Читать книгу Introducing Cognitive Analytic Therapy - Anthony Ryle - Страница 35

The time‐limited nature of CAT owed a lot to the work of James Mann (1973), and his emphasis on the importance of naming the session number, especially as the ending approaches, as a part of CAT practice. Working to predetermined time limits is not the same as using long‐term techniques for a short time. The process is intensified and most of the problems addressed in long‐term dynamic psychotherapy can be satisfactorily dealt with. Indeed, some patients with more severe disorders are more responsive and appear more safely helped in time‐limited work where the dangers of over‐dependence are much reduced and where the realistic disappointment which allows separation is clear from the beginning. For these and other reasons, “ending well” is seen in CAT as an important aim of therapy in itself. Nonetheless, it is recognized that for some more damaged and distressed patients longer‐term, supportive, and reparative work may be required. For many such patients, depending on context, complementary or consolidating approaches such as group therapy can be extremely helpful. However, longer term work should only be undertaken following discussion and reflection in a supervisory context (see also Marx, 2011; Pickvance, 2017), and should always maintain focus on ultimately “ending well,” and ideally moving on from therapy.

Termination is inevitably an issue, however, and the last sessions are seldom easy for the patient or the therapist. Almost no therapist (including the authors!) will ever feel that enough has been done and that “a bit more” might not be helpful. In CAT, the practice was introduced of exchanging “goodbye letters” at the penultimate (probably preferable to enable subsequent discussion), or last session. The aim of the therapist's letter is reflect on and to offer an ideally accurate (not blandly optimistic) account of the course of therapy and on what has and has not been achieved (jointly) in terms of modifying problem RRs and RRPs and relieving problems, to look to the future, and to identify where further work may be helpful. The tone of the letter should aim, as ever, to be collaborative and dialogical, and be informed by a genuine relational involvement (but not collusion) on the part of the therapist. The letter should stress that this is simply the view of the therapist. Feelings of disappointment, anxiety, or possibly anger by the patient, despite what may have been achieved, are expressly noted or predicted and thereby, incidentally, also “allowed.” This letter gives the patient a reminder of the unidealized person of the therapist (assisting the “withdrawal of transference”) and of the tools of the therapy, and is intended to help the internalization of the experience overall. In the same way, the letter from the patient (always suggested but not always produced!) invites thoughtful reflection and open expression of feelings, including about the therapy relationship. For many this represents a new experience (a new RRP), and an important change from previous coping patterns (RRPs), for example of “disempowered and silently soldiering on at great personal cost.” These exchanges are seen as an important aspect of “ending well.” Follow‐up at about 3 months is usually arranged. In many cases, change is maintained or expanded more thoroughly than either therapist or patient expect. If this is not the case, further follow‐up or “top up” sessions may be arranged or possibly treatment through another modality (e.g., group therapy or trauma processing work). Decisions about further treatment of whatever kind are best postponed until the effects of the therapy have become stabilized and the experience of termination has been completed. They should always occur in the context of reflective discussion in supervision (see Marx, 2011; Pickvance, 2017).