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Untying the knots: relational states of mind in Cognitive Analytic Therapy?

Potter, S., 2004. Untying the knots: relational states of mind in Cognitive Analytic Therapy?. Reformulation, Spring, pp.14-21.

Untying the Knots: Relational States of Mind in Cognitive Analytic Therapy?

Introduction
In the last issue of Reformulation (Autumn 2003) Tony Ryle’s introduction of the States Description Procedure drew renewed attention to the part that changeable and problematic states of mind play in our therapeutic work. I think this is a welcome addition to the repertoire of client-friendly research tools in CAT and hopefully in due course it will tell us more about states, self states and their regulation in relation to complex mental health difficulties in particular and more generally about the challenging task, in our contemporary society, of maintaining a ‘governing’ and relationally open sense of self.

The spotlight on states raises some interesting questions of both CAT theory and technique. In this paper I try to evoke the subjective reality of states: these distinctive ways of feeling, thinking and relating which mediate all our experience. Some trainees report difficulty combining CAT’s tools of reciprocal roles and procedural sequences and I think the key to linking them is to keep in mind the subjective reality of states and the shared description of states from very early on in therapy. In this vein I offer some reflections on timing and tactics for the early mapping of relational states of mind. I want to develop a view that if we pay more attention to states as the ground upon which our CAT scaffolding is built, we can make better, combined use of both the more ‘dialogical’ emphasis of the reciprocal role idea and the more linear, aim directed emphasis of the procedural sequence idea - which might be judged more monological (see for example Leiman and Sutton in Hepple and Sutton 2004). My argument is that the essential goal of CAT is to give dialogical intensity, height and detail of perspective to problematic states of mind using the carefully combined analytic tools of reciprocal roles and procedural sequences. More than this I think an emphasis on the relation between a reflexive sense of self and states of mind, using CAT tools in this way, opens up a fuller formulation of the ways in which states of mind are procedurally and dialogically linked to social identities/status positions.

Where do states come from and where are they when they are gone?
All our clients, like all of us, have multiple states of mind and being. Where they may differ is in the strength and versatility of their reflexive sense of self in particular states and in moving between states. CAT takes a view that early narrow and abusive relational experiences can give rise to trauma-avoidant patterns of coping, dissociation from unmanageable emotions and consequent deficits in those feeling skills that could have contributed to better state regulation. In addition, teasing, unstable, smothering or abandoning patterns of ‘dialogue’ about self-experience lead to inadequate models for making meaning of experience and damage to a capacity for a reflexive, executive and assertive sense of self and identity. In CAT’s relational understanding of states, damaging and restrictive experience associated, for example, with borderline personality disorder persists so powerfully for the individual because it ‘is seen to be due to the individual’s capacity to exact reciprocation, by overt or covert means, and by the fact that, if such reciprocation is not forthcoming, the response will be a shift to another state rather than the revision of the procedural repertoire’ (Ryle, British Journal of Medical Psychology, 1995).

Let me evoke in prose form, for a moment, something of the reality of states.

Where do they come from? Where are they when they are gone? States can mediate our experience and come and go like headaches. They can be fleeting or chronically endured. States once fleetingly embraced are subsequently fragile when achieved or pined for helplessly. States can saturate, or haunt, or empower our sense of self and other. They can be dreadfully avoided as can the people, or persons, or memories of place and time that are associated with them. We can get stuck in them; be triggered by events into or out of them. We can set our freedom of will and consciousness against them and ride above them. We can lose ourselves in them. Like a house that becomes home for many years we can live in a particular state or cluster of states and take them for granted; making it, or assuming it, to be our character and our given life space. States can go but are never far away. We sense states such as sadness lurking somewhere off-stage. States are near absences: like storms on the horizon or bursts of laughter -only a shiver, or a smile away. We self- medicate to regulate them. We can eat our way into and out of them. We can induce states; co-produce states. They can be craftily, or nobly cultivated: like states of superiority, martyrdom, grace, joy or escape. They can be shared: like collusive states of endless bickering in a marriage. They can be mutually established and maintained like states of learning, fun, love or work. States are kept apart through dissociation or are kept hidden through pretence and performance but are never far away. Distressing states can have history and lineage across time and generations. States once chronically endured or traumatically induced in a previous generation are now dreadfully avoided or unexpectedly re-activated. States can be personified (drama queen), interpersonal (babes in the wood) or associated with objects (under the duvet state). They can be enacted in varying degrees of conscious and unconscious awareness. They can nest well or badly in social roles and identities. In sum, states comprise our repertoire of ways of being in the world and can be characterised as in and of a constant, multi-voiced ‘call and response’ dialogue in relation to each other and our sense of self in the world. The recognition, accurate description and re-orchestration of states are one of the key activities of CAT whether working with straightforward or more complex cases.

