Developing a Language for the Psychotherapy of Later Life

Hepple, J., 2006. Developing a Language for the Psychotherapy of Later Life. Reformulation, Winter, pp.23-28.


The following article was originally published in The British Journal of Psychotherapy Integration. The reference is: Hepple, J., (2006) The witness and the judge, Cognitive Analytic Therapy in later life: the case of Maureen. The British Journal of Psychotherapy Integration. 2(2): 21-27

Introduction

Cognitive Analytic Therapy (CAT) (Ryle and Kerr, 2003) is a brief integrative therapy developed by Dr Anthony Ryle and others over the last 25 years. More recently, CAT theory and practice has been applied to work with older people, (Hepple and Sutton, 2004). Although CAT, as its name implies, originally sought an integration of cognitive theory (particularly ideas from information processing, personal construct theory and the collaborative nature of the therapeutic relationship) and object relations theory (notably introduced by the concept of ‘reciprocal roles’), over the last decade much interest has arisen in the development of CAT as a dialogic therapy, incorporating ideas from the Russian philosophers Mikhail Bakhtin and Lev Vygotsky (Leiman, 1992, 1997).

While I have no room here to give a comprehensive overview of these exciting developments in contemporary CAT theory, I particularly recommend the chapter by Laura Sutton and Mikael Leiman in Hepple and Sutton (2004) as further reading. In this paper I hope to illustrate the dialogic nature of the therapeutic relationship in a CAT therapy with a woman in her early seventies and to illustrate some of the ideas coined by Mikhail Bakhtin, particularly ‘The Witness and the Judge’ which seem to speak so clearly to this sort of work in later life. As the long buried narrative unfolds in the sessions in dialogue, the ‘responsive understanding’ of the therapist allows transformation of the past abuse and the creation of a different sort of future.

A word here on reciprocal roles which will help us with Maureen’s case later. Reciprocal roles describe an internalised relationship; a dance into which others are continually invited as a known and predictable way of being in the world. Maureen’s core reciprocal roles turned out to be: Abusing to Abused, Critical to Striving and Rejecting to Rejected. The child, or bottom roles in diagram form, come second, the adult or top roles first. While one pole of the role-play derives primarily from the adult or child, the reciprocal role always exists as a relationship and there is always an element of both in each person as part of any future enactment. This then gives us CAT’s two pronged understanding of counter-transference; empathic (identification with the child role) and reciprocal (enactment of the adult counterpart). For example, the therapist, in relation to the abuse narrative may empathically feel sad, angry and crushed but may also fall into reciprocal responses: dismissing, overlooking or even critical and rejecting.

Some ideas from the work of Mikhail Bakhtin (1895 –1975)

For an excellent introduction to this intriguing thinker I can recommend Michael Holquist’s ‘Dialogism’ (2004). Bakhtin had a remarkable life, living through both Russian revolutions, Stalinism, the German invasion in World War II and a period in exile in Kazakstan as a political prisoner, before being ‘discovered’ by the West in the 1970s. There are some considerable doubts around authorship of several works connected with Bakhtin, particularly as to whether his associates in the 1920s, Valentin Voloshinov and Pavel Medvedev, are really pseudonyms for Bakhtin himself, or whether he may have been guilty of some degree of plagiarism. I will here follow Holquist’s lead in accepting that works attributed to these associates are likely to have been written by Bakhtin himself.

His writings exist on the fascinating lemnisci of several disciplines, particularly literary theory (notably his discourse on the work of Dostoevsky), psychology, Marxist theory, philosophy and theology. Whatever field he is discussing, the reader soon realises that underlying all his work is a deeply dialogic understanding of consciousness and meaning. This provides something of a wake up call to those of us instilled with the intrapsychic understandings of Western philosophy and the psychoanalytic tradition. Bakhtin’s is an interpersonal world where meaning only exists in the uncertain ground between ‘I’ and ‘other’ and is articulated via ‘utterance’ in the language of ‘signs’. This intriguing perspective clearly has a lot to offer those interested in the exploration of the relationship between client and therapist in the psychotherapies.

In what follows I will attempt to describe my personal understanding of some of these key dialogic ideas, which will help us to explore some of the transcripted material from the case of Maureen. First some words from Bakhtin:

Consciousness as in between

'Everything that pertains to me enters my consciousness, beginning with my name, from the external world through the mouths of others… I realize myself initially through others: from them I receive words, forms and tonalities for the formation of my initial idea of myself… Just as the body is formed initially in the mother’s body (womb), a person’s consciousness awakens wrapped in another’s consciousness.’ (Notes made in 1970-1971, in Bakhtin, 1986).  

