Pollard, R. and Toye, J., 2006. Updating the Psycho-Social Checklist. Reformulation, Winter, pp.19-21.
The Psycho-Social Checklist was developed in 2004 following a workshop run for CAT North on social and cultural influences on clients and their therapy. It has been available on the CAT website since the autumn of that year, and 375 people have visited that part of the site.
The recent article in Reformulation (Issue 25) by Cristina Fioranti and Marisa Poggioli about a case of anorexia nervosa highlighted the cultural influences on the client: ‘Her internal self-evaluation that if she is “fat” as perceived by the culture, she will then be regarded as a failure mirrors an imagined outer evaluation by others’. Coincidentally a client of one of us, the very week the article appeared, wrote in the comments box for influences not specified on the Checklist ‘Body size? Ideal – smaller’. It looked as if the Checklist needed modification perhaps by adding a new category with the heading ‘Personal appearance’. The experience of other CAT therapists might also identify issues not included in the current version of the Checklist.
This development led us to think that maybe it was time to review the wording on the Checklist by asking for comments from those who have used it. It’s also an opportunity to reflect on its use in general.
The introduction to the Checklist reads as follows:
The social and political circumstances of our lives can have as much if not more influence on how we feel as our own individual histories and experiences. It can sometimes help us make sense of how we feel if we understand and recognise the effects of social and political forces in our own lives.
The reason for using it is to encourage clients to recognise the broader social context influencing their lives.
Rather than use the Psycho-Social Checklist selectively, I attach it to the Psychotherapy File, and so give every client an opportunity to respond. As with the Psychotherapy File I have found that people vary considerably in how they respond, but nearly everybody ticks one or two items that apply to them strongly. Some clients who do not find much to identify with in the Psychotherapy File have responded more fully to the Psycho-Social Checklist. It allows people to raise concerns that are not necessarily picked up by the Psychotherapy File or might be hard to raise spontaneously in therapy.
I have found that it facilitates open discussion between client and therapist of differences between them such as class, or ethnic background and the impact that this might have on therapy. In my experience so far the issues that have been most frequently raised are those of class, education, ethnic background, marital family background and sexuality.
It helps both therapist and client to think beyond what could be loosely termed an object relations approach to understanding mental distress. Instead it helps them consider the social context of childhood and early life experiences, as well as current interpersonal relationships, and to think about how other influences may be affecting them. David Smail refers to these as ‘distal’ as opposed to proximal effects on peoples’ lives - distal referring to people and events outside the client’s immediate life that they may well not be aware of.
In my experience the Checklist helps to reframe mental distress. Rather than such distress being seen in terms of individual pathology, the Checklist raises the possibility of its being a normal response to particular social conditions. Other people have responded or might respond in similar ways. It is also useful in challenging client beliefs about being to blame for the way they feel and/or that they are alone or ‘different’ in being distressed.
No-one so far has raised issues to do with body size/shape in the ‘other’ category, but I do think it could be useful to add such a category as it is a pervasive issue in the media that seems to affect both men and women.
Janet has been using it with two different client groups: homeless people on a resettlement programme, and trainee clinical psychologists These two client groups, very different in terms of their life experience and opportunities, respond very differently. Many of the psychologists, mostly from socially comfortable mainstream backgrounds, do not tick any of the items. By contrast when a person who has been homeless completes it they often tick most categories.
The psychologists often comment that it reminds them of how fortunate they have been, and how society disadvantages so many others. We sometimes discuss the guilt they feel about being privileged and its implications, while the category of class on the Checklist can occasionally reveal discomfort about the reactions of people outside the world of mental health to the discovery one is a clinical psychologist. Another issue that has occasionally been highlighted is the first: mental health issues. When these have been serious within the family of origin they are a feared source of social ostracism, and the Checklist can be a helpful prompt to mentioning a subject which otherwise it might feel shameful to acknowledge. We are many of us as therapists familiar with the feeling that we personally should not have any emotional problems, and this attitude can easily extend to one’s family.
Except in the one case mentioned above, use of the Checklist has not been the prompt for expressing concern about body size and shape. However, such anxiety is not unusual among this mainly female group.
The homeless group, not surprisingly, are much more aware of being outsiders on a number of counts, and offering them the Checklist is one way of letting them know that I see the relevance of those experiences. A few clients are politically very aware, acutely so of social injustice and racism, which can link in quite complex ways with their reciprocal roles. Sometimes as well the Checklist brings into discussion issues that might otherwise be overlooked, ‘sexual orientation’ being one such very sensitive subject that a client’s unprompted account of their experience may not touch on. However, for some of this client group the very fact of coming for counselling – as I call it – worries them because it is unknown. Some are also very unconfident about using written material, and one or two illiterate. Therefore sometimes I use neither the Psychotherapy File nor the Checklist. Sometimes the ‘Draw on your own emotions’ hand-out of drawings (Sunderland & Englehart, 1993) showing ways of relating to others is a better way of exploring the issues.
Thus ironically I am finding limitations in my use of the Checklist with a group to whom I would have assumed it might be particularly helpful. However, I should perhaps be more adventurous in raising the same issues in different ways.
We would be interested in hearing about the experiences of others maybe through the Reformulation letter column. In the meantime we have changed the Checklist to include ‘ personal appearance’ as one of the items. Ref lection and discussion with colleagues working in the area of disability reminds us that those two words cover a wide range of reasons why people may suffer scorn or rejection.
Rachel Pollard & Janet Toye
Smail, D (1993) The Origins of Unhappiness; a new understanding of personal distress London, Harper Collins.
Sunderland, M & Englehart, P (1993) Draw on Your Emotions Winslow Press
The social and political circumstances of our lives can have as much if not more influence on how we feel as our own individual histories and experiences. It can sometimes help us make sense of how we feel if we recognise.
Please tick the boxes that you feel apply to you:
Aspects of myself or my life that I feel unhappy about, disadvantaged by or in which I feel ‘different’ from other people.
Cognitive Analytic Therapy in People with Learning Disabilities: an Investigation into the Common Reciprocal Roles Found Within this Client Group
Psaila, C.L. and Crowley, V., 2006. Cognitive Analytic Therapy in People with Learning Disabilities: an Investigation into the Common Reciprocal Roles Found Within this Client Group. Reformulation, Winter, pp.5-11.
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.
Reflections on the Second International CAT Conference Maynooth, Ireland 15 - 17 June 2006
Donald Bermingham, 2006. Reflections on the Second International CAT Conference Maynooth, Ireland 15 - 17 June 2006. Reformulation, Winter, p.22.
'Don't Dis' Me!' using CAT with Young People who have Physical and Learning Disabilities
Collins, S., 2006. 'Don't Dis' Me!' using CAT with Young People who have Physical and Learning Disabilities. Reformulation, Winter, pp.13-15.
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