacted and their assimilation depends upon

­Not Recognizing Enactments and Procedures as they Occu  129

the safety offered by the therapy relationship; it should not be imposed by the therapist. Procedural changes are initially dependent on deliberate conscious control; the automatic mobilization of positive or at least less harmful procedures may take a long time to become established. Once the use of the reformulation is reliably established, the need to refer to the reformulation tools diminishes but patients are advised to keep them to consult if the need arises. A common comment at post-therapy follow-up is “… well of course I still get the old impulses (or voices) and may even begin to go down the old road. But now I can stop and think about them.” It is clear from an increasing literature on psychological trauma that formal processing of these aspects of RRs may also be required (see discussion in Chapters 4 and 9, and Corrigan & Hull, 2015, 2018; Cozolino, 2014; Damasio, 2012; Meares, 2012; Moffit & The Klaus-Grawe Think Tank, 2013; Panksepp & Biven, 2012; Schore, 2012; Shea, 2018; Siegel, 2012). Some of these memories may be (literally) incorporated into the body and may be amenable to and greatly helped by formal body movement and/or creative approaches. The timing of such treatment may need careful negotiation and discussion with the patient, including during supervision. It may be most appropriate during the middle phase of therapy, or may be undertaken following post-therapy review at a later date when the overall situation has become more stable and clear. Whenever trauma processing work is undertaken, careful attention needs to be paid to the patient’s feelings of safety and (relational) security including their domestic situation (see Corrigan & Hull, 2018; Schwarz et al., 2017; Shea, 2018). In more severe cases, this should probably be undertaken in the context of a multidisciplinary program, possibly in a residential facility. Sadly, the latter options are generally more conspicuous by their absence.

­Not Recognizing Enactments and Procedures as they Occur Not all patients get off to a flying start, however, and some who do go on to stagnate after a few sessions. Where clearly recognized procedures are responsible, such as the one summarized in the Psychotherapy File as “If I must then I won’t,” they will need to be repeatedly identified and challenged. Stagnation in mid-therapy is often the result of therapists being drawn into unrecognized, collusive reciprocal role patterns. Experience with audio-tape supervising suggests that such unrecognized collusions may originate in inadequate diagrams in which the therapist and patient seem to have “agreed” to omit an important procedure. This points to the need to take careful note whenever an event occurs which cannot be located on the current diagram. It also indicates one of the limitations of normal modes of supervision and the value of audio-taping; therapists cannot report and may not convey phenomena, or the absence of phenomena, which they have not identified. With or without audio-tape supervision, if a therapy seems to be drifting into stagnation it may be helpful for the therapist to write a “midway letter” to the patient reviewing what has and has not been discussed and suggesting what may be happening in the therapy relationship to account for the absence of movement. The most common explanation is that the patient’s unexpressed but indirectly communicated anger has elicited in the therapist a placatory, avoidant, passively resistant, or emotionally cut-off response. If such stalemates

130

The Practice of CAT

are not challenged the patient may go on to miss sessions and may drop out, whereas, if  they are acknowledged and challenged, the experience of having negative feelings (­possibly toward the ­therapist) acknowledged, allowed, and understood in this context can have a major therapeutic impact. As part of the challenge therapists should “shake the transference–counter-transference tree,” that is to say they should identify and name what they are feeling and consider how far it is a reciprocation to what the patient is conveying and how far an empathic echoing of what the patient cannot express. Discussing these issues in supervision is helpful; not infrequently the stalemate and emotional flatness is reflected in the way the session is reported, which creates an inert, non-productive therapist–supervisor relationship and a bored, yawning supervision group. This is less a case of “parallel process” than of serial role induction. If the patient consents intellectually to the new understandings but remains unengaged emotionally in therapy and in daily life, more active methods may be called for, such as empty chair conversations, role play exercises with the therapist, directly confronting the patient with descriptions of counter-transference feelings, or the use of drawing, painting, or writing. Work through parallel therapeutic modalities, such as music therapy or psychodrama, if available, may also be very productive at this level. All of these should be planned and carried out with reference to the reformulation descriptions of the key procedures involved in maintaining emotional disengagement.

­ he CAT Model of Resistance and of the “Negative T Therapeutic Reaction” In many models of therapy, the failure of patients to engage constructively in the work of therapy is often labeled “resistance,” and similarly the occurrence of apparent therapeutic regression following some initial progress may be described as a “negative therapeutic reaction.” These terms imply an (unconsciously) motivated refusal to get better that overrides or sabotages the consciously expressed wish for change. The terms smack somewhat of blaming the victim and it seems better to define the phenomenon as anxiety-related enactments and manifestations of one of the patient’s “negative” RRs and RRs, and the inability at that point by the therapist to have assisted change, or at least enduring change. In CAT the likelihood of problem procedures operating within the therapy relationship should have been noted in the reformulation letter. As the therapy-blocking procedure will almost certainly have been manifest in other aspects of life, it will have been described in the reformulation, so the phenomenon of non-cooperation can be made use of to illustrate and challenge a procedure of general importance. The work of therapy may need to be focused entirely on the manifestation of this procedure in the therapy relationship until it has been modified. A more general source of resistance is derived from the fact that our sense of identity is partly sustained by the enactments of individual procedures and is undermined and threatened by relinquishing any of these, even if they are harmful; this is an idea close to Fairbairn’s concept of “adhesion to the bad object” (Fairbairn, 1952). It can be helpful for therapists to remember, and to acknowledge with the patient, that change is hugely difficult, involving as it does effectively giving up and losing a part of the Self.

­Dropping out of Therap  131

­Dropping out of Therapy Although the evidence shows that CAT is particularly effective at engaging with and retaining patients in therapy, including those traditionally regarded as “hard to help” (Calvert & Kellett, 2014), there are nonetheless patients who represent a considerable challenge. This may include those who genuinely feel intractably hopeless, possibly in relation to very real life circumstances, notwithstanding this may in part represent a RR enactment. Another group of patients who may drop out of therapy are those acting on particular role procedures concerned with resisting demands. The fact that CAT requires active participation on the part of the patient may mean that it is particularly prone to provoke this reaction. In such patients all demands from others—but also their own plans and intentions—are experienced as oppressive. It is as if the only freedom lies in refusal. The underlying reciprocal role procedure could be something like to “either surrender or passive refusal” in relation to and arising from an underlying RR of “demanding—demanded of.” Such enactments can also occur in relation to a formative RR of “not listening or attending to–not listened or attended to.” This may give rise to various possible coping, sometimes retaliatory, enactments (RRPs) such as “cut off and soldiering on” or, possibly, “controlling—e.g., of others, or of food intake.” Such enactments are commonly encountered in clinical practice, often provoked by ostensibly “benign” but actually “doing to” and relationally unreflective (“Magistral”) therapeutic interventions. Such patients can be very difficult to help, despite the hollowness and self-destructiveness of their victories. Excellent fictional portraits of this are provided in Herman Melville’s Bartleby the scrivener and in Oblomov by Goncharev. A similar but more tragic pattern is found where childhood has imposed a universal sense of guilt and non-entitlement (a pervasive snag) so that any dawn of pleasure, fulfillment, or achievement is sabotaged. Another group of patients with a high drop-out rate are those with borderline characteristics. There are many reasons for this. Most have had seriously abused childhoods and have little basic trust in others, and many have sought unrealistic ideal care only to be disillusioned. The response to these patients must be based on an early, accurate reformulation, often involving successive provisional diagrams, of their range of Self states and of switches between them, with an acknowledgment of their past pain and with a particular focus on the procedures which threaten the therapy relationship. Without the Self states sequential diagram to guide them therapists are almost bound to end up confused and “back on the patient’s map” in a collusive role. This may be based on accepting idealization and then not managing the ensuing disillusion or may result from being provoked into some form of counter hostility. A more subtle collusion can take the form of focusing on only one Self state by working hard on one of the more innocuous roles, such as coping or placation or being emotionally cut off, while leaving the other, more threatening, aspects of the patient out of the room and off the map. Where patients are in the care of several individuals or agencies, maladaptive role relationships may be set up with different workers with negative effects on staff relations and on the patient. Containment and effective action under these circumstances requires a shared conceptualization, which may be achievable through an extended contextual reformulation, consultancy work, and reflective practice groups (see review in Chapter 11). Borderline-type patients easily experience the therapist as intrusive and critical on the one hand, and as unconcerned on the other, and a therapist consigned to this knife edge

132

The Practice of CAT

should discuss it explicitly with the patient and try to work jointly on keeping the precarious balance. As far as possible, ways in which the patient can retain control of the pace of the therapy should be worked out as otherwise, and often anyway, patients will do it by missing sessions. In many borderline patients, this “knife edge” phenomenon reflects the fact that the safety and understanding offered by the early sessions, perhaps combined with the requirement to reduce substance abuse, leads to more direct access to memories of the original trauma and this can be a source of increasing distress. Therapists need to be concerned and supportive as the patients experience what they have spent their lives avoiding, and no pressure should be applied to pursue, possibly traumatic memories or to go faster or further than is manageable. It is as important to be able to control feelings as it is to access them. And it is important to recognize that some memories and feelings are too disruptive or disturbing to face and are best left unaccessed, especially if patients feel they are managing some reasonably satisfactory style of life.

­ ecognizing Enactments and Procedures at Termination R and Ending Well During the last phase of therapy, the formal use of reformulation tools and rating of progress may become less important as the possibly more turbulent relationship is lived through and understood, using the shared language established in the earlier sessions. In this phase, as termination is approached, the absence of anxiety and disappointment would suggest that the reality of the end is not yet felt by the patient, even if sessions have been carefully counted and the likely feelings around ending explored. We may easily be drawn into collusive responses which serve to avoid painful feelings and maybe sustain a degree of idealization, while others find it difficult to accept how important they have become to the patient. As termination approaches, indirect expressions of fear and anger may take the form of a recurrence of the initial symptoms; these need to be accepted calmly and further fluctuations predicted. Even quite distressed patients will nearly always be able to regain the ground in the period before the follow-up meeting. Termination of therapy can also be seen as an opportunity, albeit usually a very anxiety-provoking one, particularly for very damaged patients, to enact a new role, namely that of ending well. This involves owning and communicating painful feelings of loss and uncertainty about the future. Such a role enactment will be difficult but may also be highly therapeutic, especially when mourning for past losses has been incomplete. Discussing this final piece of work in these terms can be helpful in itself, since it will not be clear to the patient why ending is so difficult for them or why it may be important to attempt to do it well. In CAT, these issues are recorded in a “goodbye letter” from the therapist which is read and discussed in the last, or preferably next to last, session. The therapist will often briefly rehearse the original list of problems and/or problem role procedures and will consider with the patient how far these have been resolved, indicating where further change may yet ideally occur. Both disappointment and gratitude need to be acknowledged but the main emphasis will be on assessing realistically and praising what the patient has managed to go through and achieve. This would include noting how the patient has tried to be open and

­Recognizing Enactments and Procedures at Termination and Ending Wel  133

seek help, and how what has been good about therapy may be held on to. Patients are also invited, indeed strongly encouraged, to write letters, and are encouraged to make these as realistic and frank as possible, partly by encouraging them to write informally, even on a scrap of a paper, and “from the heart.” The following excerpts from the therapy of a patient with a formal diagnosis of BPD illustrates many of the issues discussed above.

Case History: Rita (Therapist Kim Sutherby) Rita was aged 26 when referred for CAT. She had been brought up as the eldest in a large family but she herself had been largely cared for by her aunt. She gave an appalling history of early and persistent childhood sexual abuse from her uncle and others and at the age of 13 had become pregnant. She was taken into care and the pregnancy was terminated (against her wishes). For the next 4 years she was intermittently in care or in hospital and was involved in heavy alcohol and drug abuse. At 16 she became pregnant again and since then had lived independently and cared for her daughter, now aged 10, while working part-time and continuing her education, obtaining 3 A-levels. Throughout that time she had used cannabis every day. She was currently living with a partner who had been with her for 2 years; he had been intermittently violent but she said he was currently making a big effort to control his temper and it seemed he was able to offer some support. Her daughter had recently been excluded from school on a number of occasions for disruptive behavior. During her first three sessions Rita gave a detailed history, showing little emotion and saying explicitly that she was not ready to discuss some of her memories. The therapist was impressed by her evident capacity in rearing a child and pursuing education and by the fact that she had been economically independent through various forms of parttime work. Rita marked ++ for all the descriptions of unstable states of mind in the Psychotherapy File. She did not complete the agreed homework task of monitoring her mood changes but went on to work cooperatively on the construction of her diagram, identifying three main reciprocal role patterns from her childhood. These were labeled as follows: unsupported/neglected (B) in relation to neglect (A) (derived from self in relation to parents); scared and guilty (abused) (D) in relation to abusive (C) (derived from self in relation to both parents and aunt); (criticized) submissive and placatory (F) in relation to cruel criticism (E) (derived from self to aunt). She was distressed to describe how she often saw herself being cruelly critical (E) to her daughter just as her aunt had been to her; this often led to a guilty switch into placatory expiation (F). These three patterns were clearly differentiated. They are described as three Self states in the diagram (Figure 7.1). When Rita experienced others as repeating the patterns of rejection, abuse, or criticism she could be overcome with unmanageable feelings of loss and rage. These acted as a trigger (marked as X on the diagram) which led either to a state of rage (G) or to an emotionally cut off, zombie state (H). She had managed her life for the past 10 years by maintaining this emotionally cut off state through regular cannabis use. This trigger point probably represents the point at which dissociation was initiated in childhood.

134

The Practice of CAT

A:

neglecting

B:

unsupported neglected

C:

abusive

D:

scared, abused (guilty)

get rejected misunderstood

rage

X coping zombie

E:

F:

cruelly critical

criticised, submissive (placatory)

exhausted needs unmet

Figure 7.1  Self states sequential diagram for Rita showing reciprocal roles. B, D, and F represent childhood-derived roles which, when activated by experiences, perceptions, or memories of A, C, or E, lead to flashpoint X followed by either rage or the dissociated alternative coping zombie state. The consequences of these would be typically “rejection” and having “needs unmet” which in turn would reinforce underlying formative RRs.

Rita missed two out of her first six appointments but cooperated actively in the construction of her diagram. During these sessions she was increasingly emotionally upset and her missed sessions were probably because of this. They were not deducted from her planned 24 sessions; to have done so before a collaborative relationship had been established would undoubtedly have been experienced as punitive. The therapist was moved by Rita’s courage and pained by her story and by the continuing events in her life. Nearly all the interactions with other people which Rita reported during her therapy were examples of her interpreting others’ behavior or her own behavior in terms of the reciprocal role patterns identified on the diagram. Thus, over the 12 sessions following the completion of the diagram, 14 events or memories were linked to the A–B Self state, seven to C–D, six to E–F, and five each to G and H. The following is an excerpt from the sixth session. Rita had described being hit by her partner Derek (Derek C to Rita D) and she herself had hit her daughter Alice (Rita C to Alice D), following which her aunt had been very critical of her (Aunt E to Rita F). The following is verbatim: rita: 

She says to Derek that she is “so concerned that I hit my daughter” … well she’s never shown an ounce of concern before. If she was, why did it never occur to her that I was strung out and needed a break occasionally … (Rita B to Aunt A). Anyway one thing about Derek—he doesn’t hurt my daughter; I’m the horrible one (Rita E to self F).

­Recognizing Enactments and Procedures at Termination and Ending Wel  135 therapist: 

Can we just slow down a minute. You’re furious today about a whole lot of things. Can we look more carefully at some of them. What it seems to me is that you are more aware of what you need from other people and that means you’re more aware of what you don’t get … rita:  So what did I do? I took drugs (Rita C to self D or H). I’m fucking out of my head and I just cannot cope all the time. therapist:  I wonder how that switch from things seeming OK to suddenly becoming overwhelming happened? rita:  I’ve not been sleeping and my eating is all over the place … everything is going wrong … therapist:  I was wondering if this is to do with being angry with me? Coming here has made you open up so many painful feelings (Therapist suggests Rita D to therapist C). rita:  I thought about that and I thought I can’t take it out on you because it’s not your fault. I know I don’t want to come here but that’s not you it’s me. I don’t want to look at things that are painful and loads of things are getting stirred up. No, I’m not angry with you at all … (? Rita F to therapist E). therapist:  You know it can be OK to be angry. rita:  (shouts) I don’t often get angry … because if I do I can’t control it (G) and the next moment I’ve hurt Alice … I never meant that to happen. At the next session Rita described her increasingly clear memories of her aunt sexually abusing her when she was aged 3 (Aunt C to Rita D). (Involving the ­insertion of plastic toys into her vagina.) rita:  She is totally off her head. She and my mum had terrible childhoods and they have just shoved all that shit into me … I hate her. I think I should go home now. therapist:  It’s really hard to think about these things that make you so angry. rita:  Not angry, sick. Later in the session Rita spoke movingly about her sense of not having ever been cared for (Rita B to others A): rita: 

When you sit down and think about your life you realize that there’s been thousands of people—social workers, care workers in children’s homes—you know there’s always been somebody, but there hasn’t, if you know what I mean, been anybody (Rita B to everyone A).

Some sessions later, at the therapist’s suggestion, Rita wrote a “no send” letter to her aunt. It was at once bitter and forgiving and ended by expressing the wish never to see her again. Reading the letter provoked a fit of weeping and then the following: rita: 

I hate that woman so much but I don’t hate her as well you know. I haven’t cried like that for ages. therapist:  You managed to keep it all inside didn’t you … Do you want me to keep the letter? rita:  I don’t want it. It’s said now. I mean, I hate that woman; she’ll never regret what she’s done—she’ll just never know … therapist:  It doesn’t really come across as a hateful letter.