Relational reality

‘The other human being I am contemplating, I shall always see and know something that he… cannot see himself: parts of his body… his head, his face, his expression, the world behind his back. As we gaze at each other, two different worlds are reflected in the pupils of our eyes…’ (The Author and Hero in Aesthetic Activity, in Bakhtin, 1990).

From these snippets we begin to get a grasp of the core idea of dialogical approach; that meaning only exists in between. To put it another way: what and who would we be if we had never met another being? It is only through reflection of ourselves in the response of the other that any self-reflection can evolve (what Bakhtin calls the ‘I for myself ’). As Anthony Ryle responds to the Cartesian ‘I think therefore I am’: – ‘We interact and communicate therefore we become’. (Ryle, 2001).

This is a considerable paradigm shift for those brought up with concepts of cognitions, egos and ids existing in the intrapsychic space of the individual ‘mind’. This is a totally interpsychic theory. In his analysis of the form of the novel, Bakhtin describes utterance to be the unit of the dialogue – that which is complete in the sense that it is ready for a response from the other to which it is addressed (the addressee). An utterance can be anything from a single word to a complete body of writing. Each utterance is directed at a real or imagined other or others, always seeks to be heard and understood by the other, and is always looking to find out something more about the author (I) from the continuation of the dialogue with the other.

Responsive understanding

'The word, which always wants to be heard, always seeks responsive understanding, and does not stop at immediate understanding but presses on further and further (indefinitely). (The problem of the Text, In Bakhtin, 1986).

‘The word’ is another term often used by Bakhtin. For Bakhtin, language is the pre-eminent ‘sign’, signs being the conveyors of meaning in the in-between world of interpersonal reality. A sign is always two-sided; it always looks both ways simultaneously (to the author and to the addressee, to the I and to the other). Words are not the only signs. Gestures, movements, drawings, paintings etc. can continue the dialogue in the interpersonal world and in therapy. The tools used in CAT therapy are signs – the early reformulation letter addressed to the client from a position of empathic (or responsive) understanding, the ‘map’ where the client’s world is traced out by the hand of the therapist using the ‘eyes’ and perceptions of the client, the goodbye letter where the time spent in dialogue together is reflected upon and appraised.  

The Witness and the Judge

When I first read this little chunk of Bakhtin in his late work ‘Notes made in 1970-71’ (Bakhtin, 1986) I could not stop thinking about its relevance to therapy. It appears among a collection of late jottings – disconnected from text around it.

‘When consciousness appeared in the world the world changed radically. A stone is still stony and the sun still sunny, but the event of existence as a whole (unfinalised) becomes completely different because a new and major character in this event appears… the witness and the judge. And the sun, while remaining physically the same, has changed because it has begun to be cognized by the witness and the judge. It has stopped simply being but started being in itself and for itself as well as for the other because it has been reflected in the consciousness of the other: this has caused it to be changed radically, to be enriched and transformed’. (Notes made in 1970-1971 in Bakhtin, 1986).

This speaks to me of Clarkson’s (1995) developmentally needed aspect of the therapeutic relationship and seems to describe the process of witnessing the client’s narrative, particularly early trauma and abuse, which may never have been witnessed before; opening up a dialogue around that which seemed ‘all said and done’. It is like going back in a time machine and entering that long closed up room where the abuse is shown to a new pair of eyes; that of the witness.

What does the witness do? I think two things:

i) The witness is there beside the client (often when the client is ‘beside themselves’). The witness unconditionally accepts the predicament of the client, the mixture of feelings of anger, grief, guilt and self-loathing. The witness also shares these feelings, experiencing them both for himself and for the client. (The use of the empathic countertransference or identification with the roles associated with the abused child: Abused, Overlooked, Self-loathing, in this way CAT seems an important part of the technique, as I heard Anthony Ryle say in 2003: ‘How the client makes you feel in the session is the client’s business’). Someone else (the other) has finally noticed what happened. In the cases of older people, like Maureen, several decades may have passed while she waited for a witness to arrive.
ii) The witness sees the scene from a different viewpoint – that of the other. The witness will give a different account of the story to others, the witness notices things that the client gives little significance to, the witness sees the client in the context of the scene from the outside ‘The ever present excess of my seeing, knowing and possessing in relation to any other human being, is founded in the uniqueness and irreplaceability of my place in the world’. (Bakhtin, 1990).