States of mind and being, within and between which we live our lives and find our sense of self, are real material products which have their history. Where once the state was the direct requirement of a social position it may now function in a relayed way two generations on as the unconscious stimulus to a set of self-management procedures e.g. the grandmother, once deferential as a shop assistant now has a grandson who is shy and timid. Our history of relational states within which we find ourselves is a history like any other and CAT’s tools are as much an aid to the social historian as they are to the therapist. There is much more to be explored about this interaction between state of mind and social identity and status position – a theme returned to at the end of this paper. One possibility is to make of CAT what Stephens (1996) calls a sociological psychology of the self. Linked to this might be a return to interesting themes originally raised by Ryle (1975) in his adoption of Kelly’s Personal Construct Theory which does allow the relational linking and drawing out of personal and social intentions and identities in the world through the personal construct method.

State of mind implies a kind of conceptual language use different from either reciprocal roles or dialogical and procedural sequences. States refer more directly to real subjective experience (Ryle and Kerr 2002) whereas reciprocal roles and procedural sequences are therapeutic devices for enabling: higher level self-other reflection, more effective self-management and interaction with other people and activities. States are often first described and repeatedly returned to by clients with the flavour of how they are experienced in a kind of monological, one dimensional, stuck language (I am fed up, depressed. I am in a state). States describe stasis within flows and force fields of movement.

I think of states as little knots of relational intelligence waiting to be loosened. Some clients will describe them in terms of behaviour; others in terms of the predominant feeling, others in terms of the role played for self or others. In CAT (Ryle and Kerr 2002) we talk ambiguously about states of being or states of mind and I am sure deep philosophical problems lurk behind this. States in CAT are the same as states as studied in detail by Horowitz (1998). For him we relate, think, feel and act differently in different states. Horowitz points out that emotions such as sadness are experienced differently in different states of mind. He is interested in the normal repertoire of states we all experience and in the emotional regulation of states, and describes them as over-modulated, well-modulated and under-modulated emotionally. Over-modulation might well fit the cut-off, bottled-up state; under-modulated describes those states which, for both Ryle and Horowitz, involve rapid shifts. We can shimmer (Horowitz) between states. Or we move between the active and passive end of the reciprocal relational roles that we use to make sense of a state (Ryle). For Horowitz states are associated with various hierarchies of self-schema, which are interrelated dynamically, and some states are dissociated from, or defended against, or integrated in varying ways and degrees. CAT sees states in similar ways but with much more emphasis on their relational origins and redeployment. CAT in particular conceptualises how the self can be hijacked or partially absorbed into a particular state. It has a specific theoretical construct of the self-state to describe the particular state and associated reciprocal role procedural sequences through which the self is experienced and from which other self-experience is dissociated or kept out of mind. Self-states refer to quite enduring and unconsciously enacted sub-systems of the social self, which are problematic. In his 1995 paper Ryle uses state and self-state interchangeably but has subsequently clarified a self-state as a theoretical construct which refers to a cluster of partially dissociated feelings, behaviours, assumptions and relational dispositions that can be tracked by a discrete set of reciprocal roles and procedures.

The way in which states can hijack or become the home of the self or the way in which a different sense of self is structured by different states raises the question of how states co-act through identities to influence our sense of self.

CAT tends to focus on the self-observing or mindful sense of self but I suggest sense of self comprises four capacities:

1. Self-reflection, mindfulness or self-observation
2. Self-assertion, action and agency
3. Self orchestration, management or an executive sense of self-involving a co-ordination and synchronisation among roles, states, social identities and allegiances.
4. Self-identity, narration and lineage and coherence.

For a thorough-going exploration of the issues of sense of self, identity and organisation see Yardley and Honess (1987), Stevens (1996), Giddens (1991). CAT is good at tracking damage to the capacity for self-reflection and through its TPP’s and written and diagrammatic reformulatory activity offers a problem-centred and solution-building model of mindfulness. As a target problem focus of therapy some will want assertion of self as the issue whilst for others self-regulation and orchestration will matter more. All our clients, and indeed all of us, have varying degrees of narcissistic damage and models such as CAT help empower our orchestrating, reflexive and assertive sense of self and in the process bring us more dialogically into the world and this can increase a sense of lineage, narrative and mutual identity. However this latter aspect of sense of self – self in the world, as it might be called - depends on us holding in mind that triangle of relational engagement and meaning-making between sense of self, states of mind and social identities and positions. From a developmental point of view we are born as bundled threads of relational intelligence waiting to interact and make ties. We get caught in knots and these are the states in which we experience ourselves as stuck. Our job is to loosen the knots and draw out the threads so that ties of meaning and communication can more easily be construed and reconstrued.

