Introducing Cognitive Analytic Therapy. Anthony Ryle
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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 cross‐cultural 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 & 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, 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, 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 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 non‐blaming 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.
The Development of Sequential Diagrammatic 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