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Aims and Exits from Self-Defeating Procedures

Toye, J., 2009. Aims and Exits from Self-Defeating Procedures. Reformulation, Summer, pp.26-29.

This article arises from the experience of working with CAT practitioner trainees who asked for a seminar on exits. Preparation, in which they shared, revealed that outside the main textbooks it barely features as a topic within the CAT literature. Discussion suggested that there might be value in distinguishing the concept of aims from that of exits; thus the title of this article. Using the term ‘self-defeating procedures’ is my decision, and allows for the possibility of considering ways out of both reciprocal role and target problem procedures (RRPs and TPPs).

Overview in CAT textbooks 1990 and 2002

The overall purpose of therapy as addressed throughout the CAT literature is to enable the client to stop engaging in damaging procedures. The first textbook written by Tony Ryle (1990), refers to this as the main aim of therapy, and the word ‘aim’ rather than ‘exit’ is used in the form of rating sheet included in that book: ‘Describe problem; Describe aim’. The actual rating is made in relation to ‘aim achieved’, ‘no change’ or ‘much worse’. Ryle and Kerr (2002) place the development of exits firmly in the context of revision, which is normally expected to follow only once reliable recognition is established (p.97). They say that, where early drop-out or serious self-harm are possibilities, provisional exits may be encouraged at an earlier stage by reference to incomplete diagrams.

As CAT has evolved since 1990, increasingly the emphasis has been on the importance of the therapist not colluding with negative reciprocal role procedures. The influence of this on the client is referred to in the following statement (2002 p.101): ‘the capacity to sustain relationships is developed by the therapist’s recognising and not reciprocating destructive patterns and encouraging the patient to participate in a new form’. (My italics) This can be seen as a very broad form of potential exit-like activity on the part of the therapist, and doubtless many therapists and clients comment on it.

Definitions

It is not clear from the main texts whether a difference in meaning has been intended by the use of two terms, aims and exits. But I suggest that there is value in defining them separately, and considering examples in terms of whether they come closer to an aim or an exit.

The word ‘aim’ implies something that one is hoping or intending to achieve. It is likely to be expressed in fairly general terms, representing the fact that the client does not yet know how to achieve it.
By contrast an exit should be capable of description in terms of something that the client can actually do differently, and that is meaningful to the client, possibly idiosyncratic. It might be stated as an idea that they can use as a powerful reminder, or as behaviour that has worked in practice. In either case it is a positive and viable alternative for that individual to an unsatisfactory procedure.

Aims as thus defined are to be expected at the early stages of therapy, particularly in relation to target problems. But they may also be stated as the first step towards finding the exit from a target problem procedure or reciprocal role procedure. In discussion with clients I never use the word ‘exit’, but talk instead about ‘a way out’ or ‘something that works better’. However, the meaning of ‘exit’ is clear and well established within the ACAT community, and valuable for those reasons.

Aims and Target Problems

In connection with target problems, Ryle (1990) outlines what the general aim of therapy might be, ie to find a way out of the main problem the client has brought to therapy. In a 12 session case described in detail (Chapter 4) both the TP and the aim are clearly stated. Here the client had sought help because of her unhappiness following the break-up of her relationship with the father of her daughter.

‘Target problem: Upset in response to end of relationship. Aim: to understand better the pattern of relationships with men.’ (p.92)

Examples from my practice with clients on a resettlement programme for the homeless, include clear target problems, but often an aim is not spelt out. For instance the opening words of the reformulation letter to a client living in a half-way hostel are: ‘You’ve come for counselling at a time when you feel lonely, lost, confused and depressed. You feel overwhelmed by your problems.’ The desirability for the client of getting out of this situation is implied rather than stated. The first paragraph of the letter to someone who was doing well at the start of the resettlement process includes, ‘Nonetheless you still feel like an outsider, while wishing you were not. This is the main issue you’d like to work on during counselling.’ In this case the client had arrived with a clearer view of the nature of his difficulties. In both these examples it might have been valuable to ask the client to say what he would like his aim to be, and then to have included it in the letter. The introduction in another case included: ‘you’re aware of several “loaded guns” in your head that could start drinking off again. You want to be clear about what these are and to find better ways of dealing with the strong feelings involved.’ Here the description of an aim shows that progress has already been made on a strategy for dealing with the target problem, and the nature of possible exits is suggested.