136

The Practice of CAT rita: 

Because I don’t hate her … I don’t … I forgive her … I forgive her for everything … It all comes across as very, very sad what you’ve been through, what you’ve had to face up to … rita:  It is sad … the saddest thing is she’ll never know, she’ll never read it, she’ll never get her head around it to see what she has done. She could read the letter and it would have no impact on her at all, not until she can admit to herself, you know … what she did. Rita broke all contact with her aunt at this point, having meanwhile discovered that one of her siblings had also been abused by her. With Rita’s history it was inevitable that termination would be a very painful time. Two sessions before the end the therapist raised the coming end (not for the first time, of course). therapist:  I don’t want you to miss out on the chance of saying a goodbye that is not a rejection. Rita, after listing her most painful losses, commented: rita: That’s the only goodbyes I’ve had in my life … well, not goodbyes but byes … there was nothing good about them … Rita wrote a goodbye letter which included the following: therapist: 

It takes so long to trust someone and they have to go through the mill to prove their love and loyalty and sometimes it goes terribly wrong. I feel like I have betrayed you and never really given you a chance—well not in the beginning anyway … I do feel sad but not abandoned’ … In the event, Rita did not attend her final (6-month) follow-up and did not reply to subsequent letters. This seemed likely to be a sign of her anger at the pain she had experienced or of her choice of the abandoning role (A) rather than of the sadness of once more being left (B). It is unlikely that she would have committed herself initially to open-ended therapy (from which BPD-type patients have a very high drop-out rate) had it been available, but it is possible that a continuing supportive contact based on what was learned in this therapy would have been acceptable. Unfortunately, this could not be offered.

Case vignette (IK): Example of (fictionalized) goodbye letter (penultimate session) and response from patient. Dear Gail, This is the goodbye letter that I mentioned aiming to look back on the work we’ve done together and where we’ve got to now. I know from our recent discussions that you’ve been very worried about managing again on your own with all the exhausting struggles you have described in the past, especially after you might be feeling we’ve only just begun to make sense of them and try out different ways of being and of moving forward. But my impression

­Recognizing Enactments and Procedures at Termination and Ending Wel  137

is that there have been some really big changes for you since we first met, including in our relationship. I remember early a very difficult discussion about my exploring the idea that you might be worrying about keeping me happy and putting up a front in here too. It seems to me this procedure has changed considerably. And it does seem there have been other big changes, most notably maybe around you being able to feel you have the right to be reasonr ably assertive about your own needs and wishes, both in your life outside and in here in therapy too. You mentioned, for example, recently you were able to say no to some extra work, and to your surprise this did not upset people but rather they were supportive and sympathetic, and this in turn left you feeling much more confident, and as you put it less “stressed inside.” I think you’ve done very well indeed in sticking with this sometimes challenging process and in being brave enough gradually to open about up about a lot of things, including about your personal life and more intimate details regarding your relationships. I know these felt very difficult to talk about particularly given your tendency to feel that you ought to be able to cope, that maybe it was your fault, and that you ought not need help from other people. We have also been able to acknowledge something of the hurt and emotional neglect you felt about your early childhood experiences, especially having to cope in a famr ily where nobody was much there for you and you were frequently left fearful about the violent behavior that went on. We have also speculated about the impact of your long period in hospital when you were very small and about the surgical procedures you had to put up with, and the effect that this has may have had on your trust deep down, and on your difficulty in letting people close emotionally and physically. It may be as we have discussed that these experiences might still benefit at some point later from being worked on. I’ve been really impressed over the months by your determination to try to make use of this opportunity of therapy. I particularly remember the day we did some empty chair work when you addressed the young girl who had had to go through all those difficulties, and how horrir fied you were at this prospect which seemed so scary. But in the end, you did manage to convey a few words of reassurance to the little Gail which I think also seemed to open up the emor tional reality of what had happened for you. You were able finally to cry about this and also perhaps subsequently to feel more deeply that maybe you really were not to blame for what happened, and that you should not have had to cope with those things then or during your later life. You mentioned that your physiotherapist had commented recently in fact that your whole body seemed much less tense overall. It does seem too that just making some sense of your story has been a big step forward and perhaps a relief, along with doing some of those little social experiments outside. As well as feeling inevitably anxious at this point it may be that you are also left feeling annoyed that we will be ending now—even if you might still be reluctant to say so!—and given that we have gradually built up a very real relationship. However, I do think what we’ve done together, the insights you’ve gained, and the new experience of doing things differently will be something you can take forward and build on. Hopefully this will lead to a much more productive and less lonely and stressful future for you, despite life’s inevitable ups and downs and the real difficulties there will be in coping in the world outside. I look forward to seeing how you are getting on at the review we have arranged in a few months’ time. Meantime very best wishes and well done!

138

The Practice of CAT

End of therapy (last session) response letter (verbatim with permission) from Gail Dear Dr Kerr, I can’t believe I’m only writing this this morning as I have been thinking about it for a while. I have also been quite motivated to do it just very busy. I think I feel okay about our sessions ending at least for a bit. I am very grateful for all the time you have spent with me helping me to untangle all the painful memories in my mind I have only realized from doing all the work with yourself just how damaged my mind was and how laboring it was me every day. So I knew I was struggling but I guess what I’m saying is that it was named for me and I didn’t know what it was like to feel like at the other side. I really do feel more confident although yesterday was a hard day and nothing went fully to plan. I know that this is only one day and I feel better able now to let go any anxious feelr ings I encountered. I feel optimistic about the future—imagine if I can really live a happy life, it is surreal even considering that I have come to a place where that may be possible. I feel that I do a lot more each day as physical actions rather than some sort of mental marathon that left me exhausted. I have more faith and confidence in my decisions and feelings. I know it is okay to share them. I’m not scared to go against the grain anymore. I don’t conform to what everyone else wants or wishes. I know that I still have a long way to go but I feel like I will get there. There are times when negative feelings or thoughts creep into my mind but they are short lived as I recogr nize them now. I have had a few dreams as you know which seem to relate around panic. I am assuming this is because of all the changes going on in my mind. I truly am much more stable and confident. I’m not just saying that. I feel like I am able to plan more now and about the things that I want my future and things that I want to do. I never had that before, it is defir nitely a new thing being okay with what I actually feel or think inside and have the courage to take action so that it materializes, that is a really nice feeling. I really am grateful. I imagine it must be so hard for you to listen to so many problems of others without that influencing your own mind. I know that without your help, I wouldn’t be here writing this today as I am. Thank you. Gail

­Concluding Remarks The mid and later phases of CAT and the aim of “ending well” continue to depend on and be informed by specific aspects of the CAT model of theory and clinical practice, and in particular their underpinning by prior reformulations. These can be seen as a providing an overarching framework within which a flexible and responsive approach to individual patients may be offered. These phases continue, therefore, to demand concentration and

­Concluding Remark  139

effort from both therapist and patient. Although later phases of therapy typically involve a somewhat more open style in common with many other, for example, humanistic, psychodynamic, and person-centered approaches, the CAT framework would continue to guide and assist the therapist (and possibly also treating teams) to maintain focus, including on potential therapy-threatening enactments, and make flexibly responsive use of a range of “techniques.” As noted, this might include offering, for example, attuned and empathic silences when appropriate. Although the CAT approach is not formally manualized, therapy continues to be guided and informed during these later phases by an underlying understanding and appreciation of structure and sequence, and of ways of working, especially around the therapy relationship. Adherence and fidelity to the approach, which is demonstrably important for outcomes, should ideally always be checked out and reflected upon in supervision, whether during training or later in a peer group setting.

141

8

The CAT Model of Therapist Activity and of Supervision S ­ ummary Cognitive Analytic Therapy (CAT) evolved out of an aspiration to psychotherapy integration and out of formal evaluation of clinical practice and research, and it remains committed to these activities. Clinical research and therapist experience in CAT, and other models, confirm the generic importance of a benign, collaborative, therapeutic stance and, related to this, a robust therapeutic alliance. In addition, process research in CAT has confirmed the validity, inter‐therapist reliability, and effectiveness of the techniques of reformulation, and has demonstrated the importance of therapist competence in creating and using reformulation tools, including jointly‐negotiated description of “aims” and “exits.” Effective use of these techniques constitutes a core aspect of CAT practice, in the context of an ability to offer an empathic therapeutic relationship. Use of reformulations in CAT can provide support and assistance to individual therapists, and also enable therapists to make good use of supervision and reflective practice. Effective use of CAT can be evaluated formally and assisted by the Competence in CAT (CCAT) instrument (developed by Bennett and Parry) that addresses a number of domains (10) of generic therapist activities and “competencies.” It includes one CAT‐specific domain relating to the development and use of the CAT‐specific tools, including the therapist’s competence in engaging the client in the process of reformulation, developing the shared CAT tools, and subsequently holding this focus through use of this understanding, facilitating recognition, and revision. The measure can be of considerable helpfulness in routine practice, supervision, clinical research, and in evaluating progress in training. An empirically‐refined model of the resolution of alliance‐threatening reciprocal role (RR) enactments in therapy has also been developed within CAT (by Bennett and Parry) involving acknowledgment of the enactment, exploration, explanation, linking to the reformulation, negotiation, consensus, further explanation, contacting hitherto un‐assimilated feelings, and discussion of new ways of relating understood as aims and exits. Use of these approaches can also greatly assist therapy and supervision particularly if used alongside the audio‐taping of therapy sessions. The successful use of such approaches in evaluating therapeutic work, even with an apparently “psychologically unsophisticated,” clinically challenging patient, is illustrated below. Supervision and reflective practice are regarded as essential and central to working with CAT at all stages of therapy and in CAT‐informed generic work. Supervision in CAT includes focus Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, Second Edition. Anthony Ryle and Ian B. Kerr. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

142

The CAT Model of Therapist Activity and of Supervision

on the successful creation of appropriate reformulations and “aims,” and working at all stages with problematic, reciprocal, relational dynamics, both in and outside therapy, assisted by these. Many such difficulties (for example RR collusions of a mutually “admiring–admired” character, in relation to extreme neediness) are precisely those which may not be immediately reported or evident to the therapist or supervisor. In such cases the model offers a means of predicting and anticipating such enactments, and actively implies a need to be alert to them. Importantly, CAT provides a non‐judgmental means of identifying, owning, and working with such mutual enactments, and also stressing, but normalizing, the fact that we all have our own “maps” that we bring to our daily life and work. These considerations are ­similarly of importance in informing and enabling reflective practice and CAT‐based c­ onsultancy in ­various settings. An alternative title for this chapter might be “Does it matter what we do?” Frank (1961) argued that many different kinds of influence, including that of various therapies, could be explained as the result of common persuasive elements, notably the effect on morale of being attended to by a recognized expert offering new perspectives. Luborsky, Singer, and Luborsky (1975), referring to the Dodo race in “Alice,” made a similar point in their paper entitled “Comparative studies of psychotherapies; is it true that everyone has won and all must have prizes?” This “equivalence paradox”— the embarrassing failure of research to establish clearly that any one model of therapy works better than any other—remains far from resolved despite decades of research (see Greenberg 1991; Roth and Fonagy 1996; Gabbard, Beck, and Homes, 2005; Castonguay and Beutler 2006; Kazdin 2009; Norcross 2011; Lambert 2013; Parry, 2000; Wampold and Imel 2015; Yakeley et al. 2016). In recent years it has also become clear through a number of controlled studies that, perhaps unsurprisingly, “good” structured clinical care (or what might be described as benign, “psychologically minded” routine care) achieves, in general, comparable results to specialist treatment models of whatever “brand”. However the importance of therapeutic ‘neutrality’, in an empathic context, for outcomes has also been argued (Gelso and Kanninen, 2017). Good structured care in this context stands in marked contrast to traditional “treatment as usual” (“TAU”) which more often than not meant unfocused, intermittent, and frequently resentful or hostile “treatment” in routine, over‐worked, under‐supported, and under‐trained services. This finding also raises important questions about care planning and “prescriptive matching,” that is to say tailoring treatment packages to individual patient’s needs and also preferences, in relation to the options available through the “different” models with their different ostensible theoretical and clinical orientations and emphases. Such an approach would be axiomatic in good routine health care; for example, in oncology or cardiology. We argue elsewhere that CAT can play a particularly helpful and important role as a robust, relationally based conceptual “framework” usable by a range of colleagues within which to offer care plans and reflective practice (see also Chapter 11). Such an approach is especially important around work with problematic, treatment‐threatening, individual, and systemic relational dynamics and enactments (see Chapters 10 and 11). This emerging generic “meta‐viewpoint” of therapy outcome research is acknowledged and helpfully articulated in some of the more recent literature reviewing a range of ­treatments (including CAT), for example for Borderline Personality‐type disorders (BPD) (Bateman, 2012; Mulder and Chanen, 2013). This position is also helpfully acknowledged and articulated by the “IAPT” (“Improving Access to Psychological Treatments”) guidelines for treatment of BPD in England (Roth and Pilling, 2013 and see  Appendix 2).

­Summar  143

However, for a variety of reasons that are mostly not scientific in nature, we are still, sadly, a long way from such a respectful, integrative, “meta‐conflict resolution” of differing ­theoretical and clinical viewpoints and “brand name” approaches. However, these findings should not be taken to indicate that therapy has no effect, nor that specific techniques are necessarily without value. It remains a challenge for the future to determine more precisely which aspect(s) of which therapy model “works best for whom” (to paraphrase Roth and Fonagy (2004))—taking into consideration individual patient preference and need, and overall socio‐cultural context. Patients are smart enough to make use of a whole range of interventions given certain underlying therapeutic conditions, such as a good alliance. The latter is of course not independent of the therapeutic approach used, and it can be argued that one of the most important features of any model is the extent to which it promotes and enables such an alliance. The Dodo bird phenomenon can also be understood in terms of CAT in that (a) role procedures are related hierarchically, so that changes in a low level tactical procedure, such as stopping smoking or drinking, can both influence and be influenced by a change in assumptions about the value of the self. The former might be achieved by a behavioral program, the latter by existential psychotherapy. (b) In terms of the PSORM (procedural–sequence–object–relations) model, the continual cycle means that change in any one phase (involving either perception, appraisal, choice of action, enactment, consequences, or the consideration of consequences) may lead to a revision of the whole sequence and of underlying (formative) RRs. Thus, different therapies, focusing on different levels and on different phases, possibly by different means (e.g., insight, as opposed to new experience through a behavioral experiment), may achieve apparently equivalent results. However, and importantly, greater or less change in underlying psychological structures and processes may, or may not, have occurred. In time, and given the present proper emphasis on and the need for evidence‐based ­practice, it may become possible to distinguish between the elements common to different approaches and the specific effects of detailed techniques on particular conditions. However, it remains important, although difficult, to evaluate subtle but clinically and humanly significant factors of importance both to patients and also to service providers, managers, and commissioners. These would include case severity and complexity, selection, “user‐friendliness” and associated drop‐out rates, and treatment costs. The following sections describe some CAT‐based approaches to evaluation of therapist activities which are of considerable general importance. However some of the detailed descriptions of research procedures and outcomes, while important in considering the effective practice of CAT and other therapies, may be of less immediate interest to busy therapists involved in more routine practice. Good practice in CAT depends, first of all, on the therapist applying an exploratory, non‐ directive approach to the patient’s reports, story, and enactments; an approach derived from psycho‐dynamic practice. The agenda is set by what the patient brings and by the therapist’s initial comments being open‐ended and designed to evoke further details and associated feelings. This active empathic listening can be a challenge for those trainees used to working with the more proactive, problem‐solving types of approach prevalent in most mental health services and professional trainings. But what is learned from these exploratory conversations must also in CAT be linked to procedural descriptions and

144

The CAT Model of Therapist Activity and of Supervision

i­ dentification of underlying formative RRs. The essential act is description as opposed to interpretation, although there are inevitably overlaps to these activities. In many cases the collaborative creation and application of the revised descriptive understandings is enough to allow the patient to explore alternatives. Some particularly entrenched maladaptive beliefs or behaviors may be challenged through the use of specific cognitive or behavioral techniques, but the premature or exclusive use of these can place the therapist unhelpfully in the “expert” teacher, or even “policeman” role, as described in Chapter 4, which assumes that patients are rational and requires them to be compliant and which can reinforce existing internalized critical or controlling voices. The traditional assumptions and structure of some forms of CBT, for example, can, in these ways, block the more fundamental work of exploring and changing underlying relationally-based beliefs and values about the Self. An example of this negative effect will be found in the description of a patient (Susan) suffering from panic and obsessive–compulsive symptoms in Chapter 9. One radical difference between CAT and traditional CBT can be described in terms of the kind of scaffolding provided. In CAT, the emphasis is always on the place and meaning of symptomatic, mood, behavioral, and relationship patterns (including those apparent in the therapy relationship) within the context of the individual’s overall meanings, values, and self‐organization. A premature or exclusive focus on individual symptoms, behaviors, or beliefs can block the wider exploration of these central issues. Early research into the impact of the developing CAT model provided some evidence for the specific effects of its methods. Ratings of change in the jointly specified goals of therapy were paralleled by related changes in measures derived from repertory grids (Ryle, 1979, 1980) and such grid changes, predicted at the start of therapy, were significantly greater in patients receiving CAT than in those receiving a purely psycho‐dynamic treatment. In the last few years, systematic studies of various aspects of CAT practice have been carried out, helpfully illuminating both detailed features of practice and the overall theoretical basis of the evolved model. In summarizing these we are indebted to Dawn Bennett for her invaluable contributions. These therapy process research studies include those carried out by Bennett and Parry who demonstrated, first (Bennett and Parry, 1998), that the diagrammatic reformulation or “map” created by a CAT therapist and a patient with a BPD‐type disorder contained all the main themes identified by two separate research‐based analyses of audio‐tapes of the early sessions using well‐validated research‐based formulation methods, namely the Core Conflictual Relationship Theme (CCRT) (Luborsky 1990; Luborsky and Crits‐Christoph, 1990) and the Structural Analysis of Social Behaviour (SASB) (Schacht and Henry, 1994). This was subsequently replicated on three further cases (Bennett, 1998). This research showed that it is possible to develop in a short time and on the basis of CAT clinical skills a succinct but comprehensive and accurate formulation that captures a patient’s interpersonal patterns in a way that is validated by much more detailed research measures. No instance was found of a CAT reformulation theme that was unvalidated by the structured research methods. This was an important finding given that CAT practice depends heavily on the accuracy and completeness of the reformulation, and also because CAT therapists use the reformulation as a basis for anticipating and identifying reciprocal role (RR) enactments within sessions. Similarly, in a parallel study of blind‐rated taped therapy sessions of four experienced therapists and their patients, Welch (2010) demonstrated inter-therapist