CAT’s self could be evocatively described as an embodied, mobile, micro social system of relational states of mind nesting in, or nested by, various social identity or status positions. We have to freeze the frame to compose the relational picture. For example someone’s preferred state of even-temperedness might be experienced -by him and others -as a fixity of character and a static feature. As we get to know him we may see a more dynamic picture and track out procedures of obligation and placation which maintain the static state of even-temperedness. This is turn might only be partly nested well, or at odds, with a social identity as a good father and a social status as a bus driver which in turn has social identity connotations as low paid. Warded off somewhere, but still unconsciously influential, might be another state which is dreadfully avoided, and culturally partially remembered, and psychologically partially dissociated such as memories of humiliation and exposure linked to a social status of unemployed and at the bottom of the heap in earlier life, among peers or in a previous generation. At the heart of this is a need to clarify the three way link between a reflexive sense of self and the continuous, many voiced, hard or easy, stable or unstable, attempts at the nesting of self in states of mind and social identities and positions.

Keeping state description in mind from early on
For me the very early and very shared description of diverse states of mind with the client is one of the keys to therapeutic engagement and success. Working to achieve a helpful, linked-up description of difficult states depends a lot on the timing and technique in the use of CAT tools. Given the majority of our members are trainees and the model of CAT is still developing we don’t talk nearly enough outside our supervision groups about technique. We all put the techniques and tools of CAT together in different ways and each setting, each client and each therapist will respond with different mixes of response. There isn’t yet, nor is there ever likely to be, a manualisation of CAT. Sometimes though, we seem to be talking to each other at cross-purposes because we learnt the CAT model during its cognitive, interpersonal or dialogic phase of evolution. If we talk more about technique with each other we may sustain more readily the rich integration of perspectives in psychotherapy that CAT promises.

“How do we enter into this process of discovery done with the client and avoid it being a process of discovery done for the client?” is my interest. Initially when learning CAT we may need to go away on our own and practice prose description and diagrammatic reformulation in a locked room but we ultimately need to develop the skill of doing this collaboratively with the client. We should have more skills training practising the shared development and use of diagrams on each other. Of course the therapist may go away and self-supervise using diagrams and writing out procedural sequences for self-clarification at any time. But this use of tools for self-supervision is a different activity to working together at jointly achieved and owned diagrams.

I want to focus on the technique for moving from naming and giving voice to problematic and helpful states right at the beginning of therapy to framing them in terms of reciprocal roles and procedural sequences. I tend to develop, bit by bit, one general overarching map (the big picture map) and several more specific TPP ‘linked’ maps from the very beginning of the first session jointly with the client. I describe this to the client as a process of “map-and-tell” ( as in CAT’s adoption of Bruner’s paradigmatic and narrative approaches to learning) where the early collaborative, trial-and-error, mapping-out of states and associated threads of procedural sequence as detailed below sets off a cycle of deeper rapport. The mapping helps the telling, which in turn enriches the mapping which in turn extends the telling. At some point this mapping and telling creates something on paper between us metaphorically akin to a half-completed jigsaw puzzle. There are enough pieces on the table for the bigger picture to come into view which then offers more confident depth of engagement and the opportunity for focusing down on one static detail where something feels stuck. I end reformulation with several sheets of paper linked together like one of those travel guide books that open up with simple location maps and text boxes attached.

I tend to hold off with the prose reformulation piece of writing in the style of one big letter. It is always a very telling thing to share but it can be too much, too direct and swamp the emerging sense of ‘me and the client’ together building a ‘map-and-tell’ dialogue. I think depth of rapport and height of perspective comes through the joint attachment of bits of prose description to the diagram. As described below I do bits of prose writing as and when it arises in the session, and expect the process and result to feel like the joint discovery of a big picture with more detailed pictures combined. If I do write out prose reformulation in letter format it is double-spaced with lots of invitations for amendment and clarification. I would choose it as a therapeutic aid to encouraging not just a fuller sense of self in the moment but also a fuller sense of lineage and history. Prose descriptions tend to heat things up and promote depth of engagement where mapping cools things down and offers height of perspective. If I choose to read part or all of a prose description out, I hope I am careful to keep in mind its power as an enactment magnet and to use this process selectively with the likely enactments in mind. This is not to say that heightened emotional engagement is not central to therapy but if CAT were to have a banner statement it might be ‘height of perspective should precede and accompany depth of feeling’. If someone presents with too much emotion and rapidly changing states then perspective and mapping is all the more important.

