Playfulness in CAT

Coulter, N., Rushbrook, S., 2010. Playfulness in CAT. Reformulation, Winter, pp.24-27.


This article has evolved through our many passionate and excited dialogues regarding the notion of play in therapeutic relationships. We would like to share our ideas about using play within Cognitive Analytic Therapy (CAT). We will explore how playfulness links in with theories of Winnicott, Rogers, Bakhtin and Vygotsky and look more closely at the implications of using play within the therapeutic relationship; how it might enable us to be in the room with our clients in a manner that enhances the therapeutic bond, developing it more quickly to a deeper, more trusting and meaningful level. The principle of play is not restricted to any one therapy, but is an effective therapeutic tool borne out of an ability to practise in a radically genuine manner.

Winnicott describes the importance of play in working with both children and adults. “Psychotherapy is done in the overlap of the two play areas, that of the patient and that of the therapist. If the therapist cannot play, then he is not suitable for the work. If the patient cannot play, then something needs to be done to enable the patient to be able to play, after which psychotherapy may begin. The reason why playing is essential is that it is in playing that the patient is being creative.” (Winnicott, 1971 p54).

This is how play promotes the creative space within which to bring about change. He describes play as both “inherently exciting and precarious”. Thus playfulness creates the trust and intimacy that enables change to occur, as more risks are taken both by the therapist and by the client.

We use play to take informed risks with our clients enabling us to work mindfully in a way that feels genuine and present, allowing for more spontaneity in our responses moment to moment. This involves an ability to self-reflect honestly which lets us observe better the reciprocal roles both on the map and in the healthy roles of exits. Being authentic provides a flow and a spontaneity which leaves the therapist not always knowing what is coming up next; it feels risky yet exciting, requiring that the therapist is always prepared to be surprised and to respond with flexibility, repairing if necessary, exploring what has occurred and being open with clients about what we are trying to achieve. Furthermore, by putting more of ourselves in the room, we are modelling taking risks and are quick to laugh at ourselves and model self-deprecation and our own fallibility in a non-critical, playful way.

A useful metaphor for this is dance. A new therapist, when learning how to lead the dance for the first time, needs to concentrate on the steps. As their skill increases, they can then begin incorporating more creative steps in the dance allowing for greater expression, flexibility and flow. With time, experience and competence, if the therapist stumbles, misses a beat or misplaces a step, then they have developed the skills necessary to rectify quickly, easily and smoothly without distracting or ruining the dance. Thus the playfulness and authenticity of which we speak is a style that can be introduced over time, in the knowledge that you have the steps memorised in your body and can allow more freedom to flow. The type of dance depends on your dance partner. The skill of the professional dancer is to identify which dance would be the most suitable and have the flexibility to judge how it can be adapted to produce the most effective results.

Play includes a variety of style and strategies such as being creative, using humour, a lightness of touch, laughter, cheekiness, jokes, maybe shocking, gentle teasing, being unconventional, unexpected and off beat.

“It is play that is universal, and belongs to health: playing facilitates growth and therefore health; playing leads into group relationships; playing can be a form of communication in psychotherapy”. (Winnicott, 1971 p41).

Playfulness is both verbal and non-verbal; a look, a gesture and thus a shared language can be developed; a mediating sign, as Vygotsky describes. The playful responses in the therapist and patient dyad are a source of the sense of self, in “joint action sequences” (play) we create meaning together (Leiman 1994b).

Levels of Playful Strategy

Through continued dialogue regarding our evolving practice, we have defined two distinct levels of playful intervention, which we have labelled as “low order” and “high order”.

Low order strategies are applicable when the therapeutic relationship is in its infancy, before trust has been developed. They set the scene, paving the way for creating intimacy and facilitating the opportunity to move to higher order play interventions. A low order strategy is useful to test the waters at the beginning of therapy in order to explore and build on that particular relationship’s unique shared language of play. Lower order playfulness can be used almost universally; it does not require the trust and confidence of a relationship connection. It is essential to pay attention to work within BOTH the client’s and the therapist’s zone of proximal development (ZPD). Attempts to work outside of this ZPD could be damaging and would compromise the therapeutic bond. In terms of Paul Gilbert’s work on systems, it facilitates the client to move from the “threat system” to the “safe system” where learning and thus change can occur. An example of a lower order strategy is whilst doing a map with a new client, which looks rather scrappy saying lightly ‘Thankfully, I am not here to model perfection!’
High order interventions depend on an established relationship, therapeutic competence and self-awareness. They can be more risky and unconventional, for example, using playfulness during a client’s tears or anger. We would never recommend using a higher-level intervention with someone you did not have a relationship with, who is experiencing painful intense emotional arousal. However, when a trusting therapeutic relationship has been developed, such an intervention may cause a client to be brought up short, creating an alternative reciprocal response to one they were expecting, facilitating rapid re-processing in an unconventional, refreshing manner.

