Introducing Cognitive Analytic Therapy. Anthony Ryle
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nervous system (normally a “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 feed‐back 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, sign‐mediated, 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 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, “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,