In the first minutes of the first therapy session the client will say something that takes us to the heart of a difficult state. They may describe it in terms of symptoms, or feared feelings and actions or something others are felt to be doing to them. My response is to offer a combination of engagement and explanation such as: “It sounds a bit like you are like this, or like that when such and such happens.” “What might help is if we mark out and name these different states or feelings or positions you can get into.” In one case we mapped the client’s five different states out on the back of what he called his five beer mats and moved them about the table like playing cards until we had some sense of how they linked to each other. I always add a self-reflecting state or the observing eye noting “well, is this state a bit like what we are doing now?” The client’s experience of having different feelings and getting into different states is usually very immediate and just naming it on paper helps prepare the work ahead. As I do this I am indeed thinking to myself in terms of reciprocal roles and procedural sequences but I am inclined not to put pen to paper in those terms until a stronger sense of the different states is shared. I want the client to be able to look back and see how the relational and procedural dimensions to different states emerged (diagram 1). If need be, I ask simple prompt questions: “how do you get into that state, or out of it?” which may point to procedural thinking. Or questions like: “who does that to you or who shares that state with you?” to open up towards seeing reciprocal role relationships. The history of someone’s emotional and relational experience gets shared in this way. Some states may involve obvious emotional control procedures such as alcohol use or bingeing. Asking which states belong together and which don’t is a bit like a step towards a rough and ready grid and it usually evokes links to people and states and which states are pulled by which people or shared with someone close.
As detailed in the work on competencies by Dawn Bennett (Bennett, 1998) an attitude of tentative and engaged curiosity is modelled and we may cycle between description, exploration and explanation. Like the good sociologist on a field trip to a micro social system you are keen to show genuine empathy and understanding and not influence too much the system until you have got to know it. You know you are going to go native a bit and you hope the client will join you to be his or her ‘sociologist’ for a while. I know it is helping if the explaining is being shared half and half between us (their higher level theories about themselves are valued as much as mine) and we are in what you might call a meaning-making relationship: equally curious, equally vulnerable to misunderstanding and equally open to correction. Sure enough there will be enactments that cut across this helpful educational alliance but they, for the moment, are another story. Practically I tend to use big sheets of paper, at least an A3 sheet, and if potential descriptions of procedural sequences emerge, I may write this out in a text box or on a yellow sticky so that the detail can be held alongside or apart from the big picture diagram.

You may ask, where do target problems and target problem procedures come in? As I say they are shaping up in my ‘self-supervisory’ mind but the timing and the way of entering into a CAT-informed explanation is a dilemma for me. I can either fall into a ‘doing the discovery for you’ teacher role or I miss the client’s moments that are most pregnant with self- discovery. I shadow their meaning-making with mine and if they describe a target problem or the large part of what we would call a procedural sequence or point to a reciprocal role I will add it to the diagram saying: “does it make sense to map what you are describing out like this?”. One of the clever things about CAT is that the language of procedural sequences and reciprocal role is so near to ordinary self-descriptive language.

Once procedures are beginning to be described I may turn the provisional yellow sticky text box that I have attached to the big picture map into a fresh more precise and detailed diagram on a sheet of A4 paper (number it and name it e.g. state of feeling hurt to state of feeling guilty; tracking how it changes as in diagram 2 below) and then in prose style track out the sequence in full but with the aim, assumption, behaviour and consequence headings arrowed across the top of the page. The whole sheet of paper is allocated for one target problem procedure with a mix of mapping and prose description included. This way there is space for evocative detail, for historical links and for clear notation as to where this belongs on the big picture map. It does the same work as a letter plus diagram but this way there is more scope for easy integration of any further reformulatory work in later sessions during the active phase of therapy. If engagement falters the timing of this focusing down on one procedure may not be right. We can move back to the general marking out of states. To and fro we may proceed in this way building a number of more detailed sequences and beginning to hold to the bigger picture. In the conventional multi-states diagram, cast in terms of a number of separate reciprocal roles, and with quite condensed indications of the reciprocal role procedures linking them, the therapist and client can get confused and it is harder to scale up and down from high level description to the more detailed picture. As the therapy progresses I have this idea of, week-by-week, taking a short walk around the combination of diagrams with the client. This re-articulates the big picture and makes links to more detailed description and allows us to decide where to focus and where change is taking place this week or not. It also models the self-observing reflective process both as a joint activity and an internalising activity of the client’s – an aspect of therapy which cannot be re-enforced enough.