One example of a high order strategy was with a client who had inadvertently been invited into the abandoned place when the therapist was off sick. The client’s coping procedure was to complain profusely and repeatedly. It was brought up again as further evidence when another experience of abandonment occurred. With a strong, secure therapeutic relationship and following a number of interventions, which included acknowledging her distress and identifying her procedure, the therapist responded in a warm playful tone: ‘Oh Cynthia! Let me know when you are finished!’. The client was shocked, but then broke into a giggle. The giggle was at the shared knowledge and the recognition that here she was again. There was warmth in the shared space between client and therapist and they could move on free from the anger and re-access the “safe system”. As this intervention, whilst potentially placing the therapeutic alliance in a precarious position, was done in the knowledge of the security and strength of the relationship, it served to shift the client with a speed that enhanced intimacy through warmth in the process.

An Invitation to Play

As therapists we hold a powerful position and in the eyes of our clients we are often seen as the norm for Mental Health. We need to respect this by behaving as responsible role models, which does not mean attempting to model perfection. Through giving ourselves permission to play, we can harness our spontaneity and let go of always having to get it right. We want to demonstrate how we can dare to take risks, have a playful attitude with oneself and others and how we can recover from relationship ruptures by offering reparation.

Generally, people come with preconceived ideas about what therapy is. It is important to orientate clients to get and give permission to use humour.

This is part of the norms for contracting therapy in the service of a collaborative adult-to-adult relationship. Within our work with people with Borderline Personality Disorder (BPD), who are often sensitive to the needs of others and have a procedure of compliance, we must be clear that the invitation is genuinely reciprocal; something that they are truly collaborating in. We regularly check in with clients to ensure our continuing therapeutic contract.

Tailoring Play in the Therapy

We tailor the therapy to the needs of the individual client by developing a shared language. We do this by understanding who our client is, as in Bakhtin’s identification of the addressee in the dialogue. Every utterance according to Bakhtin “has an addressee and the addressee affects the very construction on the utterance”. We consider their style of humour, what works for them to create that spark, that magical moment within which intimacy and trust can be fostered. Some clients would find humour aversive and it is important to remain within their ZPD, not frightening and overwhelming them, but tentatively trying out new things and judging their response. As the relationship develops and the client is understood, shared language in terms of a playful style becomes evident. Verbal and non-verbal play becomes a “mediating sign” (Vygotsky) which is individually tailored.

Vygotsky stated “What the adult lets the child do or know today, the child can let herself do or know tomorrow” which Ryle (1991) has extended to “What the adult cannot let the child do or know today the child cannot let herself do or know tomorrow”. We are privileged in therapy to have the opportunity to add something to people’s repertoire that may otherwise be missed and therefore be absent in their future experience. If they can learn to play with us, they can learn to play on their own and with others.

Therapists need to have a framework, such as the scaffolding which the CAT model provides, within which the client can develop and grow. In addition, the therapist needs to be able, flexibly, spontaneously and continuously to assess and respond to whatever shows up in the room. Through play, we are experimenting to find the creative spot for change.

Genuineness

To be genuinely playful we need to have confidence in our therapeutic ability through which we can then play with ease and skill to promote therapeutic change. When we play from a position of loving care, it affords warmth and connection. It offers a generosity of spirit, a gift in the form of self-disclosure that allows connection and intimacy. It feels energising and inviting, promoting trust and giving permission to take risks, or simply to have a breathing space from relentless pain.

A vital ingredient to successful play is to remain authentic. If we play to try to be clever, this will be incongruent with who we are and how we are feeling. If we try to play from an insincere or self-serving position, we can create harm particularly when working with people with BPD who are highly sensitive and hyper-vigilant to insincerity. They typically act from a suspicious, threat system and would quickly perceive incongruence, recruiting a reciprocal role of not heard or seen from not listening/ cut off. By being genuine with our patients, we are inviting them to engage in a listening-to-heard reciprocal role.

