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Memoirs, Myths and Movies: Using Books & Film in Cognitive Analytic Therapy

Jefferis, S., 2011. Memoirs, Myths and Movies: Using Books & Film in Cognitive Analytic Therapy. Reformulation, Summer, pp.29-33.

“Caris doesn’t have words for things, Stella thinks, as she pulls on her coat. She has tantrums because she can’t say what she means. Stella considers all the letters she writes to her mother, when Caris hasn’t written one thing down on paper. I’ve got words, she thinks, and she hasn’t” - Julia Darling, The Taxi Driver’s Daughter, 2003.

Introduction

How might CAT therapists use the cultural products of our time, such as film and literature, as therapeutic tools? CAT has always welcomed and encouraged creativity in therapy, and it pays particular attention to the importance of narrative, language and dialogue in making meaning. This article provides an introduction to thinking about the use of culturally available stories in therapy. I begin by considering the historical relationships between psychotherapy, literature and film; start to consider the relevance of stories to therapy; tentatively link these issues to CAT theory; and then describe a number of different ways in which stories can be used during CAT therapy, and consider some of the advantages and pitfalls of such a task. I want to suggest that stories can act as powerful “shared tools” in therapy, and that this often has to do with the possibilities they bring for externalising feeling, finding ways to articulate experiences or states that cannot otherwise be named, and enabling a shift to take place in the therapeutic relationship and the therapy dialogue through doing so.

In the interests of keeping a tight focus, only literature and film are discussed here, but many of the issues clearly apply with equal relevance to other creative forms: certainly television, drama and poetry, and arguably also visual art, music and performance. I have also decided not to address the therapeutic power of creating works (writing, making art, playing music etc.), because there is already a substantial literature on this (e.g. Bolton, 2004; Dalley, 2004). My interest here is in consumption of culturally available material as a catalyst for change. I use the term “stories” interchangeably with “books and film” through the article.

Psychotherapy and Literature

There has long been an element of competition and suspicion in the relationship between psychotherapy and literature, a “century-long tug of war between the [writer and the psychoanalyst] over the terrain of the human psyche” (Appignanesi, 2008). Writers considered the domain of the imagination, the mind, human behaviour and relationships, and “madness” to be their own sphere of operation. This is most of the terrain to which psychology now lays claim. This notion of “competing paradigms” implies that there are incommensurable “artistic” and “scientific” ways of describing the same phenomenon, echoing C. P. Snow’s “two cultures” of science and the humanities. There is a sense that you can have either the “stringency” of science or the “eloquence” of art but something is sacrificed in either.

We can perhaps see evidence for two kinds of reciprocal role relationships between psychotherapy and literature across the century. A first pair of roles is something like “special and dismissive” in relation to “inadequate and irrelevant”. This is often how literature has seen psychology, as dangerously reductive and sapping the richness of experience (e.g. see Appignanesi (2008) commenting on Simone de Beauvoir’s fictionalised description of psychoanalysis). Sometimes psychology has seen literature in this dismissive way too, especially when in its more scientistic mode where subjective and idiosyncratic experiences are devalued at the expense of the measureable and the universal (see Newnes, 2001). Freud himself was uncomfortable with the fact that his case histories read like short stories and lacked what he called the “serious stamp of science” (Phillips 2000).

However, there is also a contrasting set of roles along the lines of “magically insightful and providing” in relation to “admiring, idealising and consuming”. Psychoanalysis has often been in an “admiring” role in relation to literature, with analytic writers fascinated by and frequently drawing on literature, poetry and myth to support and elaborate their positions. Freud said he had obtained many of his fundamental insights from literature and he drew on literature throughout his own writing (cited in Phillips, 2000); some of his ideas became inextricably linked with the stories that inspired them (e.g. the Oedipus myth). As Adam Phillips notes (2000), when psychoanalysts write about literature there is an idealising edge, as if writers are “gifted” with insight in a way not accessible to the rest of us – or at least not without a lot of hard work in analysis. He notes that analysts have a “belief in poetry as a convincing, truthful, life-enhancing eloquence” and poets become “fantasy” figures of freedom and independence. Inherent here is the notion that creative writing carries some magical factor – that there are simply some things that can’t be captured in scientific terms or language. A linked quality is the idea that the richness of creative writing brings a “truth” and emotional resonance that cannot be attained through science. So while recognising the real psychological value that stories may bring, there is also a health warning to be heeded here about uncritical idealisation.