This second function of the witness uses aspects of the self-self relationship ~ only you will have your unique reaction to the story unfolding. Reciprocal counter-transference, or in CAT terms an identification with a ‘top’ or adult reciprocal role is a feature here. The therapist may be drawn into enactments of the original role-play: Overlooking, Dismissing, Critical or may establish, even at this stage, reparative top roles: Accepting, Forgiving, Protecting.

This leads us into the judge. The witness is now allowed to express a view about the story. This is difficult territory for ‘non-judgmental’ psychodynamic therapy. There are many boundary issues here around religious, cultural and spiritual beliefs. In my view, however, clear abuses of basic human rights are OK to make a stand against. (I would say this is perhaps more essential when working with abusers). I often say something like: ‘That should never happen to a child’ or ‘All children deserve love and protection’. Sometimes the function of the Judge is implicit; the client imagines that you disapprove of, say, childhood abuse. In my experience, however, it often helps to voice this.

Finally in the Bakhtin description of the witness and the judge is the intriguing concept of transformation: ‘This has caused it to be changed radically, to be enriched and transformed’. Once transformation has happened, the past, present and future world can never be the same again. This is, I think, the core component of change in psychotherapy. It is not so much internalisation of the therapist but, through the therapeutic relationship, new ways of relating to future others are now a possibility.

Bakhtin goes on briefly to clarify:

‘This cannot be understood as existence (nature) beginning to be conscious of itself in man…, no, something absolutely new has appeared, a supra-existence has emerged’. (Notes made in 1970-71, Bakhtin 1986)  

The case of Maureen

Maureen came to see me for a CAT assessment and then 16 session therapy, when she was seventy-one. She had been brought up in the Second World War and its aftermath in great poverty. Her benevolent father was ‘invalided’ after a quarry accident. Her mother became a hard-nosed provider and protector of the family, with great self-sacrifice. Men had a dominant role in this culture and Maureen was bottom of the pecking order after her mother re-married and introduced a step-brother to the family. Maureen was sexually abused by this step-brother up to her teens when he returned from the Army, but had no ‘voice’ to describe her experience. She knew it made her feel terrible but could only believe that ‘it must be me’, my ‘terrible secret’. The step-brother married and his ‘petite’ and expensively dressed wife were subject to covert envious attack from both Maureen’s mother and herself. The result was that Maureen could admire her mother for her assertiveness and contempt (envy), hear no criticism of her, but could not own, at all, her own contempt (and rage), which got her into endless protracted disputes with her now extended family. Any attempt to name the effect she might have had by saying ‘Well, that’s the end of Christmas then’ she had already pre-empted with a collapse into a self-blaming, rejected child, leaving me feeling helplessly abusive and critical.

The first part of the therapy was a witnessing of Maureen’s abuse. As a defensive procedure against going to this desolate place she would go into a dense monologue of recounted bickering between herself and members of the family, where countless examples were used to explain how badly she has been treated. By the time she got to the end of an incident (maybe after 10 or 15 minutes) she had already sunk into self-hatred. I felt ‘squashed against the wall’, as I said to her, to some effect. Eventually we got into the abuse narrative. My role was to keep her in the thread of the narrative (she would often divert ‘beside herself ’ into another anecdote) and also to share the feelings. In a way I was saying: ‘Look, I’m here now, we must concentrate on your wounds as I know they are terrible and need attention.’ Here is a snippet of the Reformulation letter I wrote to her in session four to illustrate what we were doing:

‘In addition to these feelings of being unwanted and less than your brothers, you told me how you were sexually abused by your step-brother between the ages of 8 and 13 years. He threatened you not to tell anyone and although you felt very uncomfortable at the time didn’t really understand what was happening to you and felt unable to tell anyone until you were about to get married. You felt angry and hurt when you saw a letter from a forces friend of his showing that he bragged about the abuse to male friends. This must have been horrible to read… it was very sad to hear how this has made you feel that “it must be something in me” that was to blame for the abuse. As we realised in our last session, this is a terrible feeling to be left behind in a child who was really in need of love and protection’. 