Aims and Self Defeating Procedures

The tasks listed under Homework (2002 p.109) as relevant to the reformulation or recognition of procedures are in the nature of aims, providing guidance on the kind of activities that might in due course lead to exits meaningful to the individual client:

‘practising alternatives to identified procedures, for example practising assertion in place of placation or passive anger’,

‘identifying misinterpretations of external events’, and

‘rehearsing alternative thoughts and forms of self-talk’.

Making progress on these aims would require the client in each case to have understood the reasons for practising alternatives to procedures or the nature of misinterpretations that might occur. The word ‘assertion’ moves us closer to stating what a person might need to do to get out of a self-defeating procedure, but until the client understands what that would mean in practice it remains an abstract goal, and thus is still an aim.

Examples of more concrete aims for previously described TPPs include:
‘learning to be less clinging and demanding in relationships’ (2002 p17).

‘Try gradually to express some of your worries and emotions to people in all settings, and see what the consequences really are.’ (2002 p143)

In the latter case the words describing an exit might be only a little different from the aim, perhaps ‘express my worries and emotions, and discover….’ We cannot anticipate what would be discovered, since the discovery and thus the exit would be personal to the client.

There are also aims, for example - ‘Give others clear messages and be prepared to take risks in relationships’ (1990 p 35) – which if carried out consistently would work as exits.

Further examples of aims are given in another case history
(2002 p169).

Examples of aims from work with my clients include learning how to forgive oneself, becoming more aware of one’s feelings, developing friendships, and learning how to deal with panic attacks. These may be referred to in a reformulation letter or otherwise shared during sessions.

Exits and Self Defeating Procedures

In two examples from the main texts I have underlined the words which indicate that a change has actually taken place, not only been aimed for.

Rather than ‘maintaining tight control over your life, terrified that the powerful feelings inside you would destroy all those around you…you have taken risks believing that your worst expectations might be realised….and your fears were not confirmed’. (1990 p.45)

Another exit comes in the client’s words from her goodbye letter: ‘now I see myself as a person with my own thoughts and feelings’. (1990 p.140) A passage on the following page explains how the dilemma to which this refers and the exit itself were worked on during the therapy.

The case history of ‘Sam’, who described himself as having four distinct personalities, refers to various ways of controlling switches into destructive states. These may have started as aims, in other words what he would try to do. If he carried them out successfully, by my definition they would count as exits: ’walking away, counting, reminding himself it was the present time and not 30 years ago’ etc (2002 p196).

These examples show how varied in nature exits can be, behavioural and practical in Sam’s case, challenging in terms of communication and risk-taking, or expressed in deeply personal terms by a client who has made a life-changing discovery about herself.

How Exits Develop Out of Aims

The case example ‘Terry’ (1990 pp124/5) provides a detailed account of how a client understood, first the nature of his vicious circle, and then, by stages, discovered alternatives to his TPPs. In particular, how to be more assertive. The latter can be understood as an aim which gradually was realised through discoveries and practice in a variety of situations. The full case history demonstrates how closely related is the development of exits to the process of therapy in all its ramifications, including the personality and history of the client, his or her current experiences, and the relationship between therapist and client.

