Introducing Cognitive Analytic Therapy. Anthony Ryle

Чтение книги онлайн.

СКАЧАТЬ 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 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 circumstances. 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 СКАЧАТЬ