Psychoanalysis and Film

Psychoanalysis and cinema both came of age in the early Twentieth century, and have experienced a productive engagement over the decades and some degree of mutual fascination. Psychoanalytic theory (particularly the work of Jacques Lacan) has been put to use by film theorists wanting to understand the relationship between spectator and image (Murphy 2005). The idea here is that the film screen serves as a “mirror” through which the viewer can identify themselves as a whole or coherent self; this “completeness” is achieved through identification with a protagonist or image on screen. There would appear to be parallels here with the CAT idea, drawn from Vygotsky, that the self is socially formed. Lacanian critical theorist Slavoj Å½iÅ¾ek (Fiennes 2006) argues that “film does not give us what we desire, it shows us how to desire”, and the notion here that watching is actively constitutive of subjectivity would fit with the implication (which follows from CAT’s engagement with Vygotsky) that all our encounters with the cultural world, including film, contribute to the (relational) formation of self. Psychoanalytically-inclined film theorists have also been interested in the peculiar experience of film spectatorship and the way it has something in common with the experience of dreaming, as if films are somehow a public or collective representative of unconscious desires and fears (Å½iÅ¾ek, in Fiennes, 2006)

“Formulating” fiction

Much writing on fiction from a psychological or psychotherapeutic stance in the present day concerns itself with making psychological formulations of fictional characters, in seeking to illustrate a particular psychological model or phenomena (e.g. Gaynor 2005, Manners 2006). While this is one way of pursuing an engagement with stories, there may be a concern about reductionism here: “can the [psychologist] do to the artist what Keats thought Newton had done to the rainbow: ‘destroyed all the poetry...by reducing it to the prismatic colours’?” (Phillips, 2000). In CAT terms we might see it as a dilemma along the lines of “either we understand stories in psychological terms and spoil what is special about them, or we each stay in separate domains and miss out on what the other has to offer”. So the question arises of how to avoid such a split if wishing to use stories productively in therapy. A possible exit may be to see how stories can provoke exploration, imagination, speculation and questioning, as opposed to attempting to pin down fixed psychological meanings.

Stories and their relevance to psychological development.

Bruno Bettelheim, in “The Uses of Enchantment” (1976), describes the ways in which fairy tales can facilitate psychological development. He argues that fairy tales capture the conflicts and dilemmas faced during childhood (to do with, for instance, jealousy, violent impulses, cravings, self-esteem), and state them briefly, succinctly and pointedly enough that a child can come to grips with them. These developmental challenges can then become manageable, because they are externalised (being represented through characters and events); the indirect or metaphorical element allows the particular challenge to be approached and thought about, and the “unrealistic” nature of fairy tales allows this process to “flow” more smoothly than if the tale was a realist one. Stories have a number of other developmental functions, including developing play, curiosity and imagination (Adam Phillips, 2000, quotes Freud as considering creative writing as a continuation of, and substitute for, childhood play); learning about cultural norms and morality; and learning about emotions. Some of these strategies may be underdeveloped in people coming for help with psychological trouble later in life. Storytelling will have a relational meaning in itself, founded on, among other things, experiences of being read to as a child.

When reading and watching, a number of psychological processes are taking place at the same time. These include attending, listening and reflecting; making sense; structuring and finding order in a story (consider the discomfort involved when a straightforward structure cannot be found in a story, for instance in the films of David Lynch); distancing from reality (the “pleasure of escape into a parallel world” and the “ability to distance oneself from one’s own circumstances through seeing them from without” – Raymond Tallis, cited in Morrison 2008); and relating (a story is only a story through having a spectator or listener; and we often remember stories along with those people we experienced them with at the time). Many of these are similar to the activities we may hope to undertake through therapy.

What has it got to do with CAT?