As different states are being detailed, the relation between state and a wider sense of self becomes the issue. The often mystified, invisible or dissociated links between states can be made more tangible and traceable by the use of a procedural sequence. As in the example in diagram 2 the client’s mapping dialogue might go: I feel in a hurt state of mind and being. I can tell stories of how this hurt arises both in the past and the present. I can describe the behaviour, which arises in this hurt state such as crying. What I know I want is comfort, something to bring relief or someone to care. I can see in therapy that unconsciously or otherwise I need, desire or I aim to get comfort. I can tell I used to have to make a big fuss as a kid to get comfort. I assume only if I am really demanding of others will I have any chance of comfort. So I secretly indulge myself and binge on food or something. I end up either dreading a state of anxious exposure and rejection for being too demanding (a state I haven’t experienced for years) or of guilty badness for indulging in bingeing behaviour (see diagram 2). As the therapist we are using our CAT training to think along these sequential lines being ready to facilitate a higher-level perspective through mapping out the procedural sequence. The client’s story will rarely be sequentially told but will involve changing voices and perspectives. We are following the client’s story with compassion and interest. But also by shaping it, by offering scaffolding for formulating it more clearly and transparently. As I shall suggest in a minute we are also listening dialogically for the call and response of different voices in the course of this procedural sequence. But first we must stay with the starting point the client brings in the subjective description of states. They may talk about the feeling of the state, the aims in relation to moderating it or the behaviours associated with it. We scaffold their story to ourselves but not necessarily straight away with the client, using our special language of procedural sequences and reciprocal roles.

You could say that a lot of the work of tracking procedural sequences is linear and monological. For example Leiman describes traps and snags but not dilemmas as monological (Leiman and Sutton in Hepple and Sutton 2004) but the process, as I suggest below, is ripe with dialogical/reciprocal role moments. This is an important technical point for me that as the client and I map out a procedural sequence we will listen out metaphorically for a dialogical voice: attacking, rubbishing, overly -rescuing or the like. Such dialogical moments are most often triggered at the point of teasing out aims and assumptions for moderating emotionally unmanageable or unsustainable states. Most assumptions can be recast as dialogical voices and it is in this process that reciprocal roles can enrich the diagram as in diagram 3. Here I have tried to represent how this client is critical of herself for only thinking she can get care and comfort by being very demanding. If prompted she can see this as a demand from others calling her and saying “you’re useless”. The voice is both historical from childhood and actual both within her thoughts and in the way she elicits this from others or selectively views others acting in this way. This isn’t yet a complete diagram but the next step would be the emergence of reciprocal roles and the more conventional SDR or SSD, which are described in the literature (Ryle and Kerr 2002).

As we draw out the procedural sequences to give dimension and perspective to a state we should separate out aims - which are often benign and positive - such as seeking care or approval. Our aims are appeals to others or to objects in the world or to ourselves for something to mediate the state. I think aims should be on diagrams and teased out from assumptions into which they are often condensed. If my state is one of feeling hurt and my assumption is “only get care if demanding or indulging” (as in diagrams 2 and 3 above) then it is important to draw out the positive and healthy aspect of the aim from the assumption. It is often the assumption that is misplaced and putting the aims separately gives a visual cue to where to begin to construct exit procedures. Writing the procedural sequence in full in a provisional way and not tying it in reciprocally to another state or pole of the same state also offers an opening for joint work. It is back to the image of doing the jigsaw together. We are likely to see the big picture ahead of the client and it so tempting to fill the pieces in too quickly. It is when the client sees a dialogical link between the target problem procedure you have written out linked to a difficult state and, so to speak, puts it in the jigsaw next to a reciprocal role that you have got a self-building alliance going.

In Vygotskian terms, the CAT therapist is the bearer of more abstract language tools for exploring the client’s experience. But the client is not without his or her own theories. He or she already has higher-level abstractions about self and has his, or her, own scaffolding for mediating and making sense of their relationship with various states of mind. CAT’s approach to re-formulation is literally that - a new formulation. It is a delicate co-activity marrying the client’s existing and implicit systems of thought, action and meaning-making with the therapist’s helpful and unhelpful attempts at high-level description using CAT tools. What I am suggesting is that states are the platforms around which reciprocal roles and associated procedural sequences are tethered.