­Summar  145

reliability and validity of the written formulation the therapist shares with the patient in the reformulation letter. In this study, each of the therapists listened to the ­others’ three pre‐reformulation sessions and wrote reformulations. External judges were able to distinguish correctly matched from incorrectly matched reformulations 75% of the time and regarded the correctly matched reformulations as being similar. They were unable to distinguish reformulations based on “live” therapy as opposed to recordings. Coding using the SASB supported the argument that therapists are able to reformulate reliably. For the correlational analysis of patient’s activity, the scores for the reformulations and transcripts were in the fair range for Patients’ 1–3 and in the substantial range for Patient 4. Therapists identified similar key events in the patients’ lives, they highlighted common relationship patterns with significant others, and used striking patient phrases. Alliance ruptures due to the emergence of key relational patterns in the therapeutic ­relationship and premature drop‐out are common with patients diagnosed with borderline personality‐type disorders, considerably limiting the effectiveness of therapy (Eames and Roth, 2000; Roth and Pilling, 2013). Identifying and developing skillful practice in rupture resolution is therefore key to maintaining a patient in therapy and to good outcomes. Bennett subsequently developed a model of competent performance in relation to the manner therapists manage RR enactments that may threaten the maintenance of a therapeutic alliance. Adopting task analysis methodology (Greenberg, 1984, 1986), an ideal model of CAT therapist ­performance in resolving enactments was outlined and compared with actual resolution performances from good outcome cases. This resulted in a refined, “empirically derived” model. In poor outcome cases, therapists characteristically did not perform in accordance with the refined model (Bennett & Parry, 2004; Bennett, Parry & Ryle, 2006). A further study provided ­validation of the model in adolescents with borderline‐type disorder confirming its validity. In this study, better ability to work through the model’s stages (adherence) was associated with a session being better rated by patients, suggesting that the model has clinical meaning and indicates effective therapeutic work. Working through the model of rupture resolution was also associated with better outcomes and the authors proposed that rupture resolution was a process measure that may predict outcome (Daly et  al., 2010). A  further study from this group confirmed the widespread occurrence of alliance threats in treatments for this group—more often of a withdrawal type early in therapy, while later more confrontational—and of the importance of identifying and resolving these (Gersh et al. 2017). This empirically derived model was used to refine The Therapist Intervention Coding System (TIC) originally devised by Ryle to provide feedback to therapists (Ryle, 1997a). Three versions of the TIC were developed, first, for therapists in self supervision; second, for supervisors in a training context; and third, for observers (TIC‐O) to score a session for competence in the model. In a series of unpublished studies, Bennett found that the TIC‐O, used to rate audios of whole sessions or transcripts of short sections of enactment resolution, had good inter‐rater reliability and yielded a competence score that correlated with an independent measure of the therapeutic alliance. Therapists in good outcome cases recognized 80% of enactments of problem procedures and had linked most of these to the ­diagram, whereas in poor outcome cases recognition was only 30% (Bennett & Parry, 2004). This was consistent with an earlier sample in which therapists in good outcome cases identified 83% while therapists in poor outcome cases had identified 34% of enactments

146

The CAT Model of Therapist Activity and of Supervision

(Bennett, 1998). Experienced therapists also scored higher on TIC‐O than trainees, but the ratings of trainees improved over the course of a therapy with detailed supervision (Bennett & Parry, 2004). This research then contributed to the subsequent development of the CCAT measure.

­The Competence in CAT (CCAT) Measure In further research, Bennett and Parry (2004) developed a measure of therapist “Competence in CAT” (CCAT) and demonstrated that greater competence was significantly associated with therapists’ level of training and with independent measures of the therapeutic ­alliance. The CCAT broadened this key competence around working with problematic relational enactments in CAT. It contains ten domains of competency, of which one (Domain 3) is CAT specific while the other nine reflect factors characteristic of the CAT model but common to humanistic, relational, and cognitive therapies. This clearly gives the measure potential broader applicability. The domains are rated from 0 (incompetent), 1 (unsatisfactory), 2 (satisfactory), 3 (good), to 4 (very competent), producing a score range of 0–40 with a score of 20 used as a cut‐off as “satisfactory” (i.e., competent) CAT. The CCAT has ­adequate inter‐rater reliability, high internal consistency, and concurrent validity (Bennett and Parry, 2004). The specific CCAT domains are detailed as follows. 1)  Phase‐specific therapeutic tasks: (a) concerns competencies related to early sessions and includes the therapist engaging the client in identifying areas for work, raising hope, establishing the client/patient’s motivation and commitment, and establishing therapeutic roles; (b) concerns competencies relating to middle or late sessions and includes reviewing progress, engagement, and the value of the work. 2)  Theory‐practice links: concerns the therapist’s application of theory to practice, including the use of the CAT model to plan/structure the work and make sense of the client’s material. 3)  CAT‐specific tools and techniques: (a) is specific to the early reformulatory sessions and includes the therapist’s skill in identifying target problems, procedures, and RRs, and developing and sharing CAT tools. Section (b) is specific to sessions after reformulation, and includes the therapist’s use of CAT tools to recognize and revise procedures within and outside sessions. 4)  External framework: competencies in establishing and maintaining the boundaries to the therapy and therapeutic relationship. 5)  Common factors: concerns basic common factors and includes support and attentiveness to the client/patient’s readiness for the work. 6)  Respect, collaboration, and mutuality: concerns establishing a mutual, collaborative, respectful, and authentic therapeutic relationship. 7)  Assimilation of warded off emotions and problematic states: competencies including the therapist’s capacity to experience, stay with, and tolerate painful affect and to facilitate assimilation and integration of these experiences. 8)  Making links and hypotheses: concerns the therapist’s ability to offer links and hypotheses about the client/patient’s past and other relationships including the therapy relationship, in an appropriate and timely way.

­The Competence in CAT (CCAT) Measur  147

9)  Identifying and managing threats to the therapeutic alliance: competencies in identifying and managing in‐session RR enactments that represent obstacles and/or threats to the alliance but also opportunities. 10)  Awareness and management of own reactions/emotions: concerns the therapist’s ability to appropriately reflect, express, and manage their own feelings and reactions. CCAT scoring is concerned with the way in which therapy is being done, not the assessment of the outcome or effectiveness of the therapy. Some patients can make some use of therapy despite some limitations or “errors” on the part of the therapist, while another therapist may score highly on all domains of competence but the patient “cannot” apparently make use of it. The CCAT can specifically help in evaluating whether poor outcomes are due to poor quality of therapy, or rather due to other factors such as therapy being apparently inappropriate at that time (Kellett and Bennett, 2017). Competency represents more than adherence to a model or protocol. Treatment adherence implies that therapeutic activities detailed in a particular model have been undertaken. Competency concerns the quality of the therapist’s interactions and activities (Shaw and Dobson, 1988)—how well it was done. It implies that a key therapeutic activity had been undertaken appropriately and effectively. Competency involves skillfulness and practical and relational wisdom in exercising consistent therapeutic judgment, taking into account the individuality of the patient and the context of the session and of therapy overall. CCAT has been used in a number of CAT trials for patients with borderline personality‐type disorder in both routine practice settings and randomized controlled trials (Bennett, Parry, & Ryle, 2006; Chanen et al., 2008, Clarke et al., 2013, Kellett et al., 2013). This was undertaken to check that CAT was undertaken competently by the therapists involved so that the research could be considered as a fair evaluation of the model. During CAT training, scoring a session enables courses to evidence that CAT trainees are learning and mastering core skills. Therapists are also encouraged to use CCAT as CPD activity as it provides a framework and method of enabling and structuring self‐reflection. Kellett and Bennett (2017) offer a guide to both supervisors and supervisees on how to effectively integrate competency assessment into supervision. This can also enable a shift from less helpful performance‐driven procedures (CCAT as “judging to judged”) toward a more constructive development‐oriented process (CCAT as “scaffolding to nurtured”) and crucially to help therapists improve the quality of their therapy. The implications of each CCAT domain for supervision can be considered separately. The following example illustrates use of Domain 8. CCAT Domain 8: Making links and hypotheses: concerns the therapist’s ability to offer links and hypotheses about the client’s past and other relationships including the therapy relationship, in an appropriate and timely way. Supervision implications: can the supervisor enable the supervisee to see their relational zone of proximal development (ZPD) both within and across their therapeutic relationships, so that they can become more aware of unhelpful procedures with clients/patients? (These might include steering away from painful affect, not naming what is occurring in the therapeutic relationship, not introducing ending work early enough, and so forth). Can the supervisor help the supervisee to see any parallel processes between the position they find themselves in with the patient and the position they find themselves in during supervision (e.g., fear of criticism)?

148

The CAT Model of Therapist Activity and of Supervision

Competency fluctuates regardless of the experience of the therapist. When gaps in competencies are identified using the CCAT, supervisors can support supervisees in their development, choosing the most suitable method out of a possible range, including teaching, modeling, directing supervisees to relevant literature, encouraging self‐assessment by the supervisee, and role‐play of specific CAT approaches (e.g., rupture repair sequences). Although in these contexts CCAT is essentially a formative assessment, supervisees may still experience anxiety and supervisors need to maintain a sensitive relational awareness of the process of being assessed.

­Therapist Activities in CAT The research summarized above gives support to the emphasis in CAT on the recognition of, and, ideally, non‐collusion with, unhelpful, dysfunctional RRs and RRPs. These findings make it possible to propose some overall guidelines for good CAT practice. It should be emphasized that these should not be regarded as a prescriptive practice “manual” to be rigidly applied in any given sequence. Microsupervision has demonstrated clearly that therapists having a wide range of personal styles can apply the model, and that each patient–therapist pair develops a shared language that manualization could distort and disrupt. Clinical supervision involves the retrospective application of general rules and principles to sessions and its main aim is to, supportively, heighten the awareness and self‐reflectiveness of therapists, acting partly as reformulation does both for patients and therapists. Bennett’s model of enactment resolution can be applied to any discrete episode in the course of therapy. It describes an overall sequence but may involve repetitions and ­tangents, ultimately going through the following stages: 1) Acknowledgement. To have others know and validate one’s existence and experience is a primary human need without which any help offered may be irrelevant and is likely to be experienced as having something “done to” one rather than with one. Full acknowledgment of episodes in therapy involves an authentic and empathic acknowledgment of the experience of the other and will involve: 2) Exploration, on the basis of which 3) Linking and Explanation may be worked at. This needs to be engaged in with each new reported or enacted event, using the tools of reformulation. For this to be of meaning to the patient, a process of 4) Negotiation must lead on to 5) Consensus. The aim will be to agree on how the particular issue relates to the underlying general RR and RRP patterns, usually by locating it on the diagram. This linking becomes real to the extent that the understanding is not imposed on the patient and is associated with emotion. 6) Further explanation can show how this linking can be understood. This may involve rehearsing the individual’s history and how it contributed to the formation of the RR and procedural repertoire. The difficulty in revising established patterns can be explained in a non‐blaming way and the opportunity to reconsider these patterns can be emphasized. 7) The sense of being heard and understood and the repeated consideration of issues in these ways can lead on to

­Therapist Activities in CA  149

8) Contacting hitherto unassimilated feelings. Supported by the new understandings and the safety of the therapy relationship, repressed and dissociated memories and feelings may be accessed and assimilated. This stage often follows the achievement of a shared understanding when, in Bennett’s words, there is a “lull in the engagement” and patient and therapist recognize what they have been through and that they remain connected. Once recognition is established, alternative procedures, including new ways in which Self is seen, experienced, and understood, can be explored. 9) Thus, Exits/Aims will be discussed in terms of procedural control and revision and by exploring alternative roles involving new ways of experiencing, judging, and acting, both in the therapy relationship and in daily life, including in relation to possibly problematic dialogic voices. These stages will now be illustrated in more detail.

Acknowledgment, Exploration, and Linking A therapist’s possible interventions may be illustrated by an example: the patient has just given a bald, factual account of a friend’s grief over the terminal illness of her mother. Possible therapist explorations might include: 1) An expectant, sympathetic silence. 2) Direct questioning; for example: “When your friend was crying when she told you about her mother what did you feel?” 3) Parallel linking: a reference to a possibly similar episode already discussed, for example “Do you think the way you could not respond to her sadness was connected with the way you yourself cut off from your feelings after your father’s death?” 4) Naming empathic counter‐transference: “You gave a very matter‐of‐fact account of your friend’s grief but I found myself feeling sad. I wonder if I was picking up something you find it hard to allow yourself to feel?” 5) Linking to the reformulation. Early on in a therapy this might take the form: “This seems to me to be another example of the dilemma we identified; how you move away from strong feelings as if you fear being overwhelmed.” (This could be summarized as either cut off or overwhelmed.) “Do you think that is so?” At a later stage, when reformulation is complete, the patient might be invited to refer to the diagram and make the link unaided. 6) Suggesting a transference link: “I wonder if the fact that we have only three more ­sessions might be making you want to avoid thinking about anything to do with endings? Looking at your diagram I wonder where we might be?” Any of the responses described above may lead on to further explorations involving the following stages.

Negotiation, Seeking Consensus, Explanation, and Contacting Unassimilated Feelings In the example above, the third response of making a provisional link to another reported experience could, in the early sessions, be an important step in the process of descriptive reformulation, as it will introduce the idea of seeking common patterns and the underlying

150

The CAT Model of Therapist Activity and of Supervision

early, formative, relational experiences (RRs) that led to them. It may also allow important differentiations to be made. For example, in this case, the patient might go on to explain how he could now feel grief for his father but was aware of having been angry with his mother for her depending on him in ways which had allowed him too little space or support for his own feelings. This understanding could lead on to the exploration of his evident role in relation to his mother; this might be one of his basic role procedures identified, for example, as “submissively but resentfully caring.” If the patient recognized this, other examples might follow, for example, “I was always the one left in charge of my little sister.” The next step would be to explore the reciprocal to the caring role. This might be “weak,” or “weak but controlling,” or “selfish.” Further exploration and explanation could serve at this point both to reach a clear consensual understanding of the particular procedural pattern which determined the patient’s relationship patterns and management of emotions and to convey a wider understanding of how RR patterns are formed and sustained. This understanding could be enlarged and its emotional significance brought home by the therapist’s account of being made to feel sad (his/her empathic counter‐transference). Describing this might help the patient experience the feelings that his resentment had blocked and this in turn could initiate an “exit” from the old procedural system. Moves of this sort over the first half or more of therapy are frequently the source of a general mood of sadness that is painful but valued, representing mourning for what is now seen to have been missing in the past. In this case, a recognition of the loss of access to emotion and its maintenance by the established procedural pattern, combined with the shared “in the room” feelings, could open the way for revision which could lead to changes in current relationships. They may also represent an opportunity to discuss sympathetically and explore possible exits and aims in terms of these enactments, and to reflect on how already perhaps these have contributed to some change. Termination, or “ending well” (whether in brief or long‐term therapy), is an opportunity to experience a loss directly, neither denying sadness nor protecting the therapist from anger or disappointment. For many patients this is the enactment of a new RR and can represent an extremely powerful transforming moment. Case Example: Grace (Therapist Michelle Fitzsimmons) Not all patients are able to embark on self-reflection right away. Some may need more educational approaches and the early exploration or modeling of alternative ways of proceeding (“exits”), but this does not mean that procedural and relational understanding and change are not achievable, as the following case shows. Grace’s childhood had involved degradation and neglect; as an adult she had experienced violent sexual and physical abuse from two different partners; she had more recently terminated her relationship with a third partner who had been relatively kind. She was currently allowing herself to be used exploitatively by two of her adult children who lived with her but gave her no practical help and stole from her; one was drug addicted and criminal and one had been diagnosed as having schizophrenia. In her early sessions, Grace spoke in an uninterruptible monolog, cataloging alternately her blaming anger with others and her dismissive contempt for herself as having “bad blood.” She described how, when walking down the street, if anyone acknowledged her, she felt “honored.”

­Therapist Activities in CA  151

Abusing

Neglecting

Abused

Neglected

Unmet needs

Confirms

Cut off

Confirms

“Bad blood”

Ignored

Reject them before they reject me

Hope to be seen as good

Nothing good lasts

People pleaser

I’m not good enough

I ignore my needs

Figure 8.1  Sequential diagram for Grace.

The audio-tape of the seventh session was listened to by the supervisor. When the therapist managed to speak, her comments were emphatically positive (and not exactly in the formal negotiating CAT manner!) and they included proposing a description of a cycle of placation followed by explosive rage. This was drawn in a preliminary diagram. The therapist offered a consistent rebuttal of the patient’s self-denigration and a consistent encouragement and celebration of change. The upper part of the final diagram (Figure 8.1), which was drawn in red, spelt out the origins of the “bad blood” and traced how a snag and trap originating in this sense of self left her either sabotaging herself or placating others, in both cases leaving her needs unmet. Alternatives to these patterns were later spelled out (in green) in the form of rehearsed self-statements. She repeated these to herself and soon began to revise her behavior in current situations. At session 12 her diagram was reviewed as follows: therapist: 

Do you understand this? These exits are all the things you told me in your own words.

152

The CAT Model of Therapist Activity and of Supervision

grace: 

Oh yes. It’s getting better. It sounds terrible when you read all that (the trap and snag). I’m really doing well on these (the green). My son is out on bail at present. What he’s doing is blaming everyone apart from himself for what he does—he says it’s because he came from a broken home. I said that was a poor excuse because no matter what my parents have done, if I do wrong it’s my doing.

