Memories from a pre-CAT Time

Mikael Leiman, 2018. Memories from a pre-CAT Time. Reformulation, Summer 2018, pp.16-17.

Meeting Tony Ryle in July 1983 at the 14th Meeting of the Society for Psychotherapy Research in Sheffield was for me a life changing event. It determined my professional career for the next three decades. The career options, in turn, affected many important choices, for instance our move to a peripheral area 300 miles from the capital in the early 1990s.

After the meeting, Tony sent me his recent book on psychotherapy integration that introduced the Procedural Sequence Model. Although I was trained in cognitive psychotherapy, the book was not easy reading. My way of trying to make sense of its message was to relate it to Vygotsky’s cultural-historical activity theory. There was only one common, and quite abstract, strand and that was the understanding of action as a temporal sequential phenomenon. We corresponded on the topic and in his spontaneous way Tony suggested that I come to London to study what he was doing in clinical practice.

From mid-March to mid-July in 1984 I stayed at the Nurses Home of Guy’s trying get a more practical understanding what brief therapy was about. I participated in two supervision groups at Munro Clinic. In addition, Tony invited me to participate to all group supervision sessions and clinical consultations he was running at South Western and Tooting Bec hospitals. Both were closed in the 1990s, but I have a vivid memory of the murky corridors, the yellowish painting of the walls, and bubbling sounds of warm water pipes that were running near the ceiling. The range of consultation groups was quite wide, including a day hospital staff meetings, groups of CPNs, registrars, and psychotherapists.

In consultation groups, Tony helped the participants by formulating the patients’ problems, based on the free account of the consultee. What struck me in these reformulations, was the lack of any reference to the PSM. When appropriate, Tony used dilemmas, snags, and traps to describe the patient’s recurring problematic action patterns. Quite often he focussed on the reciprocal role that the patient invited the professional to play. He also used the concept of projective identification to articulate the patient’s unconscious and split-off inducement, which was reflected in the counter transference feelings and response tendencies. In day hospital settings, such counter transferences were also played out by the staff group fractions.

In such formulations, Tony relied on the understanding of projective identification as unconscious communication. Much later, in his 1997 Borderline book this understanding was formulated as reciprocal and identifying counter-transference. In the original, Kleinian sense, parts of self are projected into the recipient who feels the impact as an urge to enact the patient’s projection. Self-other boundary is blurred or non-existing. While receiving the projection, the therapist gains unique understanding of the patient’s disavowed experience. By containing this experience, or by the identifying counter-transference, the therapist can help the patient to tolerate and eventually manage the unmanageable feeling.

I did not know Melanie Klein’s work at all, nor the writings of Winnicott, Fairbairn, and Bion. I did know about transference, because in Finland at that time the classical Freudian psychoanalysis was the standard mode of understanding complex clients. It was quite impressive to observe how Tony helped the staff by clarifying the subtle transference enactments that he recognised in the accounts of treatment situations.
Toward the end of my stay I was convinced that this mode of brief integrative psychotherapy was just what the Finnish public mental health services needed. Together with Tony, I wrote a two-year psychotherapy training programme that also involved a research component of the individual outcomes of the training therapies. Tony’s paper “Some measures of goal attainment in focussed integrated active psychotherapy” served as the model design of the study. Tony was forty years ahead of his time, when he developed this methodology in the 1970s. At the age of personal medicine, this should be the main methodological approach to study the effectiveness of psychotherapy instead of the RCTs.

But how to train psychotherapists with the knowledge base I had at the time? Tony’s PSM book presented an abstract explanatory model for understanding problematic action patterns, but it had not enough flesh to help therapists work with the variation presented by an unselected group of often very complex patients with chronic problems. In those days, our mental health centres accepted client self-referral.

Having seen how important part the psychoanalytic object theory played in Tony’s supervision I decided to prepare myself by appropriating as much as possible during the one-year preparatory period, starting with Klein’s three-volume collected papers. I visited Tony quite frequently in 1985 and participated in his supervision groups at Munro Clinic. Tony was genuinely astonished by my Kleinian studies. He believed that his book and the revised concept of reciprocal role procedures that he had presented in his most recent paper were enough to teach the underlying theory. It is as if he had forgotten how profoundly he knew the British object relations theory, being able to use its resources in reformulating patients’ individual experiences.

Tony was concerned that I would get enchanted by the Kleinian habit of very early interpretations, including transference interpretations, not realizing that it was exactly what he was doing in reformulations. The only, albeit a very important difference was the interactive process by which the reformulation was achieved. The dyad grids, the psychotherapy file, and the Personal Sources Questionnaire were tools that structured the client’s self-perception and the descriptive tools of dilemmas, snags, and traps kept the formulation in the current range of client’s conscious awareness, or in the client’s zone of proximal development.

I thought that Tony’s worry was not warranted and still think that it is worth wile to study the psychoanalytic origins of CAT. A selection of Klein’s, Fairbairn’s, and Winnicott’s papers is currently an important part in our CAT training programmes. In my own clinical work, I found Klein’s ideas of paranoid-schizoid and depressive positions extremely helpful in understanding the fluctuating and dissociative experiencing of borderline patients. I think that without Fairbairn’s account of the coping strategies of schizoid patients I had not been able to understand and endure some clients’ dismissive and disparaging attitude to anything happening to them or what happened in the therapy. And finally, without Winnicott’s revolutionary view of transitional phenomena I would not have realized the fundamental role of signs in mediating psychic actions. But that is another story.

Full Reference

Mikael Leiman, 2018. Memories from a pre-CAT Time. Reformulation, Summer 2018, pp.16-17.

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Pragmatism: from Psychoanalysis to CAT
Professor Michael Jacobs, 2018. Pragmatism: from Psychoanalysis to CAT. Reformulation, Summer 2018, p.27.

The Genius of Tony Ryle – Past, Present and Future
Anna Jellema, 2018. The Genius of Tony Ryle – Past, Present and Future. Reformulation, Summer 2018, pp.5-8.

Fond Memories Of Someone We Were Lucky To Have Met
Marisa Poggioli and Cristina Fiorani, 2018. Fond Memories Of Someone We Were Lucky To Have Met. Reformulation, Summer 2018, p.26.

Tony Ryle Briefly Interviewed by Mark Dunn
Dunn, M. and Ryle, A., 1993. Tony Ryle Briefly Interviewed by Mark Dunn. Reformulation, ACAT News Autumn, p.x.

Letter to the Editors
Anonymous, 2009. Letter to the Editors. Reformulation, Winter, p.6.

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Memories from a pre-CAT Time

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