I have sought to describe the technical journey of discovery with clients, which begins with naming and mapping states and ends with the written and diagrammatic formulation of these in dialogically alive reciprocal roles and procedural sequences. I am suggesting we can sometimes go too quickly to working with the client in terms of reciprocal roles and procedural sequences before the client has made the educational step of actively seeing how these tools are put together as scaffolding for his or her emotional, cognitive and relational experience. The psychotherapy file and the tools of reformulation are complex tools, which can mystify as much as they recruit, motivate and explain. The client’s response to the list of states at the back of the psychotherapy file is often the most engaging starting point and only later do the traps, snags and dilemmas get scrutinised as confirmation or elaboration of what we have jointly named in the session together. I would turn the psychotherapy file back to front. But such tools can only act as assistants and there is no educational substitute for the live naming and telling of difficult states in the room, eye to eye, side by side, with the pen or pencil changing hands between client and therapist as they share in putting on paper a framework for the therapeutic experience.

States of mind and social identities
Some of the theoretical context to what I have described and how I have made my sense of the need to integrate dialogical and procedural sequence analysis with reciprocal role descriptions is described in recent conference presentations by Mikael Leiman and in the chapter jointly written by him with Laura Sutton in the excellent new book on Cognitive Analytic Therapy in Later Life which incidentally includes a clear description of the application of Vygotsky’s ideas to CAT. ( Hepple and Sutton 2004). In this vein another way to describe states of mind is that they are multiply voiced relational positions. Leiman’s use of position opens up an ambiguity which I would want to use to see how states of mind such as “fearfully striving” nest in with social status positions such as unpopular politician, dyslexic student or ageing football player. I have suggested that procedural sequences as TPP’s as relatively high level descriptions (the complexity and fullness of which are well described in Ryle 1995a p.29 ) are pregnant with dialogical links and may be used to draw out different themes from the same subjective experience of a state. According to CAT theory and practice a procedural sequence might be cast as a trap, snag or dilemma, a symptomatic procedure linked in a trapped way to a depressed state, a self-management procedure using drugs, or a relational procedure engaging others, other states and associated activities. What is less familiar in CAT is thinking of procedural sequences as linked to social role or status and functioning at the level of social identity procedures. An aim to get out of a particular state such as neglected and abandoned may be achieved only by assumptions associated with a particular social identity such as being the Good Samaritan and a social status and job as a psychotherapist. Many procedures which function as state regulation are also linked to a particular social role, status position, life-style group allegiance or a self-identity procedure.

Having placed more firmly in view the primary position of states of mind as a useful starting point for using CAT tools, I want to further link this to the reality of social identities (such as types of gendered identities or historical specific cultural identities) and social status positions. Just as we have multiple states of mind we have multiple social status positions and social identities. Social identities are bits of condensed social practice: beliefs, role expectations and role casting, codes of dress and behaviour, group allegiances. Social status positions give rise to or arise from social identities. They are distinct in our kind of society because for some of us social status (army officer) does more to determine our identity whilst for others social identity is the self-making work that it is hoped will determine status (member of a punk band). We should seek to frame CAT also as a model for psychosocial therapy, contextual reformulation or consciousness-raising and as a way of understanding power and oppression as it impinges on mental health and life difficulties more widely. We can use CAT to track how the emotionally charged role arising from a state interacts with a societally charged role arising from an identity or status position. For example how does a man in a hurt and wounded state enact a help-seeking procedure of seeking care without it clashing with a social identity role of silent, self-contained tough man? With clients I sometimes trace out procedural sequences that begin with a state and end through a series of aims, conflicting assumptions and interactions in a social identity. Such a sequence can then easily be elaborated in dialogical terms of reciprocal roles and sequences in the person’s life.

States nest well or badly in social roles, social identities and status positions. The relation between the two can be reciprocal, mutual, antagonistic or dissociated. They shape and distort each other. We all have subjective experience of being in the mood and in a role for something. We feel on song, all of a piece. In such states we feel motivated and focused. Things flow. We feel congruent (although we may have partially disassociated our state and self into that identity for the moment). Being in the mood for something points to the relational nature of the process. Equally we all have experience of being out of sorts or of feeling a lack of fluency or a clash between self, state and role. Interestingly it must be that from such dissonance in childhood and adolescence a sense of self and a capacity for self-governing arises. People who are well integrated into their social world and who have a taken for granted sense of coherence and identity may be hard-pressed to know what we mean by states and state shifts. State of mind and social identity can pull and push each other around. The social identity based activity - the thing we are in the mood for (like going on holiday or a Saturday night out ) can pull us into the mood/state. I get dragged along to Salsa dancing not in the mood but eventually the mood kicks in and once in the mood I take on the identity of the salsa dancer. The external activity pulls us into the mood and we get into the swing of things. The more diversity and democracy of social capital in our lives, the more chances we have for social identity and activity, the more chance we have for mediating and regulating emotional states and strengthening our sense of self. As long, that is, as we can stop forcing people to reciprocate our damaging states of mind independent of social status and identity positions.

