Relationships and CAT

Kimber-Rogal, N., 2008. Relationships and CAT. Reformulation, Winter, pp.28-29.


“An adult relationship does not begin the day two people meet; it starts in the childhood of each partner”
Armstrong (2002)

What is a relationship?  It is a connection, a link and involves (at least) two separate entities.  Human relations require self-awareness and self-disclosure (mutual self-disclosure in the case of intimacy). Whilst a discussion of the constituent parts of the self may be relevant here, it is beyond the scope of this article. Suffice it to say that the psychological self develops in childhood and exists in relation to the other. This process involves language, dialogue, behaviour, cognition and affect, together with the metaphysics of spirituality and cultural transmission. 

It is not necessary to be physically present to have a relationship. The other may be absent or even dead, and the converse is also true: people may be physically proximate but unable (or unwilling) to relate.  Relationships require openness, imagination, projection and the ability to internalise aspects of another.  Preclusions to good relationships include syndromes where the patient can be too remote, preoccupied or fragmented to relate; for example, Generalised Anxiety Disorder (GAD), Obsessional Compulsive Disorder (OCD), depression and personality disorder. Moreover, paranoia, delusion or persistent and intractable fixedness in relation to another is the antithesis of an openness which enhances human affiliation.

Relationships or the interconnectedness between two people has been significant in all healing since the time of Hippocrates and Galen. It seems to be one of the significant features in any major change or `metanoia’ in people’s lives, whether this happens as a result of falling in love, being in crisis, educational development, religious conversion or effective psychotherapy. Notably, meta-analyses comparing models of therapy show that relational or non-specific factors are the strongest indicator of therapeutic outcome. Results of therapy are notoriously hard to measure even though attempts are often made through rating scales, return-to-work rates, degree of cognitive shift via repertory grids etc, on both long and short-term bases. Given that so many non-specific factors are thought to affect outcome and that similar outcomes may be obtained not only from different types of therapy but also from alternative measures such as exercise or religious healing (see eg Frank), a perennial problem remains as to how the process of psychotherapy can be shown to be effective.

Psychotherapy

The idea of talking to relieve distress is not a new one. Although Freud’s particular form of talking heralded the beginning of psychotherapy as we know it, it is an age-old tradition that has been practised across countries, religions, cultures and communities, helping people who are confused about their lives and consider themselves to be ineffectual or weak. Throughout mankind’s history, various shamans, priests, sages, mystics, saints, psychologists and psychiatrists have tried to point out the best ways to live with suffering so as to live beyond it.  Indeed, many patients’ symptoms have been improved by the so-called `bed-side manner’ of the medical doctor – a skill historically under-taught in psychiatric training.  Some say it should be called the “listening cure” since the psychotherapist listens and, most importantly, recognises - without judgement - the individual and their problems. Nowadays therapy is more directive and conversational, with therapist and patient often actively engaging on problem-solving tasks.

The word ‘psychotherapy’ refers to the treatment of mental disorders by psychological rather than biological or physical means. Any treatment that does not use drugs or other physical methods could be called psychotherapy.  The most important element is talking.  It is the ideas behind the therapy, the way it is applied, and the nature of the relationships that develop between the patient and therapist which differentiate the types of therapy available. Suitable clients for psychotherapy are predominantly those with so-called neurotic problems. However, psychotic disorders may be further alleviated by psychotherapy when combined with other forms of treatment, such as drugs.  In general, there is no reason why medication and psychotherapy should not be used together.  Some therapies emphasise feelings of helplessness or the processes by which the child identifies with the parent or primary caretaker. Others focus on the importance of loss (of loved ones or cherished ideas) when considering how, for example, depression develops.  Notably, the formation of attachments (relationships) and strong attachment bonds seem to be especially important and valuable when people are faced with adversity and stress.

The opposite of the “talking cure” could be seen as the “silent treatment”. Isolating prisoners (solitary confinement) or ignoring friends (`sending to Coventry’) remains a form of punishment and control.  Interestingly, silence or disengagement on the part of a patient may be signs of mental illness, with the experience of isolation often central to depression.  Although the benefits and virtues of solitude have been extolled by Storr, healthy man, in general, is not an island.  Lack of communication with others is central to experiences of depression and anxiety and supports Klein’s assertion that loneliness is an integral part of illness.   Depression involves a lack of spontaneity related to the repression of affect associated with reciprocal roles (see Cognitive Analytic Therapy, below) and is thus consistent with Miller’s assertion that “the true opposite of depression is not gaiety or absence of pain, but vitality: the freedom to experience spontaneous feelings”. Depression is seen to involve a separation from the true self and paradoxically, an experience of isolation may be only communicated retrospectively when levels of anxiety or depression have subsided.