There are several reasons for drawing attention to the relevance of stories to CAT. First, CAT employs narrative as a key tool of understanding and therapeutic change. The power of the Reformulation Letter largely comes from its narrative form, its status as a (particular type of) story. Mindful that it is a reformulation – there is already a story, a narrative by which the person understands their predicament – in CAT we develop that story and consider different ways of telling it. This fits with the notion that life is a narrative form – “we enter a stage which we did not design and we are already part of the action; each of us is a main character in his own drama, plays subordinate parts in the drama of others, and each drama constrains the others” (or in CAT terms we might say “is in dialogue with the others”) (MacIntyre, 2007: 213)
Second, creativity is encouraged in CAT, as seen in the frequent use of creative techniques such as imagination and visualisation work (Wilde McCormick, 2008), and in the potential for experiment and flexibility in what takes place in the session, rather than adherence to manualised or standardised techniques.

Third, these ideas would appear to fit with CAT theory, especially the Vygotskian and Bakhtinian elements. Stories can carry the social and cultural meanings of a particular time and place and thus be formative of the self; dialogue about stories can be a form of joint activity; stories potentially act as a shared tool for understanding. Narrative itself can be a catalyst for memory and learning: “we can leaf through a thousand National Geographic magazines and remember virtually nothing, because the information is not processed by us as story” (Gold 1990). Mikael Leiman’s integration of Bakhtinian ideas in to CAT theory is relevant here (Leiman 1994a, 1994b). Stories are abundant with imagery and rich language which may offer powerful “signs” which can mediate learning. They carry meaning of previous dialogues – for example, myths carry a long history of human experience within themselves, and Leiman (1994a) thinks it is this richness which gives them their power in psychotherapy to transform peoples’ experience and understanding of their own situation. Stories may “transform” the therapeutic dialogue by opening new possibilities for making meaning of the personal experiences brought by the client. Stories sometimes communicate something about the nature of personal experience which may be hard to attain by other means; the therapeutic moment when a word or a nickname (such as one from a story) is found to describe a particular state - when both client and therapist know that it’s the “right” description - can be a powerful one. Bakhtin himself was also, of course, a literary critic and theorist.

There is limited research evidence supporting the use of film and literature in therapy. In CAT, there is a helpful case discussion workshop report using literature, drama and song lyrics (Elia and Jenaway 2007). Beyond CAT, there are a number of single case studies (Androutsopoulou 2001; Christie & McGrath 1989; Wedding & Niemiec 2003), anecdotal discussions (Kurtz, 2004) and several books (Dwivedi, 1997; Hesley & Hesley, 2001; Roberts & Holmes, 1998) describing the use of film and literature as an adjunct to therapy, and some books using literature to explore psychological issues (Bettelheim, 1976; Gold, 1990).

With these issues in mind, then, I will go on to discuss the possibilities for using literature and film in CAT practice. Clearly many of these ideas are not exclusive to CAT and may be frequently found in other therapy approaches including narrative therapies. I want to emphasise that this is not intended as a fixed “recipe” of techniques – creativity in process as well as content is to be encouraged.

Therapeutic techniques for using books & films in CAT

Basic use of analogy and metaphor. Metaphor and analogy are already deeply embedded in therapy and the language we use (consider “traps, dilemmas and snags”), and most therapists use metaphor and analogy habitually, as they can be extremely helpful in explaining certain concepts and experiences to a client. Many therapists have a kind of personal store of useful metaphors, and using them often enlivens the therapy dialogue, given that it allows a shift away from abstract or conceptual language. Blenkiron (2005) provides a useful summary of this kind of practice as drawn from the CBT world.

Initiating a dialogue about stories can be done in a number of ways. Mostly this is activity which will be common sense to CAT therapists, building “scaffolding” to talk and think about one or more stories. Often clients will spontaneously bring examples of things they have seen or read. Therapists can start a dialogue with invitations such as...

Tell me about a favourite film or book;
Describe a story which you remember vividly, that you heard or read when you were a child
Describe something you have read or seen recently which moved you, or stuck in your mind…

Therapists can also bring examples of their own: “It sounds a bit like...” or “Have you come across the story of...?”. The dialogue can be developed by exploring what it was that spoke to the client about that particular character or story, with the aim of making connections with the emergent therapy issues. Sometimes, especially with familiar stories, care is needed to attend to what the person is bringing rather than to fit the therapist’s pre-existing interpretations of what a story might mean.