A review of some of my recent cases shows that exits develop broadly speaking in two ways: either apparently spontaneously, or as a result of discussion and some planning between therapist and client. The spontaneous ones are those situations where the client finds him or herself doing or experiencing something differently. Such discoveries may happen at any time during therapy, sometimes very early on before an aim has been stated. Here it seems that the individual’s first awareness of a procedure enables them to notice that something familiar and unsatisfactory is happening, and to stand back from it. Not doing what one usually does can be empowering and transformative, and words to describe the alternative may then come naturally. In other cases someone may have an aim which has been worked on deliberately for some time. For instance, a client whose aim was to feel entitled had outwardly changed his behaviour fairly consistently, in effect acting as if he was entitled. But then an experience of feeling very put down by a person in authority led to further discussion and exploration of damaging childhood experiences. During a visit to a doctor for a benefits related assessment he suddenly realised he was not trying to justify himself, and afterwards realised that now he knew what it was like to feel entitled.

The experience of being in therapy may mean that the bottling up procedure starts to change in early sessions if the client is able to talk about painful experiences that up to now have been kept hidden away. The aim then may be to learn when it’s appropriate to share feelings in general, and the exit may in due course turn out to be: ‘get in touch with my feelings by sharing them with those who are not judgmental’. Or something may happen between therapist and client that changes normal procedures or expectations, for instance the client comes after missing a session expecting angry disapproval and does not get it. The aim may have been to find ways of facing up to fear of rejection and disapproval.

The experience of not being criticised reminds her that not everyone she knows behaves like her dominating father, and this can be expressed as an exit. Similarly, outside the therapy room a person’s understanding of his reciprocal roles may suddenly enable him to realise what it might be like for another person on the receiving end of his behaviour. The aim of building better relationships moves towards an exit of remembering his own and other people’s vulnerability.

Working on the aim of building self-esteem might involve a therapist-suggested activity of trying out keeping a record day by day of what has gone well, including what the client has done well. This results in improved confidence and an identifiable exit: ‘Notice and reward achievements so that I feel good about myself rather than assume I can’t cope, drink in order to cope, and then find that I’m coping even worse’. Or client and therapist draw on the SDR a constructive alternative to a negative procedure. For instance a client feels he must resentfully do what others say because they see him as incompetent, yet if he tries to do what he wants he’ll be too unsure of himself to go ahead. The alternative that emerges from discussion, and the drawing out of a pair of positive reciprocal roles on the diagram, lead to an aim: to think in terms of trying to help himself. Fairly soon afterwards, when faced with a situation where others are telling him what he should do, the client finds a way of dealing with it that works for him. He thus discovers the benefits of adopting a helpful and understanding attitude towards himself and his decisions, and this becomes an exit. Another possibility, when a client has the aim of dealing with difficult situations assertively, but lacks confidence, is to carry out role-play around a specific scenario. The client learns or absorbs something unexpected as a result of the exercise, and that can lead towards a meaningful exit.

At the heart of each person’s ability to change lies an experience that is new, whether that comes about spontaneously or through some kind of experiment. The most usual origins of intractable negative procedures are feelings that seem unmanageable or are beyond the individual’s awareness. In my experience the most effective way of facilitating change is to help the client find ways of recognising and coming to terms with those feelings, and the circumstances that provoked them. When the emotional driving force behind the procedure is experienced differently the procedure loses its force. Many ways of working towards aims and exits will be so closely connected with the procedures’ origins that any resulting change, in the context of a mutually respectful therapeutic relationship, may begin to modify the feelings. The most common therapeutic method of listening, plus in the case of CAT the reformulation letter and SDR, are also fundamental to the process. In addition creative tools such as writing, art, music or role-play play a particularly important part. Other techniques for dealing with unmanageable feelings or trauma, for example focusing (Gendlin 1997) or rewind technique (Griffin & Tyrrell 2003), may be appropriate too.

