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To Boldy Go... A View of CAT After 15 Years

Dunn, M., 2002. To Boldy Go... A View of CAT After 15 Years. Reformulation, Spring, pp.5-6.

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Dear CATs,

Here is my attempt to reflect on some aspects of our situation as they seem to me. We have been working together now for nearly 15 years and perhaps this is a good point at which to write this reformulation. It is neither the truth, nor the whole truth, in fact it may be completely wrong but maybe it will provoke a response or two.

Where will CAT be in 10 years time?

Organisationally:

It is likely that the organisation will increase in size as more and more mental health service providers in both public and private sectors are seduced by the technology and containment of CAT. Like CBT, solution focussed therapy and other similar treatments, those who work in stressing, depriving and unsupporting environments will gravitate towards therapies which contain therapists’ anxieties by clearly indicating what they should be doing towards a result (it’s session 4 – reformulate). Government pressure will also push therapists towards not just research proven therapies but towards easily auditable therapies which are time limited and therefore cost contained (if an RCT was published demonstrating the clear effectiveness of 5x per week psychoanalysis the government would still not provide it). CAT and other similar problem focussed interpersonal therapies will probably win out because the punters generally like them (even CBT is having to become consumer friendly).

With increased size and world presence of ACAT will come increased bureaucracy, the pursuit of standards (and standard training and practice products), and the harassment and persecution of deviations from theory and heretical practices. How the organisation can support and encourage creative deviations and adaptations that appear heretical should be an important issue. This is generally what splits organisations; such stretching can only be tolerated in a loose and giving (forgiving) organisational structure. The tighter the garment the more likely it is to split. However splitting and resulting choice options may be a very healthy outcome if war can be avoided (cf Swift’s big enders and little enders). Having a Big Brother is great if he is interested in encouraging your development and able to defend you against attack by other bullies but Big Brother usually becomes overly interested in interfering in how you run your own affairs. And so you split from the family….

Theory:

CAT theory has probably already passed beyond most CAT therapists’ understanding without providing the peace that passeth all understanding. Most are, I would guess, to a certain extent anxious that while they may have a vague grasp of Vygotsky, Bakhtin, Leiman and semiotics, they do not understand how these ideas work in practice and some may not care (or feel guilty). Is it OK to do CAT without these ideas? After all, CBT therapists are doing good work without these ideas. Here I’m drawing parallels with being able to drive without knowing how the engine really works or to garden without studying biology. Most people familiar with an area can draw a map to the town centre for a passing motorist, you don’t need to be a cartographer. So what can cartographers teach us about drawing the map to the town centre? Maybe we don’t have to feel guilty…

While CAT has spent much sound effort to win the argument about borderline and narcissistic personality structures there are many other areas of the human personality which remain untheorised or under-theorised in CAT. A brief list might include the following: all the other personality disorders, many ordinary neurotic problems, psychotic states and phenomena, psychopathic states and unrelatedness, sexual response and relatedness, pair and group roles and processes eg. destructive envy, group dynamic phenomena and collective roles, a more thorough examination of the phenomena of the unconscious (not just the preconscious) and the mechanisms of forgetting or what seems like motivated not remembering. There is a lot of work to do applying CAT theory to these areas.

At the same time the neurobiological revolution will be with us over the next 30 years. First fruits are already arriving of the new, almost real-time scanning of brain activity. The information that this provides for example about the architecture underlying consciousness, the way the mainly cognitive cortex interacts with the limbic affect systems will begin to inform and guide the choice and effectiveness of interventions. For example there may be no point in arguing with the patient’s cortex about a core belief when the limbic system is indicating an associated affect in need of expression. Another example would be the neural net linked to the cingulate gyrus that seems to turn adaptive rewiring on and off depending on circumstances and the therapist may be wasting her time if the circumstances are not right. What those circumstances are will soon become much clearer. CAT like every other therapy will need to change and accommodate this new knowledge. We may live in a world of social signs being exchanged but on the receiving and transmitting ends the signs provoke complex cognitive, affective and physiological responses in brains which will become much better understood.