I was beginning to add my own position (the otherness of the witness). I had brought in the previously peripheral perspective of the army colleagues who laughed about the abuse ~ a vehicle for getting at some of the anger. I also judged that she needed, and deserved, love and protection. The process of transformation was beginning. In session six we were still witnessing away and I asked her to prepare a letter to her stepbrother:

Session 6 transcript

J: Again it sounds like you are struggling to know whether you can have your own opinion.
M: Yes it is a struggle.
J: But you know what your opinion is
M: Yes I do,… (After reading the first letter to her abuser)
J: You said you’ve forgiven him?
M: I think you have got to forgive people
J: Have you really?
M: The thing is I believe in God and I go to Church and one of the things they tell you is to forgive…
J: You ‘should’ forgive but have you forgiven him?
M: They say you should forgive and forget but I can’t forget so I suppose I haven’t really forgiven him…
J: That’s OK if you still feel angry with him then you do…
M: I wish I had written down that sort of anger…

In the next session she brought something of quite a different order:

Session 7 transcript

‘I have written one letter to you which was quite pathetic, now in this one I must tell you how disgusted I am with you, the big brother I loved… I can’t find the words strong enough to describe what an unspeakable beast you were… I have gone through life with this despicable memory and only now can I talk about it, but then only sometimes…’

This is a very moving letter as it addresses me at the same time as the step-brother, with a grateful (and admiring) sideways glance. ‘But then only sometimes’, I think, refers to the therapy. The therapy progressed well with Maureen, very pragmatically making assertive changes i n her life with her current partner and her family. She experimented with expressing her ‘bottom role’ feelings to them and realising that embarking on ‘the blame game’ only ended in rejection and desolation. I include here Maureen’s simplified map (or Sequential Diagrammatic Reformulation - SDR - in CAT jargon). The feeling left by the abuse, ‘it must be me’, caused a striving, perfectionistic compensation that left Maureen feeling taken advantage of and critical of those close to her which resulted in rejection and a return to the crushed, guilty child.

Maureen’s SDR

note how small Maureen draws herself after the collapse of a rejecting experience

maureen's sdr

To conclude the theme of the witness and the judge, I include a part of a letter Maureen sent to me almost a year after the follow-up appointment.

Post-therapy letter

“… a very big thank you, I have now got rid of my horrible feeling of guilt and my black secret – it has gone now and I feel so very different, you made me see that it was not my fault and not a guilty secret”.

This is a lovely example of transformation sustained. The world is a different place from now on in the sense that new ways of relating are now possible.

Conclusion

In this short paper I have concentrated on one aspect of my therapy with Maureen to illustrate the application of the dialogic construct ‘The Witness and the Judge’. While there were many other rich veins in our therapeutic encounter I hope that this theme, illustrated throughout the therapy, may help the reader to add this concept to their vocabulary. Attention to the functions of the witness seems so important in work with older people where decades may have passed before someone arrived to take in the terrible scene and stand beside the unbearable feelings that have endured for so long. As another client, Jean (aged 86), said to me about a CAT therapy:

“I thank you for giving me the chance of this costly treatment on the NHS… I hope that just because a patient is 86 they will not be turned away… I have benefited tremendously. I now feel all of one piece, and now feel I have grown up.”

Jason Hepple
FRCPsych

References

Bakhtin, M., M. (1986) Speech Genres and other late essays. ( trans. V.W. Maghee, eds. C. Emerson and M. Holquist). Austin, Texas: University of Texas Press.
Bakhtin, M., M. (1990) Author and hero in aesthetic activity. In: M. M. Bakhtin, Art and answerability: Early philosophical works by M.M. Bakhtin, ed. M.Holquist and V.Liapunov, trans. V. Liapunov. Austin Texas, Texas University Press.
Clarkson P (1995). A multiplicity of relationships in psychotherapy. In: Clarkson P. The therapeutic relationship. Whurr.
Hepple, J. and Sutton, L. (2004) (eds.) Cognitive Analytic Therapy in Later Life. A new perspective on old age. Hove. Brünner-Routledge.  
Holquist, M. (2004) Dialogism: Bakhtin and his world (2nd Edition). London: Routledge.
Leiman, M. (1992) The concept of sign in the work of Vygotsky, Winnicott and Bakhtin: Further integration if object relations theory and activity theory. British Journal of Medical Psychology. 65; 209-221.
Leiman, M. (1997) Procedures as dialogical sequences: A revised version of the fundamental concept of Cognitive Analytic Therapy. British Journal of Medical Psychology. 70; 193-207.
Leiman, M. and Sutton, L. (2004) The development of the dialogic self in CAT: A fresh perspective on ageing. In: J. Hepple and L. Sutton (eds.) Cognitive Analytic Therapy in Later Life. A new perspective on old age. Hove. Brünner-Routledge.
Ryle, A. (2001) CAT’s dialogic perspective on the self. ACAT News.
Ryle, A. and Kerr, I. B. (2002) Introducing Cognitive Analytic Therapy. Principles and Practice. Chichester: Jon Wiley & Sons.

Full Reference

Hepple, J., 2006. Developing a Language for the Psychotherapy of Later Life. Reformulation, Winter, pp.23-28.

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