Introducing Cognitive Analytic Therapy. Anthony Ryle

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СКАЧАТЬ 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 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 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 long‐term 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 longer‐term, 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 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 СКАЧАТЬ