On a more practical level theory needs to address aims and exits more fully. CAT can be described as a theory based in pathology, describing what went wrong in the early years and how adaptations to dysfunctional family cultures leads to problems in a more neutral real world. The aim or ‘cure’ is seen to lie in increased awareness towards more effective self-management, strengthening the ego-pilot who then manages the impulses of the unruly crew in a better way. Many other therapies, often stemming from the human potential movement, theorise health rather than pathology, and it seems to me that this is something that CAT should make an effort to consider. For every damaging or restricting reciprocal role leading to pathological behaviour we can define without too much difficulty a nurturing and expanding reciprocal role leading to thriving behaviours exemplified below:

Pathological / Harming RRs   Thriving / Reparative RRs
Admiring -- Admired                    Validating -- Validated
Criticising -- Criticised                  Appreciating -- Appreciated
Abandoning -- Abandoned            Holding -- Held
Rejecting -- Rejected                     Accepting -- Accepted
Abusing -- Abused                         Nonthreatening -- Unthreatened
Neglecting -- Neglected                 Caring -- Cared for
Demanding -- Striving                    Permitting -- Relaxed
Giving in -- Omnipotent                Limiting -- Limited

Patients do not find it difficult to articulate the reparative experiences they need and long for. At any point one can ask a patient "in this situation you are describing what would an ideal mother/father have said or done?" It is perhaps inadequate to think that they need to mourn the loss of what they never got and make do with the small amount of genuine care and attention that can be provided to them in a brief therapy. Armed with a greater sense of what their needs might be, a ‘thriving map’, a patient would be in a much better position to not repeat the past. It is also worth considering that a therapist should be able to provide a more clearly defined and reparative experience in the room to the patient that directly addresses their pathological map by moving from a neutral role post reformulation to enact overtly and consciously the implied reparative roles.

Practice:

The previous paragraph has taken us on into practice issues for the future. CAT will leak out into all forms and all arenas over the coming years. Reliable and repeatable forms need to be developed for couple counselling and group therapy, management consultancy and family therapy. Courage and a willingness to put the results in the public domain are all that is required. (I am talking to myself here as I ran a group for borderlines the year before last and still have not made time to write it up!) I suspect that written reformulations will begin to disappear other than as a training requirement – I myself have now written over 200 and could quite happily never write another until the day I die! Whereas maps will always be necessary (and convenient). CAT will be developed over different lengths of duration not just the standard 8, 16 and 24 but in bigger and smaller quantities. I know there are therapists out there doing open ended CAT and at more than one session per week – I confess, I am one of them. Where time and money allow there is no need for restrictions though contracts should always be open to renegotiation. An interesting question might be "Does regression or unhelpful dependency occur in long term CAT?" which provokes the next question "does unhelpful dependency on SDRs occur in CAT?" and so on…

One symptom to watch out for in the future, and I am feeling that I am suffering from it myself, is what I call relational exhaustion. After 15 years I have seen over 500 patients, that is 500 intense emotional connections, 500 personalities reduced to SDRs, 500 goodbyes-losses. Non therapists may not have more than a dozen close relationships in their whole life. I can see that psychoanalysts may find it easier by taking up the position of not knowing, not working quite so hard and seeing a lot less patients. I often feel that I’ll have to give up CAT to rediscover some mystery and magic about human beings. The unrelenting awfulness of the human condition expressed in the consulting room requires a buddhist detachment and compassion to cope with it over any extended period of time. In our supervision-intervision group recently the group fantasy was of running a quiet flower shop! I cope by processing it into poetry. What do you do?

Mark Dunn

Full Reference

Dunn, M., 2002. To Boldy Go... A View of CAT After 15 Years. Reformulation, Spring, pp.5-6.

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To Boldy Go... A View of CAT After 15 Years
Dunn, M., 2002. To Boldy Go... A View of CAT After 15 Years. Reformulation, Spring, pp.5-6.