Recent posts
Supple. S, 2022, Seeing things differently: The creative and flexible CAT in accessibility and inclusiveness. Reformulation 55, p.41-45
But I don’t see........
I feel the warm sun and delight in warmth on my skin
I hear thebirds in the trees and feel joy at coming spring
I smell cooking thankful for how I live
I feel the warmth of another, glad for love they give.
But I do not see....
I hear others’ pity for me and the sympathy they send
I experience their assumptions but do not comprehend
I sense the presence of others, while feeling alone
I experience the injustice and tolerate the unknown.
But I do not see...
I feel the frustration of being forgotten again
I hear the intentions of inclusion, not sure of when
I sense the otherness and the not quite the same
I turn the sadness into rage once again.
But I do not see.....
I stand with the many, who also feel ‘other’
I hold in my mind, my sister and brother
I feel their losses too, for race, sexuality and gender
I know how to be forgotten and try to remember.
But I do not see.....
I tire at the fight and the tears I have cried
But I feel our sameness and how we find pride
I hold onto connection between all of us minorities
I remember my values and hold firm to priorities
I remember that nothing changes without a fight
And keep standing firm, resisting the flight.
But I do not see....
I hear the voices of people who want to ask
I listen and continue the task
I feel things changing, if oh so slow
I try to stay strong for how far there is to go
I hope for a time when all can thrive.
I see a time when maybe we’ll be wise.
Introduction
Cognitive analytic therapy (CAT) was developed by Anthony Ryle with a view towards a focussed time-limited and accessible therapy. When beginning my training a few years back I came enthusiastically to embrace CAT’s integrative approach and its creative flexibility always seeking to work collaboratively with and for the client. Yet despite the real enthusiasm for creative approaches I encountered within CAT and its teaching community, therein I found myself feeling excluded due to my disability (I am registered blind).
I anticipated some challenges to negotiate with visual materials (such as maps and diagrams). However I did not expect to find myself in certain reciprocal roles. Since my first contact with the Association for Cognitive Analytical Therapists (ACAT) I have experienced unwitting and unintentional barriers which have left me in the bottom reciprocal role of [Excluding/Dismissing to Excluded/Dismissed] on an institutional and systemic basis. For example I think back to when I first joined the training course and how I found materials were inaccessible or not readily made in available formats that I could access. The wider picture is perhaps a broader relationship with academic studies and the written word for both those with similar disabilities or those who cannot easily access textual information. However within this specific CAT context I was unable to access the ACAT website which was signposted to me as the repository for much of the training material which I needed and so I found I had to strive to work harder than my peers to access learning. I was supported by the grace and kindness of friends to help me access materials, but this also left me in a reciprocal role of [Disempowering to Dependant/Crushed]. It also meant I was in danger of falling into the bottom of [Excluding to Excluded] on account of my disability where being disabled is lacking the ability to join in and connect with. As it is with all reciprocal roles both positions can be experienced by either client or therapist and I began reflecting on which reciprocal roles could play out within a CAT with clients for whom the written word is daunting or inaccessible. I decided, as part of my training to research CAT literature in order to see what I could find out about how CAT therapists have adapted thinking and approaches to work inclusively with diversity and disability. CAT offers a framework to go beyond mere flexible ways of working, to reflect further on the reciprocal roles which are played out in the therapy relationship and culture when a person’s disability is named as a central focus of lived experience.
I explored creative approaches which may foster inclusion and accessibility when daunted by the reciprocal role of [Restricting/ Encoding to Restricted/Disabled] that I often experience as a non-sighted person in a sighted, text-based world trying to access knowledge and information. To try and manage this undertaking I largely used literature from the ACAT website, using a helper to facilitate this.
The uses and restrictions of CAT tools
CAT uses a number of written tools which require reading: the psychotherapy file, the reformulation and ending letters and the maps. We can only describe what we see and see what we describe (Ryle, A. 2003). So, what if the therapist and/or the client cannot see the diagram, either through a lack of sight or a lack of literacy?