What was the most memorable or significant thing about the story?
Who did you identify with in the story?
What feelings did you notice?
What do you make of the way you were touched/moved/upset (etc.) by that part/character/event?

Sometimes, stories are recruited to reinforce existing patterns, and so it can be helpful to consider whether to “do something different” from the normal mode of watching or reading, with the aim of promoting self-reflection. For example, encouraging the person to play about with their identifications with characters as they watch or read; to pay particular attention to relationships or character rather than to plot; or any number of other possibilities relevant to the person. In this way a story can sometimes become a “third voice” in the conversation which can promote looking at familiar situations from a new angle.

Specific functions for films and books in CAT. Anonymised clinical examples are included in italics.

Developing a shared language - Words and ideas drawn from stories can form part of the ongoing dialogue to refer to specific states or dialogical positions. Rob had a harshly critical and violent father and his difficulties, in part, resulted from having great difficulty tolerating these memories. He had read Brian Keenan’s memoir (Keenan, 1993) of his time as a hostage in Lebanon. This book, Rob said, helped him to realise what a “prison” he was in while living with his father, and the “prison” became a metaphor within therapy for a state of “impotently angry and frightened”.
Developing the reformulation - Appealing to characters and stories can help to identify problematic procedures and reciprocal roles at an early stage of therapy. Marie had difficulty describing her relationship with others and the world, and seemed somewhat hopeless about therapy. Struggling somewhat to begin reformulating, I asked her to think about a story she had been moved by, or a character with whom she identified. The following week, she told me about the words to a song describing a sexual assault. She had not had such an experience herself, but identified with the feeling of being attacked and denied a voice by a threatening world, and with the protagonist’s inner strength and dignity in telling her story. We used this to develop reciprocal roles of “alienating-to-alienated” and “attacking-to-frightened survivor”; to discuss her wish to be recognised for her success in surviving; and to explore the (previously unspoken) relevance to the process of the therapy of my being a male therapist with a female client.
Validating experience - Through hearing about others who have survived adversity, clients can gain more of a sense of “solidarity” in not being alone in what they have been through; it also sometimes serves to “normalise” their experiences. “By attending to the cry of another, we articulate our own cries, frame them, contain them, and feel less stranded” (Morrisson, 2008). Donna, a CAT client whose main aim in therapy was to work through her experience of childhood sexual abuse, brought a book to therapy called “Out of the Dark” (Caine & Royston, 2004) , detailing the author’s own abusive experiences and mental health problems as an adult. Donna saw her ability to read the book as a sign that she was ready to deal with the abuse rather than shut it away at the back of her mind.
Safe approach to emotion and “core pain” - Sometimes a direct approach to the client’s own authentic feelings is too overwhelming or threatening to bear, or may have been successfully dissociated away from conscious awareness. If a reader or viewer connects with a character going through experiences that are close to home, it can provide a way of “externalising” feelings, and may allow a client enough safety to explore previously warded-off feelings about their own experiences. When reading “Out of the Dark”, Donna’s previously outwardly assured and confident manner in sessions changed. She became much more tearful and upset, and on exploring this it seemed she had begun to connect with the pain of the young girl who was abused in the book and, in turn, with her own feelings. This gave her the opportunity to recognise and express some of her real pain, which had been too frightening in the earlier sessions.
Developing the working alliance - People often (but not always) enjoy talking about films and books. Having this dialogue in itself can enhance the working alliance; for instance, finding common ground over a book or film with which both parties are familiar.
Harnessing imagination and developing exits - Once a connection with a character has been made, the story can be used to ask the question, what happens next? The character may overcome their difficulties or find some way of coping better with them, in which case this can lead to a discussion of what those exits were, and whether they are available to the client. More likely, however, is that the character’s situation can be a springboard for imaginative solutions: for instance, by asking, how else could the story have ended? Mark’s most commonly-experienced self state was “contemptuous-to-contemptible” – in particular, being harshly self-critical towards himself. One aim of therapy was to develop a more compassionate internal voice. He talked about the film “It’s a Wonderful Life” and the position of the main character, George, who is convinced that nothing he does makes any difference to anyone else. In the film, George’s guardian angel, Clarence, helps him to see the difference he does make in others’ lives. In therapy, the characters of George and Clarence were used to denote the “self-critical” and “compassionate” internal voices. Given that the magical appearance of a “saviour” was unattainable (and its possible association with an unhelpful admired-to-admiring self-state), Mark recognised that he could develop a new version of the “Clarence” role for himself: so, on recognising unwarranted self-criticism, he became able to ask, “What would Clarence say?”
Self-reflection - Positioning themselves as a character in the story may enhance the client’s ability to self-reflect. With people for whom one of the therapeutic tasks may be to step out of the rollercoaster of emotion and develop enough reflective capacity to see the process of interactions with others (who might be characterised as having “Preoccupied” attachment styles - see Jellema, 1999), using a story as an aid to self-reflection may be of some help. For instance, in a scene from a film, one may see sequential procedures and identify what is going on without being preoccupied with the personal sense of hurt, anger or whatever other strong feelings are present.