Grace’s therapy was interrupted and shortened because of her therapist’s illness. She coped in a way which demonstrated that, despite her initial apparent impenetrability, Grace had learned to see and manage herself in a new way, and to recover when she relapsed in any way. Her weekly self-ratings showed consistent improvement. Grace’s goodbye letter read: “I have really found our therapy sessions helpful in making me the much stronger person that I am today. I am at last enjoying my life and I’m no longer worried about upsetting people. If I think they are not doing their job properly I will confront them with it as now I know I am as good as anyone else …” At follow-up, Grace reported an example of this in her successfully getting herself a long-delayed outpatient appointment in relation to some long-term physical symptoms. The therapist’s goodbye letter was accompanied by an elegant plastic card on one side of which the diagram was reproduced, in red and green, with an additional quotation from Grace: “I am a snake which has shed its skin—I’m in control.” The reverse side of the card read as follows: “If I have a day when I lapse I know it won’t ruin things for me. I have broken the cycle of long and hard patterns of behavior. I can recognize and stop things from affecting me like they used to in the past by: *Stop as soon as I recognize the old pattern. *Look at the problem. Think about the situation causing it (the trigger). *Listen to what I am saying to myself. Then ask myself: Is this what I want? Am I behaving in the way I want? If not, then ask myself: Where did it start to go wrong? When did it start to go wrong? Why did it start to go wrong? and How did it start to go wrong?” The card concluded, in green: “Then think about how to break the pattern. Remember what I have learnt—in my own words! I can control it before it gets out of hand. Remember I am good enough.” This example of unconventional CAT, in which rehearsed self-talk was applied to the understanding and control of specific interpersonal and intrapersonal procedures, produced significant change. This also reflected the therapist’s genuine and warmly communicated respect for the patient, her explicit refusal to collude with the patient’s largely self-directed destructiveness, her capacity to match the patient’s verbal flow, and her ability to build on the patient’s own descriptions to make an accurate and ­user-friendly diagram. A woman who was initially not “psychologically minded,” was relatively uneducated and very damaged, was able to make remarkable use of the help she was given. At follow-up 6 months after termination she reported that her gains were maintained and in some respects extended. There had been one episode of uncontrolled drinking.

­Therapist Activities in CA  153

The following extract from a therapy with “Dan” (de-identified) further illustrates the use of the approach. Therapist: Sarah Littlejohn Toward the end of Session 1, when Dan’s therapist returned to the room after briefly printing something off for him to take away, he said that he had been thinking about his issue with time. Perhaps being left alone after the connection of the first session had awakened this and he spoke with reflective insight of wondering if it had anything to do with his mum who was “never there” when he was young. The therapist reflected on the waiting and having to limit himself to what he got. Dan then went on to talk in detail about his issue with time and relationships. The therapist names this as wanting to hold on and he continues to do just that in the session, engaging her with reflective pertinent material. The therapist makes a link to this material “so the same thing is happening here with the sense of wanting to hold on to the care when you’re given it. The care and attention, but it ends like with mum and maybe you don’t want to have to go or her to go.” He agrees but continues, reflecting further and says that he doesn’t want to go, fearful, so he clings on. He knows that it happens with friends and a previous therapist. The therapist finally ends the session. Over the next sessions Dan arrives early and continues to cling on and in Session 5 the therapist picks this up directly. This illustrates the stages of the enactment resolution model. Acknowledgment The therapist begins by saying how she notices that he tries to get more time “… like we said, you hold onto me.” Dan responds that they could run over if they needed to, implying both that he knows she wouldn’t but he could push for it and get what he needed. Exploration The therapist gauges his awareness of this and asks how similar it is to what happens with others and he says he does this with others and elaborates. She then returns to the enactment: T Have you noticed that I don’t actually respond very much? P Yes I know, I realize that it’s the end of the time and you’re a trained therapist. Linking and explanation T  I’m wondering where it may lead you, where we may go on this map when we’re doing this? P  mm, yes I knew you’d say that (they laugh a little). I wonder if it is here? that I force you to give care. T  Yes, I think it is, we called it reluctant care didn’t we, when the other person may feel overwhelmed, stuck, and actually a bit forced into doing this. Then they may pull away and leave you, so you end up here, more hurt. P mmm.

154

The CAT Model of Therapist Activity and of Supervision

Negotiation and consensus This is in fact smooth work so far as the client is insightful and “cognitively” he knows that this pattern occurs and repeats with others and he can link it to the reformulation. The therapist has therefore been able to engage him to think with her about this such that she can raise what they can do about it in their relationship. Exits and aims are raised when the therapist asks: “How can we break this?” Further explanation and contacting hitherto unassimilated feelings Dan talks of how therapy is easier as there is predictability but with others he never knows when he’ll see them again. He starts to convey a depth of desperation and how he then forces people to say when they will see or talk to him again. Through this stage there is a deepening of affect and, although they understand what is happening across his relationships and the need to break this, it is evident that this is a powerfully driven pattern. The therapist returns to focus on the process and that therapy could be a place to explore this. Exits and aims OK, what I’m thinking though is that as we run over in our sessions and I’m failing to T  stop you talking and holding on we are in fact going though those very difficult feelings that you feel with others. I wonder if we could experiment with not doing that? I’m saying that because we are carrying a pattern that is just not working for you, it actually leaves you more vulnerable, not in control, and much harder to tolerate people being apart from you. Dan says he knows that, but he thinks he’s holding on less now, and they discuss how he relates to others. This work conveys the cycling of the model as the therapist moves back and forth through the stages, in that they work further with the links and understanding before being able to appreciate how this is manifest between them and what breaking it may involve. Further explanation and contacting hitherto unassimilated feelings The therapist tries to return again to focus on the process and suggests that the ending of each session is like a mini-ending of the therapy and wonders what the end will be like. This leads to an understanding about any limit and how he fights them to get what he needs and wants. She tries again. Exits and aims T  I suppose what I’m conscious of feeling is that we are in this together. I am failing to put a successful limit and you are crossing it. I know that is because it is hard but I’m trying to get alongside you and say what should we do about that? Consensus Again, Dan detracts from this and he speaks of wanting a real relationship with her but one in which he can get more and one in which he could see that she may break her limits for him. This would perhaps show that he mattered and that he is special. The enactment and its origins are now clearer. The therapist offers an understanding

­Supervision of Therapists in CA  155

I think it’s as if it is so hard to accept what is real in here, that there is real care on offer, T  feelings are genuine, yours and mine. Because that is hard to feel and accept then that fuels the need to get more from me, to push me for more, to be special … I’m not going to break the boundaries and limits for you but that’s not because you aren’t important, but what is happening in here is something you can believe in. Dan says he hears this but doesn’t feel it. The therapist says they need to end, and he smiles as the session has run over again.

­Supervision of Therapists in CAT Given that CAT is a fundamentally relational model, ongoing supervision of frequently highly challenging therapeutic work is also fundamental and necessary. In fact, this applies to all treatment approaches of whatever overt orientation, given that both individual and systemic relational dynamics will inevitably occur. Therapy is aimed at the patient’s ZPD and the developed model of therapeutic activity described above can be understood as defining the appropriate scaffolding for CAT. There are many parallels between the therapist–patient and supervisor–supervisee relationship. The scaffolding role of the supervisor in training CAT therapists can be considered in the light of the same theory as that considered earlier in relation to therapists. Supervisors are working in the supervisee’s ZPD in their transmission of the methods and values of the model and, given that the relevant skills involve the formation and management of a personal relationship, they are also to some extent working in what might be called the zone of “proximal personality development” (“ZPPD”)—both the supervisee’s and their own. Some of these issues may be helpfully considered in light of the discussion in Chapter 4 of the different styles of scaffolding. The “super‐addressee” of this supervision dialog is clearly the psychotherapy community and its official institutions and the particular features and structures of CAT. A trainee seeking recognition as a CAT therapist must follow the procedures and understand the principles of the model. Where conformity to these requirements and values is in question, the supervisor may correctly adopt a more authoritative or “Magistral” voice, being the officially designated conduit of the organization. However, given the variety and complexity of both patients and supervisees, the “Socratic” mode would be generally preferred, in which rules and assumptions may be questioned and in which increasingly joint explorations of the detailed meanings of particular events can take place. In dislodging obstacles to understanding or failures to grasp the point, in challenging rigid adherence to perceived versions of the model, or in confronting limits and errors in the model itself, either supervisor or supervisee should be able to indulge in “Mennipean” humor—with a serious core. Supervisors should aim to be simultaneously alert to adherence to the model (“treatment fidelity”) which may be helpfully considered and evaluated in terms of the CCAT and TIC approaches described above (see Kellett & Bennett, 2017). The integration of competency assessment into cognitive analytic therapy supervision relates also to focus on the nature of the therapy relationship. Here, transference–counter‐transference and other RR manifestations may have been missed, although possibly anticipated, or forms of reciprocal collusion with unhelpful or “negative” procedures may have gone unnoticed. Provided supervisees

156

The CAT Model of Therapist Activity and of Supervision

have understood the essentials of the model, difficulty in following it is often a manifestation of some therapist RR enactment(s) (“counter‐transference”). Such omissions and collusions are virtually inevitable and should be accepted as such; it is their recognition and recovery from them that is important and therapeutic. Having said this, as previously noted, some patients at a particular time may still not be “able” to engage with and make use of therapy. During training, weekly session‐by‐session supervision is important to allow the supervisor to obtain an in‐depth and ongoing “feel” for the case and its progress and the issues, especially relational, that may arise. Later on, case supervision may reasonably be rather more intermittent and/or more problem‐oriented. Reformulations should ideally always, as previously noted, be checked out in supervision or with a peer.

­Audio-tape Supervision Audio‐taping a session can offer an opportunity to listen to and scrutinize the overall tone and quality of the therapeutic dialog and interaction, and the type and level of activity. Not infrequently this may be surprising or shocking to trainees/therapists. For example, “I had no idea I was being so intrusive and directive” or, alternately, “I had no idea I let such long, maybe uncomfortable, silences occur.” It may also allow recognition of mutual role enactments not picked up at the time. It is often difficult to be aware of these in session, even for experienced therapists. Detection of previously unrecognized processes, especially where a collusion takes the form of, for example, not addressing certain topics, or of settling into an “inert truce,” is far more likely to be recognized if audio‐taping of sessions is employed. In such cases it may be the case that the significant enactment (commonly involving passive “resistance” in some form) has not been clearly identified in the diagram. The report of any significant event which cannot be located on a diagram points to the need to rethink and revise it. Listening to audio‐tapes of whole sessions or even of parts of sessions through the whole course of therapy would normally be too time‐consuming under most routine public health service pressures. As a workable compromise, therapists in training may be encouraged or required to audio‐tape all sessions of at least one therapy and to listen to them before supervision, and to transcribe or play selected passages. In earlier studies evaluating a number of taped sessions, Bennett and Parry (1998) showed that failures to intervene according to the model were common in respect of two key elements; namely, failing to link new material to the reformulation and failing to note and link transference manifestations. In a subsequent exploratory project (Ryle, unpublished), trainee therapists were required to listen to the audio‐tapes of their sessions before supervision. They were required to devote the last few minutes of the session to a recapitulation of the main themes. In this recapitulation, links to the diagram of reports of transference enactments should be made or repeated. These sections are transcribed and brought to supervision where they are discussed and coded. Despite the clear focus, a proportion of therapists continued to omit these key activities for several sessions. Therapists found the method exposing but usually reported that it had served to improve their practice. Subsequently, this practice was integrated into a trial of CAT for adolescents. It was hypothesized that an end of session summary to take stock of the session allowed therapist and

­Group Supervisio  157

client to reflect on the session and for therapists to have a second opportunity to name enactments or challenging moments that occurred in the session that may have been left unattended for reasons of timing or to protect the alliance. These segments were scored for all therapies in the trial to assess CAT practice (see review in Gersh et al. 2017). In a further study (Kellett et al. 2013), CCAT raters observed that use of this method allowed raters to conclude that material that was possibly judged as “missed” by therapists earlier in the session; for example, that an enactment may not have been picked up as it was not acknowledged or spoken about, had in fact been noted as it was referred to at the end of the session. Raters could judge this as competent in view of the therapist’s attention to “timing” and decision to hold this observation for consideration at a point they considered more appropriate, and more likely to be helpful, or to not threaten the alliance.

­Dialogical Sequence Analysis Supervision in specific use of the technique of “dialogical sequence analysis,” beyond simply noting and working with the existence of “voices” in association with RRs and RRPs as described previously, has up to now largely occurred in the context of research studies. The principles of this important approach and the clinical assessment of its effectiveness are described more fully in the research literature (see, e.g., Leiman 1997, 2004, 2012; Leiman & Stiles, 2001; Gersh et al. 2017).

­“Parallel Process” The emergence in supervision of feelings and role patterns originating in the patient or the therapist–patient relationship is understood in CAT as the manifestation of transmitted RRs and reciprocal role procedures (RRPs). Thus, the therapist’s identifying and reciprocal counter‐transferences, whether acknowledged and recognized or not, which reflect the patient’s RRs and RRPs, may be re‐enacted in the supervisee–supervisor relationship. In group supervision, different members may respond to different aspects. In these ways unvoiced feelings and unrecognized RRs and RRPs may be recognized or at least considered. However, it should be noted that the traditional psycho‐analytic concept of “parallel process” is complex and poorly validated (Carroll, 1996), and such phenomena should be treated as a prompt to enquiry rather than as representing any exact mirroring or re‐enactment. For this reason, the title of this section has been placed in inverted commas.

­Group Supervision Most CAT supervision of trainee therapists takes place in groups of three or four supervisees and the currently recommended minimum by the Association of Cognitive Analytic Therapy (ACAT) in the UK is to allow a minimum of 15 minutes of supervision time weekly for each patient. There are many advantages to the group format, both in terms of learning from the work of others and because the authority of the supervisor is more likely to be

158

The CAT Model of Therapist Activity and of Supervision

seen in perspective and possibly challenged. Different previous trainings, cultural perspectives, and life experiences among the supervisees enrich discussions and benefit all, ­including the supervisor. However, partly for these reasons, problematic and challenging group dynamics can also inevitably arise that the supervisor will need to be alert to and respond to as need be. Many of the issues discussed in the above sections in relation to CAT‐based supervision are helpfully addressed and further illuminated across a wide range of settings and ­applications in the comprehensive volume edited by Deborah Pickvance (2017).

­Reflective Practice Many of these same general considerations in relation to supervision inevitably arise in offering and running reflective practice groups, given that essentially similar relational and systemic dynamics arise in such settings, even although the participants are likely not to be therapists nor to be undertaking formal therapy. The use of CAT to inform and facilitate reflective practice, notably in relation to treatment in mental health service settings, is ­discussed at greater length in Chapter 11.

­Distance Supervision An expanding interest in CAT training from people in remote areas of the UK and in other countries around the world has been met in part by developing distance supervision, using email and other internet‐mediated tools, sometimes supplemented by telephone contact. Unless there has been some face‐to‐face contact then ideally the arrangements should be provisional until both supervisor and supervisee are satisfied that it works. Supervisees should have clinical experience and be prepared to study the main CAT texts, and supervisors must discover how far the potential trainee is able to convey the feel and content of sessions. If the trial is satisfactory, then a weekly exchange may be set up, the sessions being reported and drafts of letters and diagrams being sent for comment. This kind of arrangement has been surprisingly successful and can enable the formal accreditation of supervisees. A group of experienced and diligent Australian therapists in an early distance supervision project were trained initially in several intensive week‐long workshops, and went on over 3 years to carry out the “early intervention” for BPD research noted above. During this time, they emailed session reports supplemented by the addition of emailed voice recordings and met weekly for shared phone supervision. They went on to complete practitioner, psychotherapist, and supervisor training, and have established an Australasian training program. These basic methods therefore proved effective, but with increasingly sophisticated developments in technology more elaborate links are now available and are increasingly used to connect trainings in different countries and continents. The following further update is based on information helpfully provided by Dawn Bennett. By now, so‐called “Technology Assisted Supervision and Training” (TAST) is ­well‐ embedded in the CAT world and has been employed for supervision and practitioner ­trainings around the world, including in non‐exceptional circumstances and even for some

­Distance Supervisio  159

training therapies. CAT trainers are now also experimenting with providing live and ­pre‐ recorded training webinars for practitioner trainings. A survey of CAT supervisors ­conducted by Nield, Cavieres, and Stevens (Dawn Bennett, personal communication) on the topic of TAST reported that only 6% of respondents do not use TAST in any part of their CAT practice, with a large majority of TAST users citing distance and travel as the main reason, but also personal preference and pressure of time. However, concerns about accessibility are tempered with concerns about “in the room” relational presence. Many feel they are not well‐enough informed about the availability and use of TAST. In the UK, ACAT is currently exploring issues arising in the use of online/technology assisted supervision within a training context. These issues include ethical considerations such as maintaining quality, security, confidentiality, data protection, and data sharing (e.g., tools), and dynamics of managing and working within the supervisory relationship with an individual and group. Further issues include the question of whether TAST can maintain the integrity of the relational CAT model for supervision. Practical issues include questions such as whether there is a need for specific training, and what technology platforms would be appropriate to use. ACAT is currently working toward guidelines on these issues, although as yet many training organizations and professional bodies do not yet have comprehensive policies in place. In recent years, an International CAT Association (ICATA) (see www.internationalcat. org) has also been founded, largely through the vision and energy of Steve Potter. One of the aims of ICATA is to promote and enable training and practice in CAT in some very diverse settings around the world, as culturally appropriate. It has also set up a journal that publishes material aimed at furthering the use and appreciation of CAT and other relational approaches, and also training and supervision in CAT (see www.internationalcat.org).