The Evolution of Exits: Case Example

The problem ‘Peter’ brought to therapy was panic attacks, and initially he wanted to work on the aim of learning how to manage such episodes. Further into the therapy he felt ready to receive a reformulation letter, and this was the beginning of work on an aim of coming to terms with the early life and later influences that seemed to be the origin of his anxiety. We traced panic attacks to the experience of feeling powerless in relation to arrogant, blanking and controlling others, beginning with his family of origin. We worked mainly on that pair of reciprocal roles and two associated dilemmas, one involving lack of assertiveness and the other anxiety attacks or heavy drinking in connection with feelings of powerlessness. Peter did well at noticing in a general way what increased his anxiety and what led to drinking, and sometimes was able to deal with a situation constructively, but he thought in specifics about what had helped rather than generalised. While acknowledging the relevance of the diagram and its procedures, he was not thinking in those terms, and we had neither aims nor exits. I introduced the rating chart, which he said he found more helpful as a means of focusing on the procedures and possible alternatives. Each time he reported noticing and avoiding a procedure we discussed what seemed to have worked instead. Alternatives were all on relevant and fairly similar lines, but no form of words quite hit the spot. It was important that we continued with the uncertainty rather than play out Peter’s usual experience of agreeing to something under the influence of another person.

Then one day towards the end of therapy he came in exultant. At last he had understood the significance of a Biblical quotation that had puzzled him for years: ‘Go forth and tell no man.’ He had once seen an interpretation that now made sense to him: when you made a decision you should carry it out, and not tell people who might put you off for the wrong reasons. That was what he needed to do. It was a superb antidote to the dominating to dominated reciprocal role that oppressed him. I did not know the quotation; it was entirely his own. Later in the same week he had acted on the quotation when at a pub with some acquaintances. He had a sinking feeling as he talked to one of them of feeling out of place in the group he was with, then suddenly decided that come what may – a solid decision not involving anyone else – he would not have a drink. His mood switched. He felt happy, happy not to be having anxiety symptoms, and was able to socialise. The following week he produced another exit, this time to the procedure that began with powerlessness, moved on to fear of a panic attack and ended up with heavy drinking: ‘Don’t drink on bad feelings’. It was clear to me that the reason we had not used aims was because generalisations or abstractions were not meaningful to Peter.

During the same period of therapy Peter had been writing a long poem in connection with the ending of a former relationship that had involved the dominating to dominated roles. Also we were coming to the end of the sessions. Probably these factors help explain the spontaneous breakthroughs. But I like to think that throughout the therapy, while he was being encouraged consciously to identify and track his procedures, his mind was also working at a deeper subterranean level on recognising the significance of something he already partly knew.

Final Thoughts

When writing on a subject, I usually learn something more about what I already partly knew. In this instance I find the distinction between aims and exits helps me be clearer about the direction of my work with each client. I give more attention than I did to finding an aim early on. An aim such as ‘develop friendships’ clearly is going to take some time to achieve. Ideally we also identify something in the person’s experience that already works better than the procedures, though it has been taken for granted. For instance, if a client says how much better he feels when someone else understands him, it may be possible for him to realise the benefit if he were able sometimes to adopt a more understanding attitude towards himself. It may be appropriate to sketch out on the SDR the reciprocal roles of ‘understanding to feeling understood’. If the client can recognise what is good about feeling understood he is already on the way to having an exit, even if the journey towards adopting that attitude on a regular basis may be a long one, with the fulfilment of some other aims being necessary along the way.

While I have found the distinction between aims and exits helpful it may not be so for everyone. But I do think it is essential that as therapists our aim should always be to help clients find their own ways out of the problematic procedures that afflict them.

References

Gendlin E T (1997) Focusing New York: Bantam Books
Griffin J & Tyrrell I (2003) The Human Givens – A new approach to emotional health and clear thinking Hailsham: H G Publishing Ltd
Ryle A (1990) Cognitive Analytic Therapy: Active Participation in Change Chichester: Wiley & Sons Ltd
Ryle A & Kerr I (2002) Introducing Analytic Therapy: Principles & Practice Chichester: John Wiley & Sons Ltd

Full Reference

Toye, J., 2009. Aims and Exits from Self-Defeating Procedures. Reformulation, Summer, pp.26-29.

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