Mapping - the act of drawing out a client's procedures into a diagram - has become standard practice in CAT. Mapping and talking simultaneously: sketching of maps help the therapist and client to hover above the detail and to see the bigger picture (Potter, S. 2010). Co-creating a map seems helpful in both consolidating collaborative understanding and description of a client's issues and facilitating client learning. A shared map is relational and enables transference and counter-transference material happening in the room to be noticed and named between client and therapist, ready for reflection and the work of therapy.
However, what if the therapist and client are not using the same language and writing due to complex or latent obstacles? My first CAT training case in which I was keen to try to do a diagram to show I had grasped the concept comes to mind. With large paper and thick pens I could write, so I did map out some procedures on the paper yet without sufficient sight to be able to read back what I had written. As therapy progressed, I felt there was a block developing and began to reflect on how the client himself struggled with reading and also English was not his first language.
Although I had striven to develop this diagram collaboratively: discussing it together and agreeing its content, sitting between us on the table was a dead map that held little meaning for either of us and which we mutually rarely referred to. Through supervision I realised maps need to connect and carry live meaning for both client and the therapist.
An important part of creating a map is ensuring it is not just jointly undertaken but that also it has meaning and is useful. Instead of the therapist taking an expert position, leading in the creation of a map, it should be truly collaborative, reflecting live reciprocal roles between the client and the mapped words and between the client and the therapist and be alive, meaningful, and dynamic. I wonder which reciprocal roles may be created by the fact I cannot see and therefore cannot write the map out myself? Does it make it different if the client has to own the map, write the map and refer back to or read out the map?
Does this dynamic shift away from a more traditional expert/patient role, toward the client adopting a more egalitarian helper position to my helped position? This leaves me wondering if a client might feel let down if I cannot take charge of the map or if it leaves them feeling empowered to take ownership of it oneself? When reflecting on reciprocal roles and co-constructing maps it also feels important to consider broader, sociohistorical and cultural assumptions or constructions which may be relevant to both client and therapists in terms of disability or diversity. Being registered blind and faced with creating a text-based map mirrored many of my previous experiences of being in a textual or academic world and striving to participate, feeling overwhelmed by the task and ultimately excluded and living on the edge of feeling crushed. Clients react uniquely when tasked with putting emotions and experiences into words and pictures.
It feels important to hold in mind social constructions of disability as this is likely to give us clues about possible reciprocal roles getting played out between client and therapists but also self to self. Psychology has traditionally played a central role in the construction and understanding of disability, often being part of developing the negative constructions and stereotypes (Burman 1994, Oliver, 1996). Supple, S. and Corrie, K. (2004) suggest that the evolution of society’s growing awareness of disability and diversity issues, and of the obstacles blocking accessibility, has profound implications for practitioners. They suggest that therapists should hold an overarching core awareness of diversity within both clients and practitioners for within the scope of its definition, disability will affect all people at some stage of the life cycle, either through illness, injury, congenital impairment or age (Zola, I. 1989).
Adaptations and flexible use of CAT tools
CAT has been used flexibly with a variety of client groups; those diagnosed with psychosis, learning disabilities, borderline personality disorder as well as those with drug and alcohol problems, older adults and those with dementia or people with physical problems (Rice-Varian, C. 2011).
I explored ideas regarding how CAT is used with people who have been labelled as Learning Disabled. Those with this label struggle for inclusion and can be seen as hard to reach and are often inadvertently excluded from the therapeutic arena (Lloyd, J. et al, 2013). The same authors suggest that not having the ability to express emotions, or words for emotions to reflect on early life, is more frequently problematic than cognitive impairment. They advocate for creative ideas and flexible ways of working with clients who may not connect with the orthodox CAT. I feel hopeful that we can develop attuned conversations together so we can explore living reciprocal roles and procedures, beyond the stigma of diagnostic labelling. The important part is thinking about how we respond to what we find out together and what we then can do differently (Lloyd, J. et al 2013).
Such adaptations feel important to me in enabling us to find ways of working within a client's zone of proximal development (ZPD). In an early CAT training case, I offered the psychotherapy file at the beginning of therapy. Over the next few weeks, I tried referring to it with the client. I could not read nor see what had been written and so tried engaging the client to talk about it as an enactment magnet. The client explained that they found it overwhelming to see things written down and this mirrored how they found it very difficult to connect to personal feelings and experiences. She had experienced the process of trying to fill out the psychotherapy file as punitive, leaving her self-critical and ashamed. This moment in therapy enabled us to identify a strong parallel process and reciprocal role of [Criticising to Criticised] which led to self-blaming procedures. In order to stay within this client's ZPD we worked at her pace, putting the psychotherapy file aside and finding emotional language that did not leave her feeling crushed.