161

9

CAT in Various Conditions and Contexts S ­ ummary Cognitive Analytic Therapy (CAT) offers a general model of development and psycho‐pathology that cuts across current, often unhelpful and superficial, diagnostic distinctions. A central feature of its practice is an emphasis on working with whole persons, and on identifying and working “transdiagnostically” with the underlying processes and structures of the Self. The use of CAT for a variety of patient problems in various settings, including across cultures, and including at times their partial reconceptualization, is reviewed briefly along with theoretical developments and background issues associated with them. These include anxiety‐related disorders, depression, somatization and “medically unexplained symptoms,” deliberate self‐ harm, eating disorders, complications of medical conditions, substance abuse, psychological trauma (including childhood sexual abuse) with its various manifestations, psychosis, sexual and gender‐related issues, bereavement, older age, “learning” or “intellectual” difficulties, along with applications in forensic settings, primary care, groups, and organizations. It is stressed, however, that essentially the same general therapeutic considerations and principles apply to and underpin the use of CAT across this apparently wide range of presentations. In this book so far we have presented CAT as a general psychotherapy model. In this and the next chapters we shall describe some particular applications of the model to different “diagnostic” groups and to work in various settings. Given the proliferation of these applications in recent years, including those still currently being researched and evaluated, this chapter can only aim to highlight and “signpost” some of these, while noting some particular therapeutic considerations arising in relation to them. Full descriptions of work in these areas can be found in a rapidly expanding specialist literature to which reference will be made. However, we would stress that essentially similar considerations apply to work across an apparently broad range of presentations and the CAT approach does not employ “manuals” for working with various so‐called diagnostic groups. Some of the reasons for this are explored and elaborated below. Inevitably, however, it can be helpful to provide treatment in the context of specialist experience and services given particular issues that arise around certain patient groups, notwithstanding the whole person and whole context approach embodied in CAT. This might apply, for example, to working with people with Introducing Cognitive Analytic Therapy: Principles and Practice of a Relational Approach to Mental Health, Second Edition. Anthony Ryle and Ian B. Kerr. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

162

CAT in Various Conditions and Contexts

severe psychotic disorders, eating disorders, and sex or gender‐related problems. In ­offering this overview chapter we have therefore drawn upon and benefited considerably from the assistance and expertise of specialist colleagues, especially around some more challenging topics. We begin this chapter by considering and attempting to contextualize some of the problems inevitably associated with current psychiatric nosology and classification (which aspire to be ostensibly “atheoretical”), given that these have a considerable bearing on the theory and clinical application of all models of psychotherapy. Some therapists more immediately interested in the use of CAT for various clinical presentations may again ­prefer to skim over these background considerations.

­The Problem of Diagnosis Diagnosis and Formulation The word diagnosis comes from the Greek to discern or distinguish. It is a process well established in general medicine as the necessary basis for rational treatment and research, but its application to psychiatry raises a number of problems (American Psychiatric Association [APA], 2013; Francis, 2013; Herpertz et  al., 2017b; Hyman, 2010; Kendell, 1993; McGuire & Troisi, 1998; Livesley, 2018a; Roth & Fonagy, 2004; Vanheule, 2017; World Health Organization [WHO], 1992, 2019). While we use diagnostic terms, it is important to recognize their limitations and, correspondingly, the importance of meaningful formulation. These problems have been acutely highlighted by some quite acrimonious and ­ultimately unresolved disputation, both theoretical and clinical‐pragmatic, around the production of the recent DSM5 (APA, 2013) and forthcoming (due 2019) ICD11 (WHO, 2019) diagnostic and classification systems (see, e.g., Francis, 2013; Herpertz et al., 2017b, Hyman, 2010; Livesley, 2012, 2018a; Tyrer et al., 2011; Vanheule, 2017). The nosological discriminations made between psychiatric conditions, partly given their multidimensional complexity, are inevitably more arbitrary and much less reliable and helpful than those made in general medicine. In the case of psychotherapy, the emphasis should be upon treating disturbed, distressed, or depressed people in their social and cultural context, not on treating “personality disorder” or “depression.” Categorical diagnosis involves fitting cases into defined groups. Such labeling can be arbitrary, inaccurate, and reductive, although for some patients it is a relief to know that they have a recognizable and potentially treatable “condition.” However, patient focus, possibly encouraged by health services, on an external mental “illness” or “condition” may represent a defensive enactment with which it is unhelpful to collude, and be difficult to “map” and work with. But in addition to enabling appropriate, focused treatment, diagnostic categories can also aid the undertaking and evaluation of research, and clinical communication. In general medicine such categories are most usually based on clear understandings of the causes of the disorder—that is to say their etiology (see Ryle (2019) for an overview of these various issues). In psychiatry, however, given the absence of precise (as opposed to broad) understandings, and their meaningful integration, we have to rely upon a combination of features. These include the presence of particular clusters of symptoms, traits, and behaviors, their variable course through time, and their very variable response to treatment. This reflects the fact that there is no general and agreed understanding of the underlying

­The Problem of Diagnosi  163

“­ psycho‐pathological” processes but, rather, there exist competing paradigms within which these are framed. These would include for example the system‐based, but essentially biomedical, framework proposed by authors such as Insel and Wang (2010) as an alternative to DSM type approaches. Dimensional classifications seek to remedy the arbitrariness of categorization by relying upon measures of the extent to which certain features are present; these could be symptoms, personality traits, or behaviors and for some purposes they are more subtle and ­satisfactory. However, in the absence of a shared model of “psycho‐pathology,” the choice of which dimensions to measure can be equally arbitrary and may exclude important ­factors, often notably consideration of more subjective issues; for example, those relating to meaning and purpose. Such contributory causes as have been identified are of variable and partial importance. Genetic causes in mental disorders, except in rare conditions such as Huntington’s disease—due to the presence of a specific abnormal gene and essentially a neurological disorder—do not appear to account for mental disorders by themselves. Even for major psychotic disorders, such as schizophrenia or bipolar affective disorder, there is now much less acceptance that genetic factors invariably play a very significant (Plomin, 2018), or indeed any, role (James, 2018). Some recent writers suggest that these disorders may be much more heterogeneous than previously assumed, and correspondingly more multifactorial in their etiology, with psycho‐developmental trauma increasingly implicated in their causation (Barker, Gumley, Schwannauer, & Lawrie, 2015; Corrigan & Hull, 2018; James, 2018; Trotta, Murray, & Fisher, 2015; Varese et al., 2012). It is clear, however, that various other factors play their part in mental disorder and interact dialectically over time with each other. These include biological (including epigenetic) damage or disorder, psycho‐developmental relational adversity and “maltreatment,” along with more subtle disturbances of past and present patterns of relationships, overtly traumatic events, existential issues, and past and current socio‐cultural context. Competing Paradigms

Apart from the innate difficulties involved in psychiatric diagnosis, much confusion can stem from the fact that there are competing or contradictory paradigms applied to understanding mental disorder, and in many cases professionals committed to a particular perspective may over‐extend their applications to the exclusion of others. The reasons for this may, unfortunately, not always be scientific. A disorder resulting from all the factors noted above may meet a particular categorical diagnosis, and such diagnoses may be of very broad value in predicting response to treatment and in comparing different treatments, and for these reasons are a necessary aspect of understanding. But in our view their utility to the ­psychotherapist, or indeed psychiatrist or other mental health workers, is restricted. For psychotherapists, once broad diagnoses are made, the main task is to relate them to a fuller picture constructed in the form of a case formulation (see also Denman, 1995; Eells, 1997). As Kendell (1993) observed, diagnosis and case formulation have very different, complementary functions. Case (re)formulation in CAT, as has been discussed earlier, aspires to be a genuinely collaborative enterprise aiming to set patients’ problems and distress in the context of a full understanding of their lives. This may include acknowledging both biological and social realities that have to be dealt with, but the emphasis will be on formative life experiences

164

CAT in Various Conditions and Contexts

and the effects of and conclusions drawn from them. These have seldom been fully reflected on but will be manifest in the values and procedures guiding behavior and shaping experience, and the nature of the emerging Self. Whatever the diagnosis, case formulation will aim to provide a new perspective on, and a heightened awareness of, the problems which therapy will seek to remedy. It also cuts across the misleading notion that patients may ­suffer from several “separate” conditions simultaneously. These are frequently and unhelpfully described as being “co‐morbid.” In reality, different levels of damage and disturbance affecting different aspects of development and of Self structure and function are found. We suggest that a comprehensive, individualized, developmentally based, bio‐psycho‐social formulation, such as that offered by a genuinely collaborative CAT reformulation, should be a minimum prerequisite for working with any patient or client within mental health services. Unfortunately, patients are all too often treated or simply “managed” on the basis of much lesser understandings, or, in hard‐pressed services, simply in response to crises or “challenging” behaviors (e.g., self‐harm, substance abuse, or anorexia). Before considering and illustrating how this process may vary according to diagnoses and contexts, it is important to consider first how “symptomatic” disturbances may be understood and addressed.

The Scope of CAT The scope of psychotherapy is broad and its remit may be debatable depending on context and immediate circumstances. It will also depend on socio‐cultural context where therapy may be viewed variously as a commonplace aspect of the lifestyle of, for example, stressed professionals, through to cultures where distress would not be framed as psychological, and seeking or engaging in psychotherapy might be seen as inappropriate, shameful, or stigmatizing. A robust model of psychotherapy should ideally also be able to make sense of this range of responses. But feelings of unfulfillment in life, general unhappiness, disabling emotional distress, disorders of bodily functioning, damaging and unsatisfying social and personal relationships, negative self‐attitudes, and poor self‐organization may all fall within this scope. We also argue that as one major, ultimate determinant of mental disorder, socio‐cultural context should, at the least, be acknowledged explicitly and considered in any reformulation, even if it cannot be directly influenced. It may also have a part to play in the genesis or treatment of physical disorders, which may be complicated by psychological factors, or which require careful self‐management. These different problems often co‐ exist and interact. Cultural beliefs and the theoretical model of the psychotherapy offered will determine which level or type of disturbance is considered to merit treatment, and of what sort, and indeed how this is conceptualized. The model of CAT presented in the previous chapters is a general one. CAT is not a diagnosis‐specific approach, it is a general model of psychological disorder and of its treatment. The problems that bring patients to therapy are commonly accompanied by physical symptoms, negative moods, and distressing emotions and experiences of Self. These can be understood at a number of levels from the biological to the sociological. At the present time they tend to be classified in ways parallel to the systems used in medicine and to be seen by both patients and clinicians as equivalent to organically determined “illness.” The pharmaceutical industry’s eagerness, along with that of some colleagues in academic settings, to find a biologically-focused treatment for every newly defined syndrome, of which there

­The Problem of Diagnosi  165

are ­ever‐increasing numbers, further reinforces such definitions. This is in part also due to an aspiration to bestow, in our view, an inappropriate and effectively pseudo‐­scientific view of mental disorders; for example, through a purely “biomedical model.” Behavioral and cognitive therapies could be said, in general, to address intermediate levels of disturbance. Thus, the psychological understandings and interventions offered by behaviorists are largely based on simple animal models of nervous system functioning and learning. In cognitive therapy, the main focus has been on associations between beliefs and moods and behaviors and on the extensive use of computer and information‐processing, and cybernetic metaphors. It has also rested on naive and unproven assumptions that voluntaristic, individualist, and rational efforts by patients to modify these can and should always be effective, regardless also of social or relational therapeutic context. In fact, all too often these efforts do not succeed: this frequently compounds patients’ problems and leaves them feeling they have failed. Such treatments can therefore be limiting or damaging to the extent that mental disorder or problems of living are defined as an “illness” to be addressed in an essentially technical manner. And when treatments are based on reductive versions of human activity and experience, attention may well be diverted from more fundamental, human and existential issues. In CAT, the therapeutic aim is to understand symptoms and behaviors in relation to the underlying structure and processes derived from, and continuously enacted within the Self, and between Self and others. This emphasis does not deny the fact that these psychological issues may have important physiological determinants, consequences, and expressions (as discussed in Chapters 3 and 4), nor that drug and psychological treatments addressing lower levels may have an important, if circumscribed, part to play. But the CAT therapist’s concern is with anxious or depressed or somatizing people, not with anxiety, depression, and somatization. Treatment will therefore be concerned with how their symptoms are linked with their formative relational history, current context, sense of self, and procedural repertoire as it affects their self‐management and their interpersonal and social functions. Particular attention is paid in CAT to how the therapeutic relationship may reflect and reinforce, but possibly revise and repair, damaging relational and coping patterns (reciprocal relations (RRs) and reciprocal relation procedures (RRPs)), and so help to heal a damaged Self.

Strategic Issues: When to Address Symptoms Directly As a general CAT principle, it can be stated that presenting symptoms and behaviors, and syndromal diagnostic labels attached to them, should always be addressed and treated in the context of a whole‐person, transdiagnostic approach. This would view symptoms as occurring in the context of a (shared) understanding and description of that person’s repertoire of formative RRs and RRPs. These would incidentally all be seen to contribute toward, and constitute part of, a broad diagnostic category. For example, a RR of being “put down and criticized” may have led to RRPs of “striving and putting up a front.” This may eventually lead to exhaustion, hopelessness, and isolation, possibly characterized by an internalized, dialogical, self‐critical voice associated with an underlying RR—quite possibly associated ultimately with a change in levels of neurotransmitters or receptors. In other words, a “depressive disorder”! From a CAT perspective, symptoms, behaviors, and diagnoses would therefore always appear on maps, but not necessarily centrally nor as the key focus. Indeed, little explicit attention may be paid to them during therapy. Despite this,

166

CAT in Various Conditions and Contexts

these symptoms will very often be found to have diminished or disappeared following therapy (see case example below). Some may, however, need separate, active consideration at some point during or following therapy, depending on clinical judgment and discussion with the patient. These could include, for example, some panic attacks, intractably low mood, extreme paranoid beliefs, anorexia, substance abuse, or self‐harm. It should, importantly, also be noted that in many cases diagnostic categorization, and treatment based on this, can be seen to collude with, or reinforce, the original formative RRs that gave rise to presenting problems. For example, in anorexia (and in many other disorders such as somatization disorders, anxiety, or panic attacks), symptom‐targeted approaches, however well‐intentioned, may be experienced as being a re‐run or re‐experiencing of a formative RR of, for example, “controlled and unheard.” This may in turn provoke RRPs leading to “resistance,” dropping out, and/or exacerbation of original (coping) patterns,—that is, their presenting symptoms. The problem, as previously noted, of so‐ called resistance, “negative therapeutic reactions,” or treatment drop‐out is hugely important in mental health work, but can only be meaningfully understood in terms of enactment of underlying relational patterns (RRs and RRPs), including in the context of staff and systemic reactions and pressures. This will apply, we suggest, to any disorder of any complexity or severity and it is critical to understand, validate, and address these underlying formative RRs and RRPs, ideally firstly with patients. Such an approach should not be blaming or judgmental and will be less likely to be “resisted”. The following case history of a complex, multiply “co‐morbid” presentation illustrates many of these points. Case Example: Susan (Therapist IK) Susan was a young woman in her early 30s who had been referred by the local department of child psychiatry where the family had been seen because of the emotional and behavioral difficulties of her 7-year-old son. The team had been concerned about her and had referred her for an assessment for psychotherapy. Her difficulties centered largely around chronic feelings of panic and anxiety which related partly to her irritable bowel syndrome and her worry about whether she might lose control while far away from a toilet. She also suffered a continual worry that she might vomit, although this had not happened since one episode 15 years previously. These anxieties were severely disabling and prevented her going far from home, for example to pick up her child from school or to eat in a restaurant. In addition, she had marked obsessive–­ compulsive symptoms, needing, for example, to rearrange clothes in her wardrobe before leaving her bedroom in the morning, a process which could easily take up to 20 min. She was also so anxious about untidiness in the kitchen that she could not go in to cook, leaving this to her husband instead. Interestingly, she found the Psychotherapy File (see Appendix 2) disturbing to take home because there was no “place” for it there, which caused her to bring it back very promptly! Because of her chronic panicky feelings she sometimes “had” to call her husband back from work where he was a freelance IT consultant, as well as sometimes needing her mother to stay to help out. These anxieties had been clearly having a detrimental effect on her children (aged 7 and 3 years) with whom she found it hard to engage. Frequently she would enlist her mother or

­The Problem of Diagnosi  167

husband to help out. She felt the need all the time to have a system around her which made her feel safe. Susan had been the youngest of several children and she had always been, she thought, shy and anxious. She mentioned a photo of her bedroom taken when she was about 7 which was meticulously tidy and ordered. Her father was “lovely but absent.” Her mother suffered herself from severe anxiety and obsessional difficulties and had had eating problems, which had clearly got in the way of being a good mother. Susan had always kept her worries to herself and had always felt a pressure to do “wonderfully well.” She had, in fact, done well academically at school and had been expected to go to university. However, she failed her A levels unexpectedly. Just prior to taking these exams she had suffered an episode of vomiting after an allegedly suspect meal and this had left her with her resultant fear. She had done various administrative jobs and at the time of referral was working temporarily as manager in a clothes shop, although she gave this up shortly afterwards because of her symptoms. The only serious boyfriend she had had was her husband whom she had met as a teenager. She described him as devoted and loving and a “great support” although the sexual side of her relationship was described as “fine” but “not important.” He continued to worry about her and was anxious for her to receive treatment and would have been prepared to come along as well. Susan had previously had experience of brief counseling through her GP, of an anxietymanagement group, and of a trial of cognitive-behavior therapy with a psychologist. She had dropped out of all of these. During her work on anxiety, for example, she related that the more they tried to help her to let go and relax the more grimly she had “held on.” At assessment it was felt that she was not a good candidate for analytic ­psychotherapy and was referred for a trial with CAT. During her first few sessions of therapy her explicit agenda was focused around her “symptoms” as she described them, and she was very anxious to know if and how this therapy could help deal with them. It proved extremely difficult to divert her toward any reflection on their meaning or origins or indeed about her early life. It was clear that she was very distressed by the symptoms and the difficult feelings associated with them, which she was able to acknowledge explicitly. Apart from her obvious distress, however, she was recurrently obviously irritated by the lack of progress in sorting out and curing her symptoms. The therapist felt throughout the first few sessions that she was determinedly attending as if going through the motions to make a point of how difficult things were and to prove that things could never really change. This hopeless feeling was also induced in the therapist, as was a recurrent irritation that she would not act as a cooperative patient who would be willing to work. It seemed that this might have been a partial replay of what had happened during her previous failed “attempts” at therapy and might be illustrating some of the roles which were enacted at home. The Reformulation Phase When going through the Psychotherapy File the procedures she had identified strongly as applying to her were the trap of “trying to please others and being anxious not to upset them, as a result of which we end up being taken advantage of which makes us

168

CAT in Various Conditions and Contexts

angry, depressed, or guilty” and the dilemma of “either trying to be perfect and feeling depressed and guilty, or not trying and feeling guilty, angry, and dissatisfied.” She also identified the typical obsessional dilemma of “either keeping things in perfect order or fearing a terrible mess.” She also identified the dilemma of “either being sustained by the admiration of others or feeling exposed and contemptible.” She recognized the snag of feeling limited in life by something inside herself, and of “having to sabotage things as if she did not deserve them.” She noted, interestingly, that she had tended to do this at school also. Finally, she noted most of the difficult states of mind as applying to herself to some extent at various times and also some of the different states. These included “feeling bad but soldiering on and coping,” “being in control of self and other people,” “provoking and winding up others” (which she would do with her son), “feeling agitated, confused and anxious,” “vulnerable and needy,” “resentfully submitting to demands,” and “intensely critical of self and others.” The first intimation that something might change came during the drafting of the initial sequential diagrammatic reformation (SDR) (Figure  9.1) when, having jointly (a)

Key formative RRs for Susan controlling and demanding

controlled and demanded of (‘anxious’)

(b)

Simplified revised SDR/map for Susan to self

Parental voice

maybe fine for a while encounter difficulties

controlling and demanding “keep lid on even more” controlled and demanded of (‘anxious’)

(feel out of control) anxiety guilt anxiety

feel angry (“can’t slow it”) compliance

resentment

Figure 9.1  Simplified SDR/map for Susan showing key formative RR and key RRPs.