Putting these ideas together with the theory discussed earlier, we can see that the potential for using stories is probably at its greatest when the stories

emerge from dialogue (as elsewhere in CAT, beware imposing an interpretation)
are “co-created” through joint activity (where the therapist provides the scaffolding and then exploration of a story’s ideas take place together)
have personal meaning... (Leiman, 1994b, suggests that tools’ power to catalyse reflective activity depends on their potential for personal significance)
...or emotional significance (an affective link with the material is often the key, and distinguishes work with stories from traditional self-help material)
transform the dialogue of therapy

Considerations and pitfalls

Some notes of caution are appropriate. Therapists bring their own cultural experiences and assumptions, and talking about books and films is one of the infinite number of ways in which power differentials can operate. Much of the writing on psychotherapy and stories tends to reference canonical works of literature, but is also often a stage for a kind of cultural snobbery to be played out. Sensitivity may be required around individual learning styles, literacy, and what level of concentration the person can manage. The fact that stories are such powerful transmitters of culture also cuts both ways. Just because a story is fictional, it may not bring emotional “truth” – consider the idealised “Hollywood ending” where all problems are resolved and everyone lives happy ever after. Likewise, people may find books or films that seem to cheapen or oversimplify their experiences. There is some controversy (e.g. Addley, 2007) about the recent explosion in memoirs of childhood abuse and exploitation, or “misery lit”. These tend to be non-fiction written in novelistic form, and while I have certainly known clients gain valuable solidarity from reading these memoirs, the massive popularity of these books brings a potential edge of uncomfortable prurience and exploitation with it. We are all in particular reciprocal relationships with whatever stories we engage with, and their creators, and these can include unhelpful patterns. One client with a narcissistic personality structure whom I invited to think about films he had enjoyed, came back at the next session full of grandiose admiration for the director of a new film he had been to see. Although we missed it on that occasion, potentially this kind of experience offers an opportunity to discuss and understand the roles themselves.

Conclusions

In my experience, when these techniques work, they can bring all sorts of surprises into the therapy: books and films are so rich in potential meaning, it’s as if they can help us (as therapist and client) think laterally about problems and solutions. From my perspective as a Clinical Psychologist, while training, I gained a sense that the scientist-practitioner model left little room for any subjective sense of what it was actually like to have had certain experiences or problems. Of course we can only ever reach a partial understanding of another’s experience, but seeking out more personal, subjective accounts from literature seemed to me to give a renewing depth and richness to the ways we can learn to understand the kinds of life situations people come to us with. Working in this manner may also give us another way of bringing ourselves into the therapy as people; and challenges us to free up our own imaginative capabilities as therapists.

“I kept my mind on the film. It had been thrilling to be in the packed cinema with the other people, all sweating and sharing the same fear. It made me feel normal, just like everyone else, for an hour and a half: terror was something you put yourself through for fun, rather than something dangerous and dirty that you swept under the carpet at home.” - Angela Ashworth, Once in a House on Fire, 1998

Steve Jefferis is a Clinical Psychologist, and gained his CAT Practitioner qualification from the Northumberland, Tyne and Wear course in 2006. He currently works in an adult Community Mental Health Team in South Tyneside, and has recently begun to supervise Clinical Psychology trainees undertaking qualitative research projects on process aspects of CAT. steve.jefferis@ntw.nhs.uk

Thank you to Anna Jellema, Henrietta Batchelor, Caroline Dower and the NECAT network for encouragement, helpful comments and discussion on this topic.

