A credit-card sized SDR and its use with a patient with limited language skills.

Fitzsimmons, M, 2000. A credit-card sized SDR and its use with a patient with limited language skills.. Reformulation, ACAT News Autumn, p.x.

Introduction

This letter discusses the rationale behind, and the creation of, a small credit-card sized SDR for a patient with limited language skills, although such a card could be useful for any patient. I felt that a copy of the SDR would be useful in this particular case as the patient used to refer to the SDR throughout her sessions, and that a discrete, "portable" version would help her jog her memory once therapy had ended when she found herself in difficult situations.

I found myself influenced by Vygotsky’s (1978) notions about the "zone of proximal development", that is "what the child does with the adult today, she will do on her own tomorrow", leading to the idea that "what the adult cannot let the child do or know today, the child cannot let herself do or know tomorrow (Ryle, 1990). These ideas seemed especially relevant with this patient who had very little self-reflective ability.

Combining CAT and Meichenbaum

With these thoughts in mind I also chose to include aspects of Meichenbaum (1975), by bringing out a change in the patient’s internal dialogue. This was effected through the use of role-play, centred around the SDR, and the current situations the patient found herself in. The aim was to help the patient identify, listen and challenge the ways she went about situations in her everyday life, which were keeping her "trap" and "snag" alive, through encouraging her to change the self-instruction statements she was so used to giving herself (such as screaming or shouting or ‘just giving in because I’m not good enough anyway’) to ones which she felt she would like to try, such as rehearsed self-statements like ‘I’m good enough; I no longer feel like a stupid piece of rubbish’. This process was begun with very simple self-statements, and simple role-play situations. I regularly gave her praise, which she found difficult to accept, because this was something she had not experienced before.

The patient was asked to monitor what was going through her mind before, during and after she rehearsed these new internal self-statements in her home life, and to observe whether her behaviour had altered because of how people reacted to her, or how she felt about herself. This enabled her to break away from her "maladaptive and upsetting thoughts to more adaptive self-talk" (Horton et al. 1989). Each week her confidence grew and she felt more relaxed. She began to use the new thoughts in situations besides those which had been rehearsed during the sessions. She began to recognise the procedures which kept her snag and trap alive, and was soon able to put a stop to them when she recognised they were happening. She also came to accept that the praise she was receiving was justified. She began to integrate her thoughts and behaviour in a more acceptable way.

This early work during the therapy could perhaps be thought of as "behavioural CAT", but the behavioural aspects were firmly focused on the main tool of the SDR, extended to include the exit SDR, introduced at an early stage.

The Patient’s Progression

Engaging the patient early on in an active therapy helped her to become more aware of the procedures which kept her snag and trap alive and allowed her to put into practice the new procedures with which she felt comfortable. This became noticeable when I had to take time off during the middle phase of the therapy, as she was able to cope and manage very well during this time. This would seem to agree with the thoughts of Rank and Firenzi (1925) who argue about the importance of "active therapy" in the "here and now". Alexander and French (1964) spoke about how it is possible to create change by concentrating on current issues, and by adopting a "flexible empirical approach", responding to the patient and seeing things in her own language.

The SDR and its Use

For this patient, the use of language seemed a particularly important issue; that is, whether I should use my language, or allow her to express herself with her own words. I chose to use the patient’s own language because a shared understanding of what is being said was needed, in the regular reformulation, the SDR and the goodbye letter. However I felt that for this patient it quickly became apparent that her language skills (or lack of) served as a secondary problem in her life. She frequently commented on it, putting herself down because of it and always forgetting her glasses, leaving me at first to believe that shoe could not read or write. Instead of teaching the patient a whole new set of language skills, I felt it was best in her case to bring out and enhance the skills she already had. Her very low self image and feelings of not being good enough and never being listened to led her to believe and accept that this perceived language deficit altered peoples’ view of her. She believed that ‘no one will listen to me because I don’t use posh words’. I felt that if I had set out to teach a new set of language skills at this stage it would have only confirmed her feelings that she was and is useless. However by drawing on the skills she had, this helped her regain and build strength and confidence for herself. She was able to experience for herself that she is not the hopeless person she had thought herself to be. By working on her own abilities I felt that this perhaps would help her view other areas of her life in a different way.

Throughout the therapy the SDR played an enormous and valuable role in helping the patient to move forward. This is why I decided to place an exit diagram in green linked to it. I photocopied many of them and each week she rated how she had been on the actual sheet. She would indicate how she felt in relation to the trap and snag and how she felt in relation to her exits. I felt throughout the therapy her confidence grow in a two-fold way. As she was breaking down her old patterns and recognising them she was also giving herself encouragement to elaborate on her own language skills, which although were limited in terms of her vocabulary, were quite rich in metaphor and imagery, for example, ‘I now feel like the good seed from a bad apple’ and ‘I feel like a snake that has shed its skin.’ Because the SDR was so important in helping the patient get to her new self I thought of the idea of making a credit-card-sized version for her to carry around as a support, again using her own words, so reminding her that she can continue, and that she is a worthwhile person. I look upon it as a sort of transitional object, small enough to be inconspicuous and large enough to read and jog her memory.

Technical Explanation of the Card

The process of creating the card was quite simple. I used a desktop publishing package - "PagePlus" - to position the text on the page, sized to twice the size of a credit card. DTP packages allow you to specify exact sizes, and let you position text exactly on the page. Colour was an important part of the SDR, so I re-used the same colours for the smaller version. Once the cards were printed a high-street printshop laminated them. The total cost is around £2 per card.

The card is double sided, and folded in half.

Michele Fitzsimmons

Full Reference

Fitzsimmons, M, 2000. A credit-card sized SDR and its use with a patient with limited language skills.. Reformulation, ACAT News Autumn, p.x.

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