­The Problem of Diagnosi  169

sketched a rough core “subjective” self which seemed acceptable to her, the subsequent implications of her role enactments, both outside and in sessions, were persistently explored by the therapist. At this point she became for the first time overtly very angry and tearful, saying that she did not want to open up her “messy” side and that it was “none of your business.” The initial, rough SDR or map centered around a “core subjective self” is shown in Figure 9.1 and the subsequent simplified version showing one key reciprocal role procedure in Figure 9.2. What emerged powerfully from the work around the initial version was her intense and desperate inner feelings and the consequences of her attempts to cope with them by enacting various role procedures. These appeared to have in common the attempt to keep things under control (either her own emotions or other people’s behavior). It seemed important to acknowledge what a struggle this was and also her frustration and irritation when people would, for example at church, “jolly her on” without understanding just how bad things were. She was also able, with reluctance, to describe bursting out angrily at times when she could no longer contain her feelings, mostly with her husband who could, as she put it, “cop it.” She also described a “keeping busy” coping mechanism which, however, never seemed to help for long. The therapist noted on the SDR those procedures which she might be enacting with the therapist in the room (shown as “? in here” or “? with me” on Figure 9.1). With persistence, this focus of the work was reluctantly accepted. It continued to be difficult for her, however, to own the “controlling–controlled” role pattern which was subsequently highlighted on the simplified diagram (Figure 9.1). Target problem procedures (TPPs) or key issues were described as follows: 1)  Because of your formative RR of feeling controlled, then trying to keep to yourself worries about your imagined inadequacies, your anxieties, and your angry feelings for fear of terrible consequences if they came out, but as a result feeling isolated, exhausted, and desperate about how you can carry on. Aim 1: Try gradually to express some of your worries and emotions to people in all settings and see what the ­consequences really are. 2)  Dealing with your worries and your “messy” side resulting from your formative RR by keeping busy and keeping in control of things and of people (like me in therapy), which has the result that no one gets “let in” and that nothing ever changes. Aim 2: Try to consider that keeping in control of everything all the time may actually make things worse and try out the effect of “letting people in” (like me). Rating Progress For TPP 1 there was little recorded change on her rating sheet during therapy for either recognition or revision. Interestingly she wrote on her rating sheet for TPP 2 that “I like being in control!” For this procedure her ratings showed increasingly good recognition but little apparent change. In therapy she continued intermittently to be angry at the therapist for apparently ignoring her symptoms and not curing them and for focusing on her feelings and role enactments. Similarly, she continued to insist

170

CAT in Various Conditions and Contexts

until the end of therapy, despite seeming at times more relaxed and able to discuss her feelings and the consequences of her role enactments, that this would never really help. She insisted that she was only going through with it in case she ever needed further help so that it would not be held against her that she had yet again dropped out. She repeatedly accused her therapist of being unempathic and not really understanding her difficulties or helping with them and this was very much the tone of her farewell letter, although she did say that she had found therapy “challenging.” Nonetheless, her therapist did feel that by the end of therapy Susan was noticeably more open about discussing her feelings and difficulties and more able to be “in dialog” and that she was possibly also surprised that this could happen. Parallel to this she reported that her irritable bowel symptoms had curiously diminished. In addition to clinical impressions that her symptoms had diminished, her scores on routine psychometric measures (“CORE” (see Barkham, Gilbert, Connell, Marshall, & Twigg, 2005) and a standard anxiety questionnaire) also reduced considerably. The “CORE” reduced from 76 at the start of therapy to 46 at the end with subscale ratings related to anxiety showing a parallel decrease from 36 to 23. At 6-month follow-up these scores had diminished even further (“CORE” overall reducing to 34, with the anxiety-related subscale ratings reducing to 14, with parallel shifts in standard anxiety measures). She wrote a letter 6 months post-therapy saying that things had improved considerably in her life and stated that: I originally came to you with one set of anxieties and insecurities; these seem to no longer play a large part in my life and, although lonely and isolated at present, I feel there is hope for the future. It seems clear that for this patient the symptoms with which she presented were aspects of one key reciprocal role pattern around a controlling–controlled axis. What is of particular interest is that the enactment of this key RRP had undoubtedly prevented her from simply and cooperatively working on her symptoms as had been previously attempted by symptom-focused approaches. Indeed, such approaches could have been seen to be examples of colluding with this RRP, hence intensifying her “resistance.” This case illustrates the point that, unless these role enactments in the therapy relationship are identified and worked on as a principal focus, the work will be sabotaged and the patient will acquire the label of being “difficult” and elicit all the unhelpful reactions that go with it. As an interesting and significant aside to this case history, we note that an eminent behavioral therapist reviewing the first edition of this book (Marks, 2003), chose this case to assert that, in contrast, a more straightforward, purely behavioral approach would have been more effective. However, he failed to note that “Susan” had already undergone such treatments without success, and that it was precisely sustained work on the challenging relational issues arising in therapy that proved ultimately helpful. (Marks, 2003, and see response—Ryle & Kerr, 2003).

­CAT in Some Specific Conditions and Setting  171

­CAT in Some Specific Conditions and Settings Anxiety Related Disorders This group of diagnostic categories includes, in recent classifications such as DSM5 (APA, 2013), a list of entities such as generalized anxiety disorder (GAD), social anxiety, phobias, panic disorders, separation anxiety, and agoraphobia. Generalized Anxiety Disorder

GAD is usually described as a syndrome marked by excessive and widespread worry. Anxiety is a very general, normally adaptive, phenomenon, and response to challenging or threatening circumstances including relational. A predisposition to or predominance of anxiety in human psychology has historically been placed exclusively at the center of some, for example, psychoanalytic approaches. Anxiety has arguably been rather under‐emphasized in CAT where it has been recognized rather as a mediating phenomenon or a feature of a RR (especially if associated with traumatic memories) than as a “stand alone,” primary, explanatory entity or “illness.” Current guidelines and reviews such as NICE (NICE 2014a) typically suggest the use of CBT‐type approaches, initially at least, for GAD, as well as for sub‐categories such as so‐called “social anxiety disorder,” given evidence for some efficacy (see, e.g., reviews in Gabbard, Beck, & Holmes, 2005; NICE, 2014a; Yakeley, Johnstone, Adshead, & Allison, 2016). However, with any but circumscribed and less severe cases there are problems and limitations with such approaches as previously noted. Because of the poor response of anxiety to conventional cognitive therapy, Wells (1999) several years ago proposed a cognitive model in which the therapist, having identified the situational and cognitive antecedents of worry, explores the “metacognitions” which serve to maintain “negative feedback loops.” This metacognitive therapy model seeks to address higher order beliefs but, while this clearly represents an important advance on a focus confined to symptoms themselves, it shares with basic CBT a focus largely confined to individual mental processes, paying little attention to the formation and maintenance of self‐managing procedures in interaction with others. Some more recent CBT‐based approaches have begun to address and incorporate interpersonal and attachment‐based understandings into treatment particularly of “refractory” cases (see Gabbard et al., 2005; Leahy, 2001; Yakeley et al., 2016). However, like conventional psychiatric models of anxiety, they still show surprisingly little interest in the content and meaning of the worry or in the life circumstances with which the patient is coping or in which they grew up. Whether or not these circumstances are objectively threatening, the fact is that they are beyond the patient’s ability to evaluate and manage using their current procedures. The connection between adverse early life (relational) experiences, later threatening life events and circumstances, and a vulnerability to ­anxiety disorders has been clearly and unequivocally demonstrated by many workers (Finlay‐Jones & Brown, 1981; James, 2018; Marteinsdottir, Svensson, Svedberg, Anderberg, & von Knorring, 2007; Weich, Patterson, Shaw, & Stewart‐Brown, 2009). From a CAT perspective, to understand generalized anxiety on the basis simply of ­enumerating faulty cognitions and metacognitions and deficient coping skills remains essentially impersonal and superficial. It fails to acknowledge adequately real life, formative, anxiety‐provoking, or overtly traumatic relational experience and memories, and how

172

CAT in Various Conditions and Contexts

relational enactments and social situation may perpetuate it. CAT would see it as being fundamentally important to seek to understand, acknowledge, and work with the person’s relational experience that has led to their sense of self feeling inadequate, along with a diminished grasp of, and ability to influence, reality or, in severe cases, feeling that the whole of existence rests on shaky foundations. In such cases the individual will usually feel essentially isolated and without social support and will thus be effectively “out of dialog,” which has destabilizing and anxiety‐provoking consequences in its turn. As ever in CAT it may be acknowledged, including in reformulations, helpfully to many patients that some people may be more temperamentally vulnerable to such problems. In many such presentations “aims” or “exits” (in the context of prior reformulation) aimed at exposing the patient to the real‐life experience (very possibly, e.g., accompanied by the therapist) of confronting and surviving feared and/or anxiety‐provoking situations (such as going shopping, taking a bus, or speaking their mind) may be of particular importance in aiding therapeutic change, in addition to the insights, aims, and support offered by the relational aspects of therapy. In this context, the basic skills of CBT‐type approaches, which as noted previously should also to be within the repertoire of CAT practitioners, may be of considerable usefulness. Thus, therapy based on the exploration of both historical, internalized, relational meaning and current circumstances, and as recorded in the narrative and diagrammatic reformulations of CAT, and the experience of the therapeutic relationship itself, possibly along with real‐life behavioral experiments, can offer such patients new, more fulfilling ways of describing and managing their life in the world. Many of these issues are illustrated in the preceding case illustration (Susan) and elsewhere in the book, given the widespread occurrence of anxiety as a responsive phenomenon.

Obsessive–Compulsive Disorders This group of disorders, although usually diagnosed in terms of an individual mental disorder, are also frequently described in terms of obsessive–compulsive personality disorders in current classifications (e.g., in DSM5 as a “cluster C” disorder). Most people (and many other animals) show some tendency toward ritualization and social life relies heavily on symbolic rituals, notably in the areas of religious authority and the assertions of military and political power. In this way, they induce the sense of a shared meaning and also ­provide a means of coping with the pervasive anxiety inherent in the human condition, arguably especially in the contemporary “post‐modern” one. The underlying procedural patterns found in people suffering from obsessive–compulsive symptoms can be seen as pathological exaggerations of these general tendencies, often expressed in the dilemma “as if either absolute order or dangerous chaos,” or in the perfectionist dilemma where, in reciprocating critical conditional acceptance, the choices are seen to be either shameful failure or absolute success. Pseudo‐moral preoccupations with questions of sin and dirt are often part of the story. The symptoms of OCD represent attempts to limit the dangers perceived or previously experienced in the world and (internalized) in the Self through keeping in control, rituals, avoidance, and symptoms. We do not regard these, nor is there convincing evidence for a view of them, as manifestations of primarily neuro‐biological dysfunction (although this may nonetheless be observed secondarily), other than in some rare cases such as post‐encephalitis‐type syndromes. It is of course likely that some individuals may be

­CAT in Some Specific Conditions and Setting  173

t­ emperamentally more prone to such behaviors than others. Likewise, we do not regard some earlier psychoanalytic ideas attributing obsessive–compulsive behavior to repression of inherent, unconscious envious, greedy, or destructive impulses as valid or plausible. However, everyday activities and relationships may generate forbidden intentions or ­frightening affects and the perceived dangers of these may be managed by repetitive “­magical” rituals involving completing arbitrary or symbolically related acts (as hand washing was for Lady Macbeth) or the use of mental exercises such as counting. In full‐ blown obsessive–compulsive disorders, these magical ritualized attempts to control feared feelings become largely controlling of the patient’s life and often of those involved with the patient. Assessment must take account of the full relational and procedural repertoire and of how the obsessive–compulsive symptoms operate in current relationships; in some cases, partners or families reinforce the rituals and may need to be involved in treatment. Genetic factors may also play a part in predisposing to severe anxiety or obsessionality and contribute to obsessive–compulsive disorder, and by implication determine what therapy can aim at or achieve. There is evidence from neuro‐imaging studies of abnormalities of brain function, although it is more likely that these are a consequence rather than cause of the condition. One classic study showed in fact that these changes resolved following treatment whether with drugs or cognitive‐behavioral therapy (Baxter, Schwartz, Bergmann, et  al., 1992). However, typical current psychiatric assumptions that these ­disorders are largely endogenously arising biomedical disorders appear unsubstantiated. In individual CAT, where the interference of the symptoms with life is moderate, self‐ monitoring can indicate how their frequency and intensity vary in relation to the context or the current procedures. Revising these procedures and challenging irrational guilt often allows the obsessiveness to recede. Where the pattern is established more thoroughly, and where the reinforcement of the rituals by the short‐term relief experienced when they are repeated has become dominant, behavioral methods, notably response prevention, may be helpful whereby, in a way analogous to graded exposure in phobic avoidance, patients are supported to resist repetitions for increasing periods of time. In severe cases medication may also have a part to play. But understanding and revising the interpersonal and ­self‐management procedures in which the symptom plays a part remains essential, and ­overcoming their impact on the therapy relationship can be a daunting task. Some of these issues are illustrated in the preceding case example of Susan. A preliminary formal study of cognitive analytic therapy for symptoms of OCD has also been reported (Boogar, Rezael, & Yosefi, 2013).

Panic and Phobia Phobic avoidance of situations or panic evoked by cues such as spiders or feathers and more general avoidance behaviors such as agoraphobia can often be understood in terms of conditioning and can be treated by supported graded exposure or by other basic behavioral techniques (see Marks, 1987 and reviews in Gabbard et al., 2005; Yakeley et al., 2016). It has been suggested that our liability to simple phobias is due to predispositions to be afraid of certain stereotyped dangerous stimuli which have been highly conserved in evolution (McGuire & Troisi, 1998) and which would explain their relative independence of developmental and interpersonal issues. Symptom monitoring can identify the antecedent and

174

CAT in Various Conditions and Contexts

accompanying thoughts, and cognitive rehearsal of alternatives may offer some control. Secondary worries about the accompanying symptoms, notably rapid beating of the heart or the fear of losing control, can usually be relieved by explanation. Instruction in symptom monitoring may be accompanied by the paradoxical injunction to have the symptom as thoroughly as possible as this often abolishes the symptom, presumably because you cannot deliberately lose control. In these self‐reinforcing conditions, it is appropriate to use CBT methods first, but where such direct methods fail the wider issues of context and relational procedural systems must be addressed, in particular by attending to the interpersonal (usually controlling) role of the symptom. For these more circumscribed and uncomplicated (although possibly debilitating) purely panic type disorders and phobias, it does appear that behavioral approaches may be most effective at least initially (see reviews in Gabbard et al., 2005; Yakeley et al., 2016) and may often be less related to a damaging psycho‐developmental formative history. Nonetheless in our view, and as noted above, every patient, even with apparently focal symptoms, should be treated in the context of a comprehensive reformulation. The issue of symptom‐focused treatment offered alone or in the context of a CAT‐type approach is one that arguably merits further formal research. The use of medication, likewise, to control symptoms may be effective and a satisfactory short‐term response, but its use should not leave wider issues unexamined. Given the intensity and distress associated with such symptoms, prescribing is likely to lead to a pressure for long‐term medication with its associated problems of habituation, addiction, and unhelpful “medicalization.”