Trauma-driven or talent-led states of partial dissociation
In the context of linking sense of self and states and social identities, I want to turn to the role of trauma in dreadfully avoided and fragilely achieved states, as well as chronically endured ones, and the role of talents of one kind or another in leading someone into a partly rewarding and partly escapist compromise state. CAT’s model follows and develops the understanding of dissociation as a response to trauma developed initially by Pierre Janet (see Herman 1992). For example I might be feeling hyper-aroused because of exposure, or feared re-exposure, to an abusive experience and dissociate into a cut-off state such as hiding under the duvet or being timid and withdrawn. In this sense dissociation is a movement away from something hyper-arousing and frightening and a movement into something protecting. In CAT terms it can be understood as a double movement between states - away from and towards. In addition I may only partially dissociate and shimmer in and out of hyper-arousal and manic attempts to find meaning and resolution to the traumatising state. To complicate things a bit more and underlying Ryle’s frequent distinctions between repression and dissociation I may be dissociating from a traumatic and abusive situation and repressing inner desires such as rage or confused sexual feelings. CAT by mapping and following this multi-voiced, multi procedural simultaneous call and response process can offer some hope of containment and change. Dissociation is also a social identity process.

If trauma and the resultant hyper-arousal in an abused state drives us into a dissociated state then a talent for something can be the siren voiced outlet that offers us escape or compensation. My interest in part is how the person with the talent in mind gets into it and is held by it. In contrast to those states of rage, anxiety, hurt and despair that are often the focus of therapeutic work, I have been increasingly interested in the process of being in the right or wrong state for highly self-reliant work such as scholarship, sports training and artistic activities. Partly this interests me because this self-motivated, often solo, in for the long haul, kind of achievement activity is not so easily held by a containing social role and status position. For some who put enormous effort into academic, sporting or musical activities there is a process akin to dissociation. A loss of self into the talent and achievement-led state. Such partially dissociated states take enormous effort or sacrifice to get into, can be addictive and can feel disturbing to come out from. For some the conscious effort to get absorbed by their talents may re-awaken memories of early trauma and dissociation.

Some who lose themselves so fully in talent-led activity seem to have excessive trust in a background self-environment that they can take for granted whilst they disappear into it for hours on end in work. The lessons to be gained from these creative, talent-led ‘dissociators’ need describing in more detail but our work of helping people with very fragile and unstable selves and states may be helped by knowing how talent-led absorption takes place psychologically. I think there is scope for interesting therapeutic work with those who combine reactions to early trauma by partially dissociating into compromise cut-off states (such as collecting stamps, playing the guitar or reading a book) and in the process discover the means to develop a life-long talent. These relational learning stories can equally be life-long compromise states. They are partially functional as a distancing from the hyper-arousal of trauma and the associated unmanageable feelings and partially functional as the nesting place for the assertion and cultivation of a self-reassuring talent. Difficulties arise when some new emotional or relational demand is made of the talent led dissociation and the person must perform or be exposed to scrutiny for the talent. Or after a life time of a career built around the sheltering value of the talent-led and trauma-driven dissociation the person finds that the associated social identity as a football player, successful academic or musician is coming to an end and no longer can function as a sheltering self-state.

Conclusion
CAT’s model offers a dialogue between a static, a holistic and a relational understanding of the self and the states of mind/being in which it ‘finds’ itself. A dialogue which continues between the subjectively experienced and ‘static’ me-in-the-moment; the assertive, orchestrating I-in-action; and, the state shifting, life spaces of this me in relation to a multi–voiced world of us- you- me-it. The state of mind is the subjectively real place to start and end. Just as states of mind can be endured, desired, fleetingly experienced or dreaded and avoided, so can social status and identity positions. How status, state and identity nest in each other and how, in dialogical terms, they call out for each other, or against each other, and in relation to other social status positions, identities and mental states, is the fertile ground for CAT reciprocal role and procedural sequence tools.

