Читать книгу Introducing Cognitive Analytic Therapy - Anthony Ryle - Страница 30

By the mid‐1980s, the CAT model of self processes therefore incorporated ideas concerning procedural sequences linking internal (mental) and external events, but the origins of these in early development were not clearly described. Current theories appeared unsatisfactory. On the one hand, the dominant object‐relations school, largely derived from theory‐based speculative hypotheses regarding psychological development based on the psychoanalysis of adults, emphasized innate conflicting, frequently destructive, drives, largely neglected the role of experience, and paid little attention to the expanding body of observational studies of real life, early infant development. On the other hand, simple cognitive descriptions, such as were included in the original PSM, while useful as guides to identifying negative or maladaptive patterns, did not offer an adequate understanding of structure or of their relational developmental origins.

The introduction into CAT, initially by Mikael Leiman (1992, 1994a, 1997, 2000), of Vygotsky's understandings of the social and historical context and formation of higher mental processes and of the key importance in human learning of meaning‐making and sign mediation, linked with Bakhtin's illuminating understandings of the role of interpersonal and internal dialog, allowed a radical restatement of object relations ideas. The theoretical language now referred to RR relationships and accompanying dialog acquired in interaction and meaning‐making with caretakers and others, mediated by signs that are used first in outer and then in inner dialog. The theory supported the use of the concrete mediating signs and meaning‐making created (partly through the “psychological tools” of diagrams and letters) through the reformulation process in CAT. This relational “mediation” was understood as being the medium of the internalization through which change of the patient's internal psychological structures and processes could be achieved. These theoretical developments have also been informed and supported by the extensive body of observational and experimental research into infant–caregiver interactions over the past few decades (see Hobson, 2002; Lyons‐Ruth, 2008; Reddy, 2008; Stern, 2000; Trevarthen, 2001, 2017; Tronick, 2007; and see also Chapter 3). CAT was now able to move on from the traditional psychoanalytic model (or one dominant version of it) of an internal world populated by frequently conflicting “objects” or “part objects” derived from ego and others, frequently driven by endogenous destructive forces, and operating like little “ghosts in the machine.” The emerging CAT model described instead internalized relationships and associated “voices” located within a Self, the structure of which is actually constituted by (as opposed to simply “representing”) these internalized relationships. These have been acquired in activity, interaction, and conversation with others, but are now equally involved in external and internal communication, activity, and control. (A more detailed account of the CAT concept of the Self and its formation is given in Chapter 3.) By this point, the key CAT concepts of “reciprocal roles” and “reciprocal role procedures” reached their current point of evolution and therapeutic application. These are currently best understood as follows (and see Glossary):

A Reciprocal Role (RR) is a relational position between Self and other. An internalized (formative) reciprocal role, originating largely in relationships with caregivers in early life, comprises implicit, therefore often unconscious, relational memory, possibly traumatic, and also the emotions, cognitions (including cultural values and beliefs), expectations, and bodily states associated with it. A RR may be associated with a clear specific or general dialogical “voice.” An internalized reciprocal role is understood to comprise the experience of the whole relationship, that is both poles of that subjective experience, both childhood‐derived and parent/culture‐derived. RRs may be enacted in both “external” interpersonal situations and in “internal” self‐management. Being in or enacting a reciprocal role always implies another, or the internalized “voice” of another, whose reciprocation is anticipated, sought, or experienced.

A Reciprocal Role Procedure (RRP) is an aim‐directed “coping” or “responsive” stable pattern of interaction, with associated emotions, cognitions, and memories, arising out of the experience of formative reciprocal role(s). RRPs are usually long‐standing, often unconscious, and highly resistant to change. They determine current patterns of relationships with others and self‐management, and may be highly maladaptive, symptomatic, and self‐reinforcing. RRPs may be enacted in both “external” interpersonal situations and also in “internal” self‐management. RRPs may be described as “traps,” “snags,” or “dilemmas” depending on their configuration. Playing or enacting a role procedure always implies another, or the internalized “voice” of another, whose reciprocation is anticipated, sought, or experienced.

Formative RRs are understood to determine and underlie our sense of Self, of Self in relation to others, and also the repertoire of “responsive” (as initially described by Leiman) or “coping” patterns we subsequent develop (“reciprocal role procedures”). Common RRs range from, for example, “properly caring for/loving—properly cared for/loved” at one extreme, through to “emotionally neglecting—emotionally neglected,” or, “abusing—abused” at the other. The actual verbal description of a RR in therapy, however, would be always be negotiated with a patient to whom it must make personal sense. Importantly, the experience or enactment of a RR or RRP always unconsciously anticipates, or attempts to elicit, an expected reciprocal reaction from a historic or current other. In CAT, all mental “activity,” whether conscious or unconscious, is understood (following Vygotsky) to be rooted in and highly determined by our repertoire of RRs, as is, correspondingly, virtually all human psychological distress and disorder or “psychopathology.”