Such experiences have helped me to become more sensitive to working within a client's ZPD. For clients who struggle with literacy or who have a negative association with academic texts or questionnaires or those diagnosed with dyslexia and dyspraxia, as well as younger people in general may be intimidated by the long version of the psychotherapy file. Therefore, I often choose to use the shorter and simpler version of the psychotherapy file (King, R. 2005). I have also thought a lot about how I introduce the psychotherapy file, acknowledging that different people experience it very differently, and overtly discussing the use of it, thinking about how it aims to be helpful and is not compulsory. Although initially the simpler version was developed for clients with Learning Disability, I also feel it is of value for those for whom textual information is daunting or complex.
Creative adaptations of CAT within work as part of a community learning disability team emphasise that cognitive and emotional intelligence are not synonymous and therefore caution against judging individuals with an intellectual impairment as incapable of engagement with therapy (Smith, H. et al 2010). They argue for a common reciprocal role for this client group rooted in the lower reciprocal role of [Controlling to Controlled]. They also touch on the issue of self-silencing, an issue which I found to be very relevant to disabled people during my own doctoral research, i.e. implying that often disabled people feel they should not or cannot talk openly about their disability (Supple, S. 2002). This suggests that making any reciprocal role linked to disability overt within the CAT is important if we want to avoid colluding with social taboos linked to negative constructions of disability. The practical barriers within CAT can be tackled fairly easily, and tasks such as writing a diary can be modified using pictures and photographs to depict family relationships alongside the use of feelings boards and pictorial diagrams etc. (Smith, H. et al 2000). They do not offer a reformulation letter and instead an ending letter with simplified language is offered within the client’s ZPD so that the client does not rely on a carer to read it for them.
CAT has also been used with clients with acquired brain injury. Sending external prompts via a mobile phone to remind a client to reflect on enacting specific negative procedures has been explored (Rice-Varian, C. 2011). In another example, they used staff at a residential home to facilitate external prompts to support the client in switching out of a negative role state. Again, they consider a client's context and relationship with carers and services as being central to any work. They also had to think about how to pace sessions, taking breaks when necessary, mindful of the traditional 50 minute session which may lead to a striving procedure already present for the client. They suggest when working with such clients, a 24 session CAT is more appropriate to allow for pacing and creativity (Calvert, P. 2014). She suggests it was more helpful to use CAT ideas flexibly to support the team than to adhere to a more traditional approach and reflects that to do so risks not working within the ZPD of the individual, service, or wider system.
Simplifying CAT concepts seems useful with clients for whom an over-reliance on text or complex diagrams may be inappropriate (Jenaway, A. 2009). In her work with adolescent populations, she suggests focussing on developing the therapeutic relationship and selecting specific issues to focus e.g. on self-harm itself and not the underlying procedures (which may be overwhelming). The therapy focus on a dilemma can be suggested and drawn. For example, either I keep quiet (image of locked cupboard) or open up and risk getting angry (image of an explosion). The therapy task is then to find a middle ground where feelings can be named and thought about safely in the shared therapy relationship.
The importance of attending to the system in which a person is embedded has been highlighted (Shannon, K. and Swarbrick, P. 2010). In their work with clients with a diagnosis of bipolar disorder they feel it is important to reflect on issues of stigma and lack of control. I would suggest this is also of great significance when working with someone who is perceived as disabled. A CAT approach can reflect on how this may link to the formation and perpetuation of certain reciprocal roles such as the [Disempowering to feeling Disempowered]. They conclude that CAT supports reflection on self-blame and stigma derived from unreflected sociocultural values as well as unnamed self to self reciprocal roles.
The above adaptations all focus on a specific client group and broadly tread the path of adaptation of creative tools into different visual formats as either pictorial or textual iterations. However, is this applicable for the visually impaired clients for whom textual information remains elusive?