Depression The reported massively rising incidence of depression worldwide and, in developed countries, of suicide, notwithstanding debate about the validity of some of these statistics (Kessler & Bromet, 2013; Tøllefsen, Hem, & Ekeberg, 2012), over the past decades can only plausibly be attributed to general social changes. Clinically, patients who are depressed commonly report a sense of exhaustion, existential isolation, hopelessness, the loss or lack of acknowledgment, care, and love, and the experience or anticipation of criticism, possibly mediated by a dialogical voice, and experience or anticipation of control or abuse from others and from themselves, the latter possibly experienced in the form of irrational guilt. The experience of self‐critical and hostile voices by depressed patients can be accounted for as the enactment of early internalized RRs resulting in the “silencing” of any expression of anger or in an inability to assert oneself. As noted by Leiman, RRPs that are “forbidden” may be as important to address as those that are actually enacted. Such factors are not necessarily operating in the present, for we do not live only in relation to our current social world, we have internalized the established values and rules of that world. Physiological and psychological responses may therefore be initiated by events in the current social context identified with, and ­triggering, remembered, anticipated, or imagined events, or by actions or intentions that provoke internal judgments derived from the past. Experiences that would be distressing to anyone, such as bereavement or loss of employment or status, may provoke more profound and persistent changes in those possibly more genetically vulnerable to abnormalities of mood control. More severe symptoms, such as poor sleep with early waking, low mood in the morning improving through the day, poor ­concentration, altered appetite, lack of interest in sex, and the presence of suicidal

­CAT in Some Specific Conditions and Setting  175

­ reoccupations and irrational self‐blame, point to physiological and biochemical changes p which make it very difficult for the patient to make any use of therapy. This does not, however, represent proof of a primary neuro‐biological causation for such disorders. Nonetheless, in some such cases medication may possibly be helpful before or in parallel with therapy. In working with patients who present with symptoms of depression, CAT will, as ever, aim to focus on identifying and challenging underlying RRs, partly by offering a new benign, non‐collusive, therapeutic experience and also working on RRPs which maintain negative or unhelpful attitudes to Self and the enactment of submissive tendencies to others. Some of these are discussed in terms of “self‐esteem” and are considered in Chapter 4. “Aims” or “exits” will include encouraging alternative enactments and activities, but only in the light and context of prior reformulations. These may have a positive therapeutic effect in themselves including on underlying RRs. Indeed, such work may be a principal if limited (see above) focus of many CBT‐type interventions. There is frequently a long period of development of formative RRs and RRPs in any serious cases and, as previously noted, therapeutic change would not be expected to occur rapidly, nor in a simple linear manner, nor always to be sustained in the face of subsequent stresses. The likelihood of possible reversion to previous RRs and RRPs and associated moods is a point worth acknowledging (e.g., in reformulation letters) to patients who may otherwise feel, all too readily, that they have “failed” or are “not good enough.” There is now extensive naturalistic evidence, along with generic therapeutic presumption, for the effectiveness of CAT for depression (see Garyfallos, Adamopoulou, & Karastergiou, 2004; review in Williams and Craven‐Staines 2017; Hamilton, et al., In press), along with its user‐friendliness and effectiveness in engaging and retaining patients in therapy (Calvert & Kellett, 2014). This includes depression as a presenting problem and as an associated or secondary issue in other disorders and in settings as various as general practice, student counseling services, health service out‐patient departments, and in the independent sector, as well as in different cultural settings (e.g., south India—see case example below by Rafi). Some of these issues are illustrated by the case example of Dominic in Chapter 6.

Unresolved Mourning The loss of others whom one needs or values, the loss of one’s own health and capacities, the loss of one’s beliefs or illusions, and the losses imposed by time in the receding past and diminishing future are all unavoidable aspects of life. These issues constitute an important and implicit focus of work in most forms of psychodynamic therapy (see reviews in Gabbard et al., 2005; Yakeley et al., 2016), and a central and explicit focus in some, notably attachment theory‐based, approaches (Marrone, 1998; Murray‐Parkes, Laungani, & Young, 1996). Coping requires acceptance of the fact of loss followed by the assimilation of its meaning. The focus here will be on bereavement but other losses involve similar processes. We note that many such presentations have been re‐named “persistent complex grief ­disorder” in DSM5 (American Psychiatric Asssociation [APA], 2013). The period of early mourning following the death of a loved person is normally marked by emotional instability, with shifts between states of acute distress, of protest or anger at the deceased, of intrusive memories or hallucinations, and of denial or disbelief. These

176

CAT in Various Conditions and Contexts

fade with time as acceptance is gradually accomplished. In modern industrial societies, the social rituals and conventions surrounding illness and death are generally impoverished and we have generated no replacement for the role played by religions in the past of supplying support and giving meaning to the experience. Failures to complete mourning are common and only a few people make their way to the available resources of self‐help groups and counselors. Maybe for these reasons, and also because of the more general loneliness of many people in our individualistic societies, incomplete mourning is ­frequently an aspect of the difficulties that bring people to psychotherapists. It commonly presents as depression and restriction which serve to avoid or suppress the more powerful effects of grief and rage associated with loss. Sadness may have been intolerable at the time of the loss due to the absence of support or the need to cope and care for others, or there may be anger or resentment, either pre‐existing or reflecting the sense of abandonment which, because irrational and not respectable, has not been expressed. This anger may be redirected at professional carers who are seen to have failed to look after and save the dead person. Whatever coping mode was adopted at the time, the most common ones, which involve suppressing feeling and getting on with the practical tasks, can become habitual. In some cases, the particular relationship with the dead person and the role procedures active in it may further complicate the mourning process, most notably where the subject feels guilt as if the death occurred as a result of his or her hostile feelings or actions. One experience of loss and mourning requiring assimilation is a product of therapy itself. The reformulation commonly confronts patients with how their own past procedures have restricted and damaged their life so far. The appropriate recognition of this lost possibility is an important step on the road to change. More generally, therapy can reach beyond the defensive dulling of incomplete mourning. The termination of an emotionally powerful therapy relationship can be an emotional recapitulation of past losses which can be supported in ways allowing the revision of the previous restrictive modes. Here, the time limit of CAT, its intensity, and the direct focus on loss at termination which is recorded in the “goodbye letter” are all features which make it a suitable intervention for patients with problems in this area. On the other hand, the reformulation of the patient’s role procedures allows the recognition of specific relationship issues and general strategies which may have contributed to the incomplete assimilation of the loss. Some of the issues surrounding the negotiation of death, dying, and mourning are explored further from a CAT and Bakhtinian perspective in Kerr (1998b).

Trauma and Post-Traumatic Stress Disorders The interrelated concepts of stress and (psychological) trauma broadly conceived continue to assume greater importance in relation to mental disorders due variously to advances in understanding and documenting their role in etiology, the rapid advances made in neuroscience over recent decades documenting the effects of relational trauma, and also due to advances in their treatment using various still debated “brand‐name” treatment approaches, some incorporating adjuvant pharmacotherapy (see Adshead & Ferris, 2007; Chen, Gillespie, Zhao, Ren, & Maclean, 2018; Corrigan & Hull, 2018; Cozolino, 2014; Grand, 2013; Lane et al. 2015; Ogden & Fisher, 2015; Ross, 2009; Schenberg, 2018; Schnurr et al., 2007; Schore, 2012; Schwarz, Corrigan, Hull, & Raju, 2017; Shapiro & Forrest, 2016; Shea, 2018; Mithoefer, Grob, & Brewerton, 2016; Yakeley et al., 2016; Van der Kolk, 2014). It is

­CAT in Some Specific Conditions and Setting  177

noteworthy that developmental neglect, deprivation, and relational adversity have long been recognized as important contributory factors to mental disorder within the more psycho‐social literature (e.g., Bowlby, 1951, 1988; Brown & Harris, 1978; and see reviews by Barker et al., 2015; Grant & Lappin, 2017; James, 2018; Varese et al., 2012; Weich et al., 2009). Some would argue that the whole field of mental disorder could be reframed as essentially representing the effects of varieties of trauma ranging from the subtle or brief, to more protracted and ultimately “severe and complex” trauma, as well as the effects of either single or multiple later life incidents. Certainly the ubiquity of histories of trauma and, more broadly, maltreatment and relational adversity occurring in the background of virtually all psychiatric disorders raises huge questions not only about their conceptualization, but also as to whether unrecognized trauma may be frequently untreated, including in the context of talking therapies. Problematically, it is also recognized that the incidence and outcome of post‐traumatic disorders is also inextricably enmeshed with other essentially relational developmental and socio‐cultural factors, all of which influence the impact of trauma and the course of any treatment and its outcome. This group of disorders remains significantly and curiously the only one (properly) defined in classification systems in terms of specific causative, etiological factors rather than in terms of apparent clinical syndromes. Classification also continues problematically to evolve, again not always helpfully. In the recent DSM 5 system (APA, 2013), several ­varieties of disorder are defined, including “acute stress disorder,” a more controversial “persistent complex grief disorder” seen as distinct from more depressive disorders (also proposed in ICD11), and post‐traumatic stress disorder (PTSD). These categories in DSM5, however, show only incomplete concordance with the current ICD10 and proposed ICD11 systems (WHO, 2019). The DSM definition of PTSD includes, for example, notably disorder of cognition and emotion. A category of “complex trauma” in the impending ICD11 (WHO, 2019) will open up a whole, more carefully defined, although still problematic, area for research (see discussion in Sachser, Keller, & Goldbeck, 2017). The proposed definition of severe “complex trauma” is “A disorder which arises after exposure to stress or typically of an extreme or prolonged nature and from which escape is difficult or impossible. The disorder is characterised by the core symptoms of PTSD as well as the development of persistent and pervasive impairments in affective, self and relational functioning, including difficulties in emotion regulation, beliefs about oneself as diminished, defeated or worthless and difficulties in sustaining relationships.” This also implies likely problems with somatization, dissociation, and identity disturbance. These clearly overlap problematically, but not surprisingly given some of the preceding discussion, with concepts of personality and/or dissociative disorders, and indeed with many other mental disorders. Research in this field does, however, clearly support the paramount significance of psycho‐social (including developmental) and also cultural factors in the genesis of these and all ­serious  mental disorders, albeit in the possible ­context of temperamental variation in vulnerability. In terms of treatment, it appears that a range of apparently different approaches are effective (Benish, Imel, & Wampold, 2008). Common features would, broadly, include stabilization (including development of a sense of a safe or secure place), re‐attribution and emotional processing (by various means), re‐integration, and psycho‐social support and rehabilitation. Precisely which aspects of which approaches are most helpful in which cases remains to be determined, although certain key features appear clear. Complicating

178

CAT in Various Conditions and Contexts

factors which may include developmental and relational problems that not only increase vulnerability but also complicate therapy are increasingly recognized by proponents even of more cognitive‐behavioral‐type approaches such as traditional CBT or Eye Movement Desensitization Reprocessing (EMDR), certainly in treating anything more than isolated, single incident trauma such as a road traffic accident. More recently, approaches claiming to access deeper unconscious implicit traumatic memories at the level of the core self in the mid‐brain (see also discussion in Chapter  4) have claimed significant efficacy based on naturalistic clinical experience, and formal studies are being undertaken (see review by Corrigan & Hull, 2018). The extent to which these treatments can and should be helpfully embedded or “nested” within relationally based approaches such as CAT to improve outcomes and engagement remains to be formally demonstrated, although clinical experience suggests a secure ­relational framework is very likely to be helpful or indeed necessary (see Shea, 2018). Likewise, the extent to which CAT concepts such as RRs need to be further developed to accommodate these emerging understandings is uncertain. Treating psychological trauma appears increasingly to be a very considerable challenge for mental health services in ­general (Corrigan & Hull, 2015) and for models such as CAT. The category of PTSD is of some historical interest and importance given it was the first such disorder to be recognized and defined, unusually in psychiatry on the basis of clear etiological factors. PTSD usually develops weeks or longer after experiencing or witnessing highly threatening events. Individual susceptibility clearly plays a part; according to a review by Adshead and Ferris (2007), between 20 and 30% of individuals exposed to major disasters go on to develop PTSD. In theory this vulnerability could reflect both biological and psychological factors. As regards the latter, an individual’s reaction to fear and helplessness or proneness to shame are likely to reflect procedures developed earlier, perhaps in analogous circumstances, which it will be helpful to identify. The symptoms include ­anxious re‐living of the trauma, intrusive memories or images associated with it, vivid nightmares, avoidance of thoughts or places associated with the trauma, and alternations or combinations of emotional numbness, hyper‐vigilance, chronic anxiety, and depression. Where the trauma has been a single, brief, and unpredicted devastating event, hyperarousal, intrusive memories, and avoidance are marked. Sustained or repeated stress, such as may be experienced in warfare and in abusive relationships, where helplessness and irrational guilt are commonly experienced, leads to similar initial symptoms but these are likely to be dealt with, with incomplete success, by dissociation which in turn may damage relationships and self‐management and may lead to prolonged depression, anxiety, and substance abuse. The symptoms of PTSD may last for decades and in chronic cases are associated with neurological and neuro‐endocrine changes (Corrigan & Hull, 2018; NICE, 2018; Van der Kolk, 2014). Although the recent “rediscovery” of the neuro‐psychological consequences of trauma was prompted by work in the USA with Vietnam war veterans, it has become increasingly accepted that a repeated experience of childhood trauma and deprivation has a comparable, but more pervasive, damaging effect on the personality. This has come to be conceptualized as “complex” PTSD (Hermann, 1992), or as a “disorder of extreme stress not otherwise specified” (DESNOS) as categorized in DSM 5. As noted above, ICD11 will include a formal category of “complex trauma.” This emerging and powerful body of

­CAT in Some Specific Conditions and Setting  179

e­ vidence adds weight to the views of those who have historically advocated deficit/trauma theories of psychopathology. Brewin, Dalgleish, and Joseph (1996) have previously suggested that the features of PTSD can be explained in terms of two forms of memory, one automatically accessed in response to contextual cues and one verbally accessible, the former having the quality of re‐experiencing the traumatic event and the latter being open to successive editing. In the view of these authors, incomplete emotional processing is manifest in mood disorders and distortions of attention and memory, whereas premature inhibition of processing leads to memory impairment, dissociation, phobic states, and somatization. Psychological treatments for PTSD and trauma appear generally more effective than medication, but pharmacotherapy may also have a place and the two may be combined (see Mithoefer et al., 2016 and review by Schenberg, 2018). Systematic desensitization to cues or memories which have been avoided and cognitive restructuring methods are the common approaches to fear‐based PTSD, with the later addition of EMDR (eye‐movement desensitization and reprocessing) (Chen et al., 2018; Shapiro & Forrest, 2016). Further promising approaches to trauma treatment overall are being developed (see Frewen & Lanius, 2015), including some still being evaluated in more formal extended effectiveness studies. These include “Amygdala Depotentiation Therapy” (or “Havening”) (Ruden, 2011), Brain Spotting (Grand, 2013), sensorimotor psychotherapy (Ogden & Fisher, 2015), Comprehensive Resource Management (CRM) (Corrigan & Hull, 2018; Schwarz et al., 2017), or Deep Brain Reorienting (Corrigan, in press). Some further recent approaches include use of adjuvant medication such as MDMA or ketamine in conjunction with therapy (see Mithoefer et al., 2016; Schenberg, 2018), or even transcranial magnetic stimulation (Pradhan, Kluewer D’Amico, Makani, & Parikh, 2015). The exact contribution of these various modalities remains as yet to be fully evaluated. Where interpersonal issues, such as shame as well as fear, are an important factor, and where long‐term symptoms have become associated with pervasive personal and interpersonal problems, a more general therapeutic approach appears called for and it is here that CAT may have a part to play. At present there have been no systematic studies, although work with PTSD and trauma has been undertaken by an increasing number of several practitioners (see examples below). However, it should be noted that although efforts to prevent the development of PTSD by early counseling of those exposed to trauma are common, they are of uncertain effectiveness and may be harmful (Mayou, Ehlers, & Hobbs, 2000; NICE, 2018). Thus, early interventions (e.g., one session debriefing) has been found to be of uncertain value or unhelpful given a natural tendency for spontaneous improvement. Current NICE guidelines (NICE, 2018) advise against their use and suggest rather a policy of “watchful waiting” and follow‐ up as needed. In many cases it may be more important to mobilize existing personal and social support. On the international scale it can certainly be argued that counseling has been over‐sold. Summerfield (1999) is particularly critical of the sending of Western‐ trained counselors to devastated areas on the grounds that only local communities can offer culturally relevant ways of supporting their members. He suggests that practical and economic aid would be psychologically more supportive. Some of the broader philosophical, cultural, and clinical issues arising in the treatment of psychological trauma are ­considered by Bracken (2002), who is highly critical of much conventional psychiatric

180

CAT in Various Conditions and Contexts

thinking and practice, including its unthinking and inappropriate application in non‐ Western ­settings (Bracken, Giller, & Summerfield, 2016). The following two case histories of patients treated by Ceri Evans and Alison Jenaway demonstrate the potential of CAT in this area. Case Example: Richard (Therapist Ceri Evans) Richard was a man in his early 30s who had been referred by his GP to a traumatic stress clinic. He had been experiencing considerable problems in living since an episode 5 years previously when he had been threatened with a gun during a robbery in a pub where he had been manager. He was clearly suffering from PTSD as assessed clinically and by standard questionnaires. His symptoms included long 1–2 min “video-like,” highly distressing, intrusive re-experiencing of the episode when the gun had been held to his head and when he had feared he would be killed. In addition, he suffered from what were described as “mind rages” (precipitous and explosive outbursts), he had developed a serious drink problem and had become cut off socially and depressed. He reported symptoms of morbid arousal, including insomnia, irritability, and hypervigilance. These difficulties had resulted in the break-up of a previously stable relationship and in his losing his job. Richard himself was also able to link these difficulties with a history of childhood victimization and sexual abuse at the hands of a male neighbor from the ages of about 8–13 which he had previously “coped with.” His background also included childhood experience of a difficult and abusive relationship with an alcoholic father and an “absent” mother who was remembered as passive and powerless. In addition, he had had a bad experience of school where he felt lonely and isolated. Given the presence of complicating, pre-morbid personality factors, Richard was offered a 14-session course of CAT by the traumatic stress clinic. He engaged well and committed regularly to therapy. Early assessment sessions elucidated childhood coping strategies of cutting off and withdrawal as well as indulging in risk-taking behavior. He also expressed a sense of shame and guilt about the sexual abuse. Notable procedures which he identified in the Psychotherapy File (see Appendix 1) included the “trying to please” trap, the dilemma of “keeping feelings bottled up or risking making a mess” and “if I must then I will not,” as well as most of the dilemmas around behaviors with others. He also identified most of the unstable and difficult states of mind. These procedures and role enactments were rehearsed in the written and diagrammatic reformulations where the formative RR of “victimizing and threatening” in relation to “victimized and threatened” was noted, and subsequently a RRP of “in control, threatening, and cut-off.” It was this precarious control which had apparently been shattered by the more recent traumatic episode. This was also a role which was experienced by the therapist in session and required much attention. The work of therapy subsequently centered to a considerable extent around experiencing and communicating painful emotions, especially his childhood memories, without resorting to these defensive role enactments. Some work was also done on identifying triggers for his intrusive memories. However, most of the work focused on his earlier experiences and their consequences, which had the interesting effect of enabling him to work on later experiences and difficulties himself. He reported a rapid improvement in his social

­CAT in Some Specific Conditions and Setting  181

r­elations, alcohol consumption, and PTSD symptoms, although, interestingly, little of the work had focused on these explicitly. The therapist’s goodbye letter emphasized that future stress might cause him to revert to old role enactments and that this was something which, with the help of the tools of therapy, he would need to continue to work on. At follow-up after 3 months, he reported considerable improvement in his general wellbeing as well as in the specific symptoms he had presented with. In addition, he had a new partner and job and overall felt that he had made a “full recovery.” This clinical impression was confirmed by psychometric testing which showed remarkable improvements on all measures used. These included shifts on the Revised Impact of Events from 65 to 1, the Penn Inventory from 51 to 17 and the General Health Questionnaire from 7 to 1.