References

Addley, E. (2007). “So Bad it’s Good”. The Guardian, June 15th 2007.

Androutsopoulou, A. (2001). Fiction as an aid to therapy: A narrative and family rationale for practice. Journal of Family Therapy, 23, 278-295.

Appignanesi Lisa (2008). “All in the Mind”. The Guardian, February 16th 2008.

Bettelheim, B. (1976). The Uses of Enchantment: The Meaning and Importance of Fairy Tales. London: Penguin.

Blenkiron, Paul (2005). Stories and Analogies in Cognitive Behaviour Therapy: A Clinical Review. Behavioural and Cognitive Psychotherapy, 33, 45-59

Bolton, G. (2004). Writing cures: an introductory handbook of writing in counselling and psychotherapy. London: Brunner-Routledge.

Caine, L. and Royston, R. (2004). Out of the Dark. London: Corgi.

Christie, M. and McGrath, M. (1989). Man who catch fly with chopstick accomplish anything. Film in Therapy – the Sequel. Australia and New Zealand Journal of Family Therapy, 10, 145-150.

Dalley, T. (ed) (2004). Art as Therapy: An Introduction to the Use of Art as a Therapeutic Technique. New Edition.. London: Routledge.

Dwivedi. K. N. (ed.) (1997) The Therapeutic Use of Stories. London: Routledge

Elia, I. and Jennaway, A. (2007). “’You’re Driving Me Insane’: Literature, Lyrics and Drama through CAT Eyes for Clients and Students”. Reformulation, 28, 43-44.

Fiennes, S. (Director) (2006). Slavoj Å½iÅ¾ek – The Pervert’s Guide to Cinema. UK: Channel 4 Television.

Gaynor, K. (2005). Inspiring Holden. The Psychologist, 18, 88-89

Gold, J. (1990). Read for Your Life: Literature as a Life Support System. Ontario: Fitzhenry & Whiteside.

Hesley, J. and Hesley, J. (2001). Rent Two Films and Let’s Talk in the Morning: Using Popular Movies in Psychotherapy (Second edition). Hoboken: Wiley.

Jellema, A. (1999). Cognitive Analytic Therapy: Developing its Theory and Practice via Attachment Theory. Clinical Psychology and Psychotherapy, 6, 16-28.

Keenan, B. (1993). An Evil Cradling. London: Vintage.

Kurtz, A. (2004). Introduction to Special Section: Novelists in conversation with psychologists. Psychology and Psychotherapy: Theory, Research and Practice, 77 (2), 141-144.

Leiman, M. (1994a). Joint Creation of Symbolic Tools in CAT. ACAT Newsletter, 3, 21-25.

Leiman, M. (1994b) The development of cognitive analytic therapy. International Journal of Short-Term Psychotherapy, 9, 67–82.

MacIntrye, A. (2007). After Virtue. Third Edition. London: Duckworth.

Manners, P. (2006). Frodo’s Journey. The Psychologist, 19, 98-99.

Morrisson, Blake (2008). The Reading Cure. The Guardian, January 5 2008.

Murphy, P. (2005). Psychoanalysis and Film Theory Part 1: ‘A New Kind of Mirror’. Kritikos, Volume 2 (February).

Newnes, C. (2001). On Evidence. Clinical Psychology, 1, 6-12.

Phillips, Adam (2000). Promises, Promises: Essays on Literature and Psychoanalysis. London: Faber and Faber

Roberts, G. & Holmes, J. (eds) (1998). Healing Stories: Narrative in Psychiatry and Psychotherapy. Oxford: OUP

Wedding, D. and Niemiec, R. (2003). The clinical use of films in psychotherapy. Journal of Clinical Psychology, 59, 207-215.

Wilde McCormick, E. (2008). Change for the Better: Self Help Through Practical Psychotherapy. Third Edition. London: Sage

Full Reference

Jefferis, S., 2011. Memoirs, Myths and Movies: Using Books & Film in Cognitive Analytic Therapy. Reformulation, Summer, pp.29-33.

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