Since the mid 1990’s demand for the talking cures of psychotherapy and counselling has continued to increase and a large proportion of patients attending GP’s surgeries present with problems considered best treated by psychological rather than physical means.  Reasons for this may include the break-up of the nuclear family, break-down of community living and values and a lack of religious involvement.

Cognitive Analytic Therapy (CAT)

One of  the most complicated issues in the study of close relationships is whether a supportive relationship leads to better psychological well-being (`the protection hypothesis’), or whether it is just those with good psychological health who are able to form close relationships (`the selection hypothesis’).  It seems likely that there would be an interaction which compounds good relationships for those with some ability to form them; and that, in the capacity to form good - that is, rewarding and close - relationships are based on the taught role-repertoire in childhood.

Avoidance and conflict is inherent to people who had painful experiences of chronic parental criticism and rejection.  The need to bond with the rejecting parents makes the person hungry for relationships, but their longing gradually develops into a defensive shell of self-protection against repeated parental criticisms. Loss and rejection are so painful, patients will choose to be lonely rather than risk trying to connect with others.

CAT is a short-term therapy that explains the connections between early patterns of relating and present problems. It aims to help people to co-exist with aspects of the self more peaceably.  The (relational) self is established through reciprocal roles - internalised aspects of the primary caretaker - and idiosyncratic responses to these. These are called, respectively, adult and child-derived reciprocal roles.  For example, the child may develop a rejection role in response to a critical parent or an anxious attachment in relation to a psychologically remote carer.  The extent to which these selves or part-selves are accentuated and integrated determines the psychological well-being of the individual. Fixed and polarised roles (eg bully/victim) predict mental ill-health or dysfunction.  Role pairs are experienced as the self and others are invited to reciprocate a known and predictable way of being in the world.  Unfortunately, this does not always work well for the individual and poses questions regarding human nature’s apparent desire for pleasure and avoidance of pain: we seem to elicit roles in another with we are familiar, regardless of the difficulties inherent in this role re-enactment.  Role responses (or repertoires) involve behavioural, affective and cognitive components. Therapy aims to identify and positively adjust maladaptive responses (called reciprocal role procedures) played out transferentially during sessions.

As stated earlier, an adult relationship, be it romantic, platonic or in a doctor-patient setting, does not begin the day two people meet; it starts in the childhood of each partner. One approach to conflict or irreparation in relationships suggests that individuals harbour a desire to maintain a righteous indignation at unmet demands from the past.  For example, there are situations – some of them central to the experience of childhood – in which we cannot avoid suffering. These would include small things regarding gratification of impulses by, typically, the mother or father - for example, to be given presents, to stay up late, and so on.  How can a pleasure-seeking creature cope with this?  One way – depending on severity of deprivation - may be through dissociation; another by taking unconscious satisfaction in deprivation. Righteous indignation is a simple example of this kind of pleasure; it allows one to indulge, with supreme justification, in aggressive feelings. The pain of being denied what one longs for becomes mixed with the pleasures of superiority and justified anger.  These expectations or patterns of being become unconscious and can be played out later in a number of settings.  Like an addict, we get attached to someone with whom we can repeat a self-harming, but familiar (and therefore relatively safe) pleasure. 

We learn to love as children. Or more accurately, we learn a style of relating which governs our adult behaviour when it comes to love.  Central to this thesis is the disturbing contention that we are generally unaware of this underlying style of relating – it governs our adult behaviour without our noticing. In a romantic setting, and sadly, the exciting thought `this is the one for me’ may be ironically true in that we have identified a potential source of our preferred misery: the suffering which love gives rise to is often connected with the roots of love itself.

Nicola Kimber-Rogal

References

Armstrong, J. (2002). The Conditions of Love. Penguin
Jung, C.G. (1933).   Archetypes of the collective unconscious. New York. Coll Wks., 9, 1.  In: Fenton, R. `Ordinariness’:  Fear of it and contempt for it (1982). Journal of Analytical Psychology 27, 263-272.
Kelly, G. A. (1955). The Psychology of Personal Constructs.  New York: Norton
Klein. M. (1963). `On the sense of Loneliness’ in The Writings of Melanie Klein III. London: Heinemann Medical.
Klein. M. (1975). Envy and Gratitude and other works 1946-1963. Virago.
Miller, A. (1979). The Drama of being a child. Virago.
Ryle, A. (1997). The Structure and development of borderline personality disorder: a proposed model. British Journal of Psychiatry, 170, p.82.
Ryle. A.(1992). Cognitive Analytic Therapy: Active Participation in Change.  Wiley.
Vygotsky, L.S. (1978) Mind in Society; the Development of Higher Psychological Processes Cambridge, Mass;Harvard University Press.

Full Reference

Kimber-Rogal, N., 2008. Relationships and CAT. Reformulation, Winter, pp.28-29.

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