Case Example: Tamara (Therapist Alison Jenaway) Tamara was a 35-year-old lady who was referred with a 20-year history of chronic constipation. She found it almost impossible to go to the toilet when she felt the urge and had learned to hold on for as long as possible. This led eventually to a blocked bowel, extreme pain, and sickness and she needed admission to hospital for intensive treatment to clear the blockage. This was happening every few months and was disrupting her life. She had revealed to the physicians looking after her that she had been sexually abused from a young age and they were hopeful that psychotherapy could break this pattern. On meeting Tamara, and hearing her story, I was struck by how normal she seemed. How was this possible, when she had been repeatedly raped by her father, and other men, in the family home, while her mother turned a blind eye? Much of this abuse had taken place in the bathroom, and this meant that every time Tamar went to the bathroom, her traumatic memories were triggered and she had to get out as soon as possible. She also restricted food and fluids so that she did not have to enter the bathroom. This, and physical damage from the abuse, explained her constipation. Despite terrible neglect and abuse, Tamara had built a life for herself, with a loving relationship with her husband and two daughters, and work as a successful medical secretary. She also had a best friend, Jenny, who had known her since childhood and so knew everything about the trauma. She had survived by blocking out her feelings and making herself numb, most of the time. Her parents had separated when she was a teenager, and she was still in regular contact with her mother, although her father had since died. There was a cost to this blocking off though, as she rarely felt real or truly connected to herself or her feelings. She often felt as if she was just going through the motions and not really living her life. The blocking off also failed at times, as she had frequent nightmares and found it very difficult to stay asleep, she also had frequent vivid flashbacks to the memories of abuse. She often felt suicidal but had never acted on these thoughts. Tamara had been having counseling for several years and had built up a feeling of trust with the counselor, but felt that she needed a more active therapy to push her to talk about the traumatic experiences, which she had not been able to do so far in her counseling. To some extent, the counseling had provided the stabilization work needed in order for Tamara to be able to

182

CAT in Various Conditions and Contexts

Hoping for….. Perfectly loving, forever

Do too much for others, neglect myself, no sharing

Totally loved and safe

Appear strong and normal, look perfect, take care of others

Block off feelings Taken advantage of, stressed, exhausted, alone

Need to be numb restrict food and scratch myself

Overwhelmed with tears

Abusing

Rejecting

Abused, trapped, can’t get away

Rejected

Figure 9.2  SDR or “map” for Tamara.

access her traumatic memories; however, the early CAT work was essential in building the therapeutic relationship of trust between us. Her CAT diagram (Figure 9.2) showed the extreme abuse and neglect she had experienced as a child, and the ability to block this out in order to appear normal and keep others happy at all costs. She started to be able to use mindfulness as a way of tolerating the unbearable feelings triggered in the flashbacks and identified her dog as a real support to her in this (her only comfort as a child had been her much loved pet cat and so the comfort of animals was really powerful for her). Tamara struggled with creating positive resources in her imagination, as she had never felt truly safe, but we were able to use her hobby of running as an activity which made her feel calm and centered. She was also able to create a team of her counselor, her GP, and her friend Jenny to help us with the trauma processing work. Particular traumatic early memories were chosen to represent clusters of memories, as there were so many that it was not possible to target each one. At first, Tamara was not able to speak about her experiences, as she was too afraid and ashamed to describe what had happened to her. Initially she wrote about it on a piece of paper within the sessions, and later brought me a letter describing some of the experiences. Gradually she began to be able to talk about the traumas. One memory that we processed was focused on the abuse in the bathroom and this allowed her to feel more comfortable in her own bathroom and more able to listen to her

­CAT in Some Specific Conditions and Setting  183

body when she needed the toilet. Our sessions were interrupted at one point by her physical health problems, and she returned to therapy having had a gastrostomy tube inserted to help her take the laxatives she needed. This meant that she was free of her extreme physical pain and this made the trauma processing much easier. After many sessions, she had fewer flashbacks during the day and was more able to cope with them, eventually finding an imaginary way to escape from the abuse and seek comfort with Jenny, and later creating an imaginary metal door to shut out the memories. We kept four sessions of CAT to work toward ending and this was very difficult for her, as she still felt that she could not take care of herself or value herself on her own. Sticking to an ending was important, however, to show that I had confidence in her ability to manage alone. Tamara also had the option of going back to her previous counselor for ongoing support. At follow-up, Tamara reported a sense of being much more in touch with her feelings, which had been very painful at times, and more able to be assertive with others, particularly her husband. She had also broken off all contact with her mother and felt proud of this. She had returned to her private counselor for a while but had soon felt that she wanted to try and manage on her own two feet, so she had ended that work also. She continued to have problems with constipation, probably due to years of avoiding going to the toilet, but she felt more able to work with the necessary physical health treatment.

The Effects of Child Sexual Abuse The incidence of psychological trauma and of sexual abuse in childhood is higher in most psychiatric diagnostic groups than in the general population. It is particularly high in ­borderline‐type personality disorder where, in those genetically predisposed, it may be the common initial trigger for dissociation (see discussion in Gunderson, Herpertz, Skodol, Torgersen, & Zanarini, 2018; Livesley, 2018a; Reichborn‐Kjennerud et al., 2015). It is only in recent decades that the high rate of abuse has been acknowledged; discussions in the media served to make it something that could be talked about publicly and this seems to have enabled many people to recall and report experiences which had not been thought or talked about for many years. CAT is not primarily concerned with the (impossible) task of autobiographical reconstruction. But patients who recover or, as is more common, extend their recollections of childhood abuse during therapy need to be helped to make sense of and assimilate these memories. A major focus needs to be on disputing the almost universal irrational guilt suffered by victims of sexual abuse. The common forms of abuse are those involving family members, most often siblings and stepfathers, and those occurring in institutional settings. Within the family there is often associated violence toward the child and between the parents, often combined with evidence of personality disorder and substance abuse, all of which have damaging effects on the development of children. As Zanarini (2000) comments, sexual abuse may be “the childhood event most horrific to clinicians … it may not be so to patients. Rather, it may be emblematic of the ongoing chaos and insensitivity that they faced on a daily basis.” The effects of the abuse itself are more damaging where it involves

184

CAT in Various Conditions and Contexts

penetrative sex, is repeated and is accompanied by threats of, or actual, violence, but sexualization of an affectionate parent–child relationship and the blurring of generational and gender boundaries can also be a source of confusion and guilt. The psychotherapy of adult abuse survivors will usually be concerned with the overall distortions of their self‐management and relationship procedures. These are likely to take the form of the re‐enactment of abusive procedures toward self and others, sometimes but not always including repetitions in the form of a variety of abusive sexual practices, or to involve restrictive and avoidant procedures. The narrative reformulation of CAT can help the integration of the many survivors with partially dissociated Self states, and the ­diagrams are of particular value in preserving therapeutic relationships in the face of distrust. Pollock (2001) has edited a book in which the use of individual and group CAT to treat abuse survivors is described in detail, sometimes in combination with other methods such as “power mapping” (Hagan & Smail, 1997). He presents important contributions from his own work and that of other CAT therapists to the treatment of adult survivors of childhood abuse. In his own uncontrolled but comprehensively evaluated study of the treatment of 37 patients, he demonstrated reductions in scores on a wide range of measures. Repertory grid measures showed that after therapy survivors saw themselves as closer to their ideal self and their abusers as more like people who should feel guilty. The successful use of CAT in a group format for survivors of sexual abuse has also been reported (Calvert, Kellett, & Hagan, 2015). True or False Recollections of Abuse

After many decades in which memories of abuse were routinely interpreted as fantasy by psychoanalysts, the acknowledgment over recent decades that it was a common and real event led to a reversal of attitudes and to a general tendency for therapists to accept such memories as being at least based on actual experience. More recently, ­however, there has been a growing realization that this is not always so and, more importantly, that therapists can easily suggest, or can seem to offer validation of, false memories. To have an experience of abuse denied can be abusive, especially where threats and lies had accompanied the abuse, and in the past many patients suffered in this way. But it is also abusive for a parent or others to be falsely accused of having committed abuse. The fact that recovered memories are liable to surface during therapy and that some therapists had actively sought for (and indirectly suggested the presence of) such memories generated a passionate reaction and divided people, including professionals, into believers and non‐believers in the possible truth of recovered memories. The debate about “false memory syndrome” was therefore fueled and obscured by much pain and anger on both sides. It is now generally accepted that most but not all memories of abuse, even those recovered after periods of amnesia, are based on real experience; but that, in line with all the research on memory, what is recalled is a mental construction with a variable and often distorted resemblance to what occurred (Brandon, Boakes, Glaser, & Green, 1998; Offer, Kaiz, Howard, & Bennett, 2000). However, in the absence of corroboration, there is no way of distinguishing between true and false memories; in particular, the ­latter can be as detailed and vivid as the former. Where adults recall memories after decades of complete amnesia, where the memory refers to very early childhood and where elaborations such as accounts

­CAT in Some Specific Conditions and Setting  185

of satanic rituals are reported, the likelihood that the memory is a false construction is greater. Some of the broader, including ethical, implications arising around these issues are reviewed by De Prince, Allard, Oh, and Freyd (2004), while some of the more practical implications for therapists have been spelled out by the Royal College of Psychiatrists (Brandon et al., 1998) and the British Psychological Society (1995). Techniques involving hypnosis or powerful suggestion should be avoided, and the suggestive potential of detailed questioning should be borne in mind. It should be made clear to patients that all memory involves selection and reconstruction and that the truth or otherwise of uncorroborated memories cannot be established. Because false memories may be held with great conviction and because their effects on current family relationships can be devastating, responsible therapists will be careful to remain uncommitted about the truth of uncorroborated memories of childhood abuse. Elaborations of fantasy of the kind emphasized by Freud, distorted interpretations of innocent events, retrospective revisions based on later experiences, sociological changes influencing gender roles, unresolved psychological tensions in the family, and other factors may all be the source of partially or totally false recovered memories of abuse, and their relative weights and frequencies have not been established.

Somatization, “Somatoform Disorders,” and “Medically Unexplained Symptoms” This area has been historically challenging for models of psychotherapy, including famously the early attempts by Breuer and Freud (1895) to treat “hysteria.” Conceptualization, nomenclature, and treatment approaches have continued to change, not always helpfully. In the recent American DSM5 system (APA, 2013), a new broad, apparently dichotomous distinction is made on the basis solely of behavioral and symptomatic criteria, between so‐called “somatic symptom disorder” and “illness anxiety behaviour.” Concerns have been voiced that the former will prove to be over inclusive and the latter simply organically focused. Distinguishing possible psychological and/or physical causes in such presentations is typically difficult and fraught, involving as it does par excellence both sides of the mind–body interface and interactions—or all aspects of the Self. Typically, patients may easily feel that their symptoms and distress are not being taken seriously if psychological considerations are raised, even in terms of the possible contributory role of “stress.” Difficulty or “unwillingness” to consider psychological aspects of presenting problems may, however, constitute a core part of the problem itself. Somatic symptoms may occur in association with a wide range of other psychological problems such as anxiety and depression, “severe and complex” personality‐type disorders, and notably, consistent with these, in the context of developmental trauma and relational adversity. However, it is clear that psychological treatments have an important role to play in addressing this group of disorders (Koelen, Houtveen, Abasss, & Luyten, 2014). Patients with such problems also commonly present as so‐called “frequent attenders” in primary care where their difficulties may remain unresolved, to the frustration and demoralization of all concerned. From a CAT perspective, somatic symptoms may be understood in part to occur independently as manifestations of procedural problems,

186

CAT in Various Conditions and Contexts

notably internalized (possibly culturally related) “prohibitions” on the expression of anger or assertion, and associated submissive role ­procedures. One feature of the complex of procedures enacted in somatization is very ­commonly an inability to communicate anxious feelings, often in relation to an internalized role of feeling one “ought” to cope alone. It has been suggested that this inability may be partly constitutional and represent the complex of temperamental factors referred to as “alexithymia” or, literally, inability to put feelings into words (see Taylor, Bagby, & Parker, 1991). However, this inability may also reflect the difficulties in self‐reflection and self‐expression that individuals who have been subjected to childhood relational trauma, ­maltreatment, or adversity are known to experience. Such internal processes, often acting in concert with ongoing social or interpersonal situations, may produce chronic physiological changes and may cause or exacerbate psychosomatic “diseases.” These may in turn play a part in controlling interpersonal procedures, as when a depressed, submissive ­individual develops somatic disturbances which elicit care from others. In “somatoform” disorders, a full procedural analysis or “mapping” of the patient in relation to his or her formative and current relationships is therefore necessary and important (see also the case example of Susan, in this chapter). This should enable a non‐judgmental acknowledgment and understanding of how early RRs and subsequent RRPs may be anxiety related, but also show how their enactments may be unwittingly “self‐stressful” and possibly contribute to, or worsen, symptoms (it can be helpful to map this). Naturalistic clinical experience suggests that, in many instances, resolution or improvement of somatic symptoms will follow a typical trans‐diagnostic CAT approach. This may likely involve assistance on “aims” or “exits” directed at unhelpful RRPs (or TPPs) often involving communication and sharing of difficult emotions, and often experienced first within ­therapy. As discussed above, exclusive therapeutic focus in such cases on presenting symptoms (in some CBT‐type approaches) or on diagnostic labels (some more biomedical approaches) may be especially unhelpful and may actively exacerbate problems or provoke “resistance,” to the typically ongoing chagrin and frustration of all. The relational dynamics around these presentations may well also unfortunately provoke hostility, ­disparagement, or rejection from treating services, and here use of extended “contextual” CAT consultancy approaches, including possibly in reflective practice groups, may be helpful all round. These approaches all require further, more formal evaluation although they are consistent generically with a range of therapies for such problems. The successful trials of brief psychodynamic–interpersonal therapy for a range of somatoform disorders (Sattel, Lahmann, Guendel, & Guthrie, 2012) involving as a key element joint, psychological “re‐attribution” of symptoms, in our view address and modify these role enactments by means of a therapy which, as has been noted (Margison, 2000; Trevarthen, 2017), has much in common with CAT.

CAT and the Management of Medical Conditions A considerable proportion of patients with medical conditions do not adhere to their treatment regimes, even if they are given full explanations and support. Two conditions in which such failure has serious consequences and where the use of CAT has been evaluated are diabetes and asthma, in both of which there is some research support for the value of CAT in improving self‐management.

­CAT in Some Specific Conditions and Setting  187

Management of Insulin-Dependent Diabetes

Insulin‐dependent diabetes is a condition where modern techniques using regular ­monitoring of blood sugar levels and carefully spaced and adjusted injections of insulin, combined with keeping to a strict diet, can allow the majority of patients to avoid the serious complications of damage to eyes and kidneys, arterial disease, and peripheral neuritis. However, a sizeable proportion of patients develop these complications despite being fully educated and supported by diabetic nurses. Proper self‐care in insulin‐dependent diabetes is a tedious business and the effects of poor control are not immediately obvious, so it is not surprising that many patients take risks. Work by Fosbury, Bosley, Ryle, Sonksen, and Judd (1997) with CAT has demonstrated that the reasons for failing to adhere to diets, do blood tests, take appropriate doses of ­insulin, and so on are various and in no way specific to the condition. They are often manifestations of more general patterns of self‐management and are related to procedural ­patterns of which the patient is often largely unaware. The CAT approach is therefore ­particularly appropriate, reformulation allowing the “symptom” of poor self‐care to be set in the general procedural repertoire. CAT does not require the patient to submit to ­instructions—­an important point in that a passive resistance in relation to authority in general and the clinic staff in particular is one common pattern. Other procedures underlying poor management include depressive self‐neglect (which can extend to what amounts to slow suicide), eating disorders where, in the pursuit of weight control, omitting insulin can replace or supplement purging and vomiting, and resentment at having the disease expressed in denial or defiance. Fosbury et al. (1997) demonstrated benefits from CAT compared to nurse education in the reduction of HbA1 blood levels (an indication of the average blood sugar level over past weeks). There were no significant biochemical differences at the end of the 16‐week interventions, but 9 months later the HbA1 levels in the CAT group were significantly lower. It should be noted that these were long‐standing patients, few of whom had expressed an interest in counseling or therapy. This study suggests that early recognition of damaging self‐care and preventive CAT would be humanly and cost effective. Similar work replicating these approaches and confirming the effectiveness of CAT in routine clinical settings (e.g., in St Thomas’ Hospital, London) continues to be routinely undertaken (Stephanie Singham, personal communication). Management of Asthma

A broadly similar study relating to asthmatic patients’ failure to use suppressive inhalant medication as recommended was undertaken by Sarah Cluley et  al. (personal ­communication; and see Cluley & Cochrane, 2001). In a study of non‐compliance with inhaled steroid medication, in which a concealed microchip recorded the actual use of the inhaler, a group of patients with severe asthma was identified and those showing poor compliance were randomized between usual care and CAT: 14 of the 17 patients allocated to CAT completed a 16‐session therapy. Identified reciprocal role patterns were similar to those found in the diabetic study, notably, patterns of critical control to either crushed or rebellious, neglecting–neglected or ideal care fantasies. At 6‐month follow‐up there were significantly better measures of treatment compliance (p