Contemporary mental and social well-being does depend on a higher level ability to associate ourselves in the right mood or state, in the right role with the right group. We do have to orchestrate ourselves, to morph and meld and at times be a chameleon. We have to do this without losing some over-arching sense of self, self-identity and narrative. Fifty or forty years ago still the big institutions: the army, the factory, the class order, the neighbourhood with a complete way of life and fixed gender identities on the surface and the clear and harsh markings of deviance and exclusion were known, taken for granted or resisted (Jenkins 1996) We now have to adjust to and find our freedom and dignity in what Giddens (1991) describes as a life politics of the self. We are continuously exposed to re-alignments of identity, state of mind and social role. It is not surprising we find a resonance in Bakhtin’s multi-vocal world. Alongside CAT’s primary focus of therapeutic interest on those complex or simple cases where damage to self-functioning is central, is the wider challenge that we now live in societies where a heightened capacity for a reflexive and relational sense of self is called for. An educational and sociological understanding of the exposed nature of self-experience these days: the saturation of self (Gergen) and the idea of a new and historical specific construction of self or life politics (Giddens) is something to which CAT can contribute.

CAT offers: the reciprocal role method for discovering how states are internalised and re-elicited and re-enacted. It can track the call and response of different voices within a state and between states. Bit by bit the sensitive therapeutic work of client and therapist discovers how the difficult states they experience are at one pole of a reciprocal role, the other pole of which they are dramatically engaged with by either enacting it to themselves or putting it out passively or actively for others to play.

CAT offers: the procedural sequence as a piece of educational scaffolding (Ryle, 1995 Bruner 1986) to enable the person to recognise the aim-directed or mis-directed detail of a state they are in. In the context of reciprocal roles it is used to help the person (who primarily experiences themselves as shifting unhelpfully and unwittingly from one state to another) to see the denied or forgotten, or hidden, sequence and thereby have more options to slow down, or opt out of, the damaging aspects of the state shifting.

Reciprocal roles and procedural sequences can be linked very neatly to a dialogical sequence approach. The challenge is to keep the CAT dialogical scaffolding tethered to the states of mind from which they arise and to which they return. The reflexive sense of self poetically described by William James (see Stephens 1996) in 1871 does involve both movement and stasis: ‘like a bird’s life, it seems to be an alternation of flights and perchings’.

Steve Potter

References

Giddens, A. (1991) Modernity and Self-Identity. Polity.

Ryle, A. (1975) Frames and Cages. London: Sussex University Press.

Ryle, A. & Kerr, I (2002) Introducing Cognitive Analytic Therapy: Principles and Practice London: Academic Press.
Ryle, A. (1995) Cognitive Analytic Therapy: Developments in Theory and Practice Wiley.
Gergen, K.J. (2000) The Saturated Self, Basic.

Ryle, A. (2003) The States Description Procedure, Reformulation Autumn 2003, Issue No 20 ACAT.

Leiman, M and Sutton, L in Hepple, J and Sutton, L (2004) Cognitive Analytic Therapy and Later Life, Brunner-Routledge.

Bruner (1986) Actual Minds, Possible Worlds, Harvard.

Lewis Herman, J (1992) Trauma and Recovery, Basic Books.

Yardley, K. & Honess, T. (1987 Self and Identity, Wiley

Horowitz, M.J. (1988) Cognitive Psychodynamics, Wiley.

Jenkins, R. (1996) Social Identity, Routledge.

Stevens, R. (1996) Understanding the Self, (1996) Sage

Steve Potter

Full Reference

Potter, S., 2004. Untying the knots: relational states of mind in Cognitive Analytic Therapy?. Reformulation, Spring, pp.14-21.

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States Characterisation Procedure (SCP) for supporting the reformulation of patients with borderline/dissociative features
Ryle, A., 2007. States Characterisation Procedure (SCP) for supporting the reformulation of patients with borderline/dissociative features. Reformulation, Winter, pp.9-11.

Letters to the Editors: Improve Your Reformulation and Contribute to Research - Try the States Description Procedure (SDP)
Ryle, T., 2003. Letters to the Editors: Improve Your Reformulation and Contribute to Research - Try the States Description Procedure (SDP). Reformulation, Spring, p.5.

The States Description Procedure
Ryle, T., 2003. The States Description Procedure. Reformulation, Autumn, pp.13-16.

Early Signs of Dialogical Sequences in CAT
Leiman, M., 1997. Early Signs of Dialogical Sequences in CAT. Reformulation, ACAT News Winter, p.x.

History and Use of the SDR
Ryle, A., 2003. History and Use of the SDR. Reformulation, Autumn, pp.18-21.

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Untying the knots: relational states of mind in Cognitive Analytic Therapy?

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