I wonder if we can travel a different path…
Collaborative creation and drawing of the use of metaphor in CAT is an alternative form of reformulation. Our humanity spans generational use of metaphor as method and as communication for ideas and information e.g., mythology, biblical parables and children's fairy tales (Kirkland, J. 2011). For Kirkland, objects, relationships, and activities can also hold metaphorical meaning, including relational moments of how a client is met and led into the therapy room. Crossing from specific moments to a wider universal generalisation can also deepen understanding by tapping into feelings, hidden thoughts and meanings through the use of metaphor. Looking for how procedures or reciprocal roles are enacted or present metaphorically feels more helpful in my search to find a non-textual way of accessing CAT ideas. Yet not all therapists are comfortable or congruent with such creative uses, even if potentially meaningful to the client (Turner, J. 2011).
Concepts derived from movies, myths and literature are a rich repository which enables therapists to use the cultural products of our time as tools (Jefferies, S.2011). He suggests that stories can act as powerful shared tools in therapy and offer a pathway to facilitate externalising feelings and finding ways of articulating experiences or states otherwise unnameable. Reflecting on already existing narratives or stories can help develop the Observing Eye/I to aid the Other to step back and trace their procedures, separating the self from immediacy to reflect more prior to reaction. By using ideas already in the social domain, it encompasses some of the Vygotskian ideas present in CAT concerning how our sense of self is social in origin. Films, books, poetry and music and multi-media transcend limited visual or textual ideas, facilitating broader universal accessibility. Stories too – rich in cultural meaning -facilitate an exploration of socially constructed ideas, drawing on the Bakhtinian tradition in CAT. This may be useful in helping to explore social assumptions and narratives surrounding disability or diversity.
To go further, the Six Part Story method allows for a client to create their own story. This technique can be used to facilitate an exploration of coping styles and possible reciprocal roles as an aid to help clients who prefer drawing and telling stories over written diagrams or letters. One of its strengths is the use of metaphor, freeing people to express more creatively and helping to develop self-reflection (Dent-Brown, K. 2011).
Moving closer to objects and the body as object itself, is an area which has been considered as the field for respectful tactile mapping (McCormick, E. 2012). The therapist can ask the client to describe an object and to think about how to position it. The relationship between objects and their position can then be explored and also, they can be played with and moved around. The body itself can also be used to reflect on its reciprocal roles and procedures. The idea of a body sculpt (i.e. acting out the two poles of a reciprocal role) as a way of exploring how it feels to be at each end and also exploring the relationship between the two, working toward finding a softening of the positions and seeking a middle, alternative position (McCormick, E. 2014). Similarly, the body in dialogue has been discussed (Burns-Lundgren, E. et al 2008). They suggest we need to be aware of and listen to what the body communicates to us and its parallel relation to the therapeutic endeavour. This has the advantage of taking the exploration out of a purely verbal realm. Attending to shifts in felt energy within the room can be useful and can take us out of our heads, back into our bodies.
In drawing attention to the biological effects of trauma, deprivation, and stress, respectfully attending to the body of the client and therapist gives us deeper insights and empathy. This has the benefit of not being visually based and allows for consideration of a person’s relationship with their body as well as societal constructions of their body and disability.
Reflections
I have inhabited two perspectives throughout this essay, one as a therapist seeking to adapt to my client's needs and the other as a disabled person seeking to access CAT. I need to keep reflecting on how these two positions may interact and to be aware of any potential conflicts.
I began this essay from the position of considering how my own disability had at times left me in the bottom reciprocal roles of [Excluding/Dismissing to Excluded/Dismissed]. However, the creative adaptations I have found have left me feeling nourished with hope that inclusiveness is not only possible within CAT but that flexible ways of working are sought and enjoyed, making for a richer therapy experience. Future exit reciprocal roles of [Curious to Encouraged] and [Creative/ Flexible to Accessible/Included] are possible and desirable, already embedded within the traditional CAT model. I have felt most included and connected with CAT when able to experiment with using objects or the body in exploring. It has been important to reflect on my own learning through researching authors to work within my own ZPD, using approaches which feel comfortable and congruent with my own identity and feel this will also be true for other therapists seeking to be creative in working with and supporting diversity within CAT.