We note an important theoretical and clinical distinction that should be made between early “formative” or developmental RRs that are internalized to constitute aspects of the developing Self, and those “situational” RRs subsequently or currently encountered (e.g., a “benign” therapeutic role, or an adverse “victimizing” role; for example, in a bad marriage, or possibly in a “demanding” or “rejecting” mental health service). One of us (TR) has previously illustrated the idea of such a “situational” RR by the example of a “self—fishmonger” situational RR experienced when shopping for fish! A situational RR could also be experienced (e.g., “teaching–taught”) in a training workshop. However, these situations might also further evoke or trigger other underlying formative RRs (e.g., “criticizing–criticized”). Importantly, these latter situational roles may also gradually be internalized, although evidently very much less fundamentally than formative RRs. Indeed, this is a desired outcome of the therapy relationship itself. In reality, formative and situational roles exist on a spectrum, but the distinction is important especially with regard to conceptualizing the early formation (or deformation) and constitution of the Self. The idea of internalization of relational experience as formative RRs is analogous to the concept of internalized “object relations” (albeit in some very diverse conceptualizations), upon which the PSORM is founded. It may also be important therapeutically when sharing such understandings and their consequences with patients. While clinical experience suggests that formative RRs may be modified and attenuated, in part simply through their naming and recognition and through their emotional processing, they are never entirely negated, and their enactment and re‐experiencing may recur under conditions of stress or difficulty at any time. This may be a point worth anticipating with patients, for example close to termination of therapy, or in “goodbye” letters. These differing forms of RRs should be borne in mind and helpfully noted in diagrams (see Chapters 4–6). These key concepts (RRs and RRPs) can be seen as representing, broadly, the “analytic” and “cognitive” aspects of CAT respectively.

We note here also that a particular CAT concept of Self, as described in the first edition, has increasingly come to constitute a key “organizing construct” in CAT theory and practice. As such the word has been capitalized to imply a substantive entity used in this particular manner (see Glossary and Chapters 3 and 4 for further explication). Within CAT, the process of development is understood to result in a Self that is subjectively and “objectively” fundamentally different and diverse depending on formative interpersonal and socio‐cultural experience. This point has also been made from the perspective of cross‐cultural psychology and psychiatry (Bruner, 2005; Bhugra & Bhui, 2018; Bhui & Morgan, 2007; Paris & Lis, 2013; Kirmayer & Ryder, 2016) and further elaborated elsewhere from a CAT perspective (Kerr & Ryle, 2006; Kerr et al., 2015). This developmental process also generates our values and beliefs and our very “felt sense” of individual self, and of relations to others. Indeed, the very notion of an individual self would be inconceivable in most more traditional cultures (see Chapter 3). CAT stresses, therefore, the importance of social and cultural factors in contributing to mental disorder and also in limiting the likely outcome of treatment. These would include, for example, inequality, powerlessness, poverty, unemployment, hopelessness, collective demoralization, and so forth as documented and corroborated by various authors from different fields (e.g., Dorling et al., 2007; Hagan & Smail, 1997; James, 2018; Stieglitz, 2012; Trevarthen, 2017; Weich & Lewis, 1998; Wilkinson & Pickett, 2009; Weich, Patterson, Shaw, & Stewart‐Brown, 2009). From this perspective, therefore, it is understood that in an important sense there can be no such thing as an “individual,” just as Winnicott postulated with regard to the nursing mother and baby. Rather, the individual is seen also as a dynamic fragment of a social whole, and, correspondingly, individual mental health and well‐being can only be considered as part of that overall socio‐cultural context.

The concept of Self would be currently described from a CAT perspective as follows (see also Chapter 3 and Glossary):

The Self in CAT is understood to be a bio‐psycho‐social entity that emerges through a synthetic or dialectical, semiotically‐mediated developmental process involving all these dimensions. It is understood to be characterized by a sense of agency, coherence, continuity, of embodiment, of subjective and reflective awareness, identity, and for some by a sense of spirituality. The structure and function of Self is understood to include and integrate such functions as perception, affect, memory, thinking, self‐reflection, empathic imagination, relationality, creativity, and executive function. It is understood to comprise both subjective and experiential as well as observable functional aspects. The Self is also characterized by a tendency both to organize and be organized by experience. It emerges developmentally from a genotypic Self characterized by various innate predispositions, notably to intersubjectivity and relationality, so enabling and needing engagement and interaction with others from the beginning of life. The mature, phenotypic Self is considered to be fundamentally constituted by internalized, sign‐mediated, formative interpersonal experience and by dialogic voices associated with it (reciprocal roles), and to be characterized by a repertoire of emergent adaptive, “coping,” or “responsive” patterns of interaction (reciprocal role procedures). Although profoundly rooted in and influenced by early developmental experience, the Self is understood to be capable of a degree of choice and free will. The Self is understood to be dependent on others and on social location for its well‐being both during early development and throughout life.

It became, however, gradually clear through work with patients with “borderline” personality‐type disorders (BPD) that harmonious and consistent mobilization of RRs and RRPs within a well integrated Self does not always occur. This topic will be discussed further in Chapter 10. Many borderline features are best explained as the result of the partial dissociation of the patient's core RR and RRP repertoire, dissociation being understood in part as discontinuities in, and incomplete access between, different RRs and procedures. This response is understood to occur in the face of extreme adversity, emotional deprivation, or overt trauma. These are seen to result in abnormal development of the meta‐procedural system in subjects possibly more genetically predisposed to dissociate (see Chapter 10). This borderline structure is depicted in diagrams by describing separate cores to the diagram indicating what are best described as different Self States (dissociated RRs and associated RRPs). This somewhat clumsy title helps to prevent confusion between the theoretical concept of the Self State and the subjective experience of a state of mind or state of being. At any one time, the behavior and experience of an individual with borderline‐type problems is determined by only one of these Self states. The switches between, and the procedures generated by, these discrete states are mapped in Self‐state sequential diagrams (SSSDs) or “maps.” Similar structures are found to some extent in many patients who do not meet full criteria for borderline personality‐type disorders (see the case history at the end of this chapter). This conceptualization, implicit in CAT, of increasing degrees of severity and complexity in relation to damage and dysfunction of the Self and its structure and processes represents, we suggest, a more helpful dimensional and “transdiagnostic” approach to the understanding and description of mental distress and disorder.