I would suggest it is essential that issues of disability and diversity are respectfully reflected upon early in the therapy to avoid colluding in a reciprocal role of [Silencing to Silenced] which risks perpetuating social taboo or an unspoken fear of offending. One of CAT's strengths is that it enables these burdening dynamics to be voiced for reflection to further understand and aid mutual inclusion of client and therapist in the therapy.
Then we can draw on creativity, flexibility and personal orientation for which tools are to be used for the relational and reflective foundations of CAT to work toward developing inclusiveness for a range of disabilities and diversity.
Correspondence:
References
Burman, E. (1994) Deconstructing Developmental Psychology London & New York, Routledge.
Burns-Lundgren, E. & Walker, M. (2008) The Body in Dialogue Reformulation, Summer pp18-19.
Calvert, P. (2014) Applying CAT in an Acquired Brain Injury Neuropsychological service: Challenges and Reflections Reformulation, Summer 16-21.
Dent-Brown, K. (2011). Six-Part Story making – a tool for CAT practitioners Reformulation, Summer, pp34-36.
Jeffries, S. (2011). Memoirs, Myths and Movies: Using Books and Films in Cognitive Analytic Therapy Reformulation, Summer pp29-33.
Jenaway, A. (2009). K.I.S.S. (keep it simple stupid) Reflections on Using CAT with Adolescence and a Couple of Case Examples. Reformulation, Winter, pp13-16
Jenaway, A. & Rattigan, N. (2011) Using a template to draw diagrams in Cognitive Analytic Therapy. Reformulation, Summer, pp46-48.
King, R. (2005) CAT, the Therapeutic Relationship and Working with People with Learning Disability Reformulation, Spring, pp10-14 Kirkland, J. (2010) When I'm The Dark Angel I Feel Worthless And Don't Deserve Love Reformulation Winter pp19-23
Lloyd, J. and Clayton, P. (2013) Cognitive Analytic Therapy for people with intellectual disabilities and their carers Jessica Kingsley Publishers
McCormack, E. (2012) Change for the Better. Self Help Through Practical Psychotherapy 4th ed., Sage Publications
McCormack, E. (2014) Body Sculpt Workshop. Presented as part of training course for East of England.
Oliver, M. &Barton, L. (eds.) (1996) Disability & Society: Emerging Issues and Insights, Harlow, Longman.
Potter, S. (2010) Words With Arrows The Benefits of Mapping Whilst Talking. Reformulation, Summer pp37-45
Rice-Varian C. (2011) The Effectiveness of Standard Cognitive Analytic Therapy (CAT) with People with Mild and Moderate Acquired Brain Injury (ABI): An Outcome Evaluation. Reformulation, Summer pp49-54
Ryle, A. (1997) Cognitive Analytic Therapy and Borderline Personality Disorder: The Model and the Method. Chichester, J. Wiley & Sons
Ryle, A. (2003) History and Use of the SDR. Reformulation, Autumn, pp18-21
Shannon, K. & Swarbrick, R. (2010) The Development of a Cognitive Analytic Therapy (CAT) relational framework for Bipolar Disorder (BD) Reformulation, Summer pp17-25
Smith, H. and Wills, S. (2010) Creatively Adapting CAT: Two Case Studies from a Community Learning Disability Team. Reformulation, Winter pp35-40
Supple, S. (2002) Voicing the Identities of Disabled People University of Surrey: Year 2 dossier, Practitioner Doctorate in Psychotherapeutic & Counselling Psychology. Unpublished manuscript
Supple, S. & Corrie, S.(2004) Seeing is believing: Adapting cognitive therapy for visual impairment Counselling Psychology Review, p19 (3)
Turner, J. (2011) Metaphor and Pictures: An Exploration of the Views of CAT Therapists into the Use of Metaphor and Pictorial Metaphor Reformulation, Summer pp37-41
Zola, I. (1989) Towards a Necessary Universalising of Disability Policy Millbank Quarterly, 67 (2) pp401-428
Footnote:
Page 1: I choose to use the word 'disabled' to signify the social model of disability I adopt, see Oliver, M & Barton, L.(1996).