Carl Rogers described genuineness as one of three core conditions. He perceived that being “real” facilitated learning and when the facilitator was real, being true to her/ himself without presenting a facade, then the therapist would be more effective because they were aware of their own feelings and acting accordingly.

If a therapist’s style were naturally more serious, less playful, then this would hold true to the idea of remaining genuine. However it is important for therapists to expand and be flexible, giving themselves permission to loosen the boundaries and constrictions that might come from remaining in a traditional ‘therapist role’. This is what we ask of our clients so we need to be prepared to ask it of ourselves. When we are in a stereotypical therapist’s role - serious, measured - is that truly genuine and congruent with who we are as social beings? Are we playing a role and therefore denying our patients and ourselves a wealth of opportunity to explore within a different medium? In play we let go of ‘expert therapist’, really risking being present with another. To do this means to lose an artificial style so that we too are prepared to meet in this space. “In playing, and perhaps only in playing, the child or adult is free to be creative” Winnicott (1971): we would consider this true for both client and therapist.

Advantages of Play

Through play we are better able to develop trust and intimacy; or rather it appears to accelerate the process. Play creates a spark that facilitates change and generally enhances the quality of relationships.

“Only in the forgetful intimacy, unobscured by the mother’s controlling and over-conscious aims, may the transitional object become saturated by its magic” (Leiman 1992 p214).

When we use playfulness, particularly higher order playfulness, the function may be either to create a break by offering a moment of relief from the distress or to engage in exploration, by creating some distance. A clinical example is a client, who came into a session deeply distressed about her friend’s cat that was very ill. This led her to morbid thoughts of losing her own cat, then of losing members of her family to the point where she had urges to self-harm. Based on a deep and well-developed relationship, the therapist used higher order playfulness; ‘Your poor cat! There he is waiting for his dinner and a cuddle and you’ve gone off to his funeral’. The client paused a moment, perhaps shocked, and suddenly she was laughing and locked in with something new. This created enough of a break in the horror of her terror to enable the therapist and client to work with her issues of abandonment which they had not been able to achieve hitherto.

People with BPD often experience life as if it is unrelenting misery, as if tragedy defines them as opposed to being something that has happened to them. Playfulness in therapy can potentially inject some lightness, taking them on a journey to somewhere different. Play, in such moments, can challenge assumptions about how clients relate to their distress. They are unlikely to notice warmth, humour or kindness in another, being too frightened and suspicious to acknowledge what is offered to them, thus missing the opportunity to enter a reciprocal encounter of cared for-to-caring. By injecting playful moments, the therapist is inviting them to experience this new reciprocal role themselves, so that they can develop a repertoire of play and increase their awareness when it is offered by others. Hence, humour can help shift a client into a different self-state.

A clinical example is working with a BPD client who was very depressed, presenting with flat affect and little engagement. Following many attempts at therapy, she had yet to tell her story, for fear of exposure. The therapist initially started their sessions with mindfulness; however this had limited impact as the client appeared to dissociate. So the therapist suggested that they practise mindfulness in throwing a ball to each other, which seemed to enable the client to remain focussed, particularly when she was given some trickier shots. She began to aim at the therapist’s head and vice versa until both therapist and client ended up giggling. When they resumed talking, the client was much more engaged. Furthermore, her dissociation markedly decreased and she started to develop her playfulness both in treatment sessions and in her life. Whilst not taking away the pain of her past, it provided an opportunity to process it and alleviated the misery of her present.

To facilitate change, it is important that the therapist provides a different response from the client’s existing reciprocal role repertoire. One client had a history of suicidal urges, was extremely self-critical and, in the early days of her therapy, her speech was littered with self-denigrating statements. She had never experienced friendship and felt as if she was always on the outside. Humour was introduced, initially by pointing out gently and lightly that she was putting herself down again (low order intervention), developing to a high order intervention: “There you go again!”. This evolved into a non-verbal communication, expressing mock horror when she left the therapy room with yet another statement along the lines of “I bet you are glad THAT is over”.

This expression became a shared sign, a short hand prompt to halt self-deprecation. After a few weeks, self-deprecating comments steadily reduced until they were so infrequent that, when she did find herself saying something, she would catch it immediately, as if shocking herself. At her final session, having started to form tentative relationships at her work, she reported that for the first time in her life she was able to be with others and perceive that they were laughing with her, as opposed to, at her. This shift in her perspective enabled her to make connections with people who had previously appeared unavailable to her. In not reciprocating in the way that the client expected from her repertoire of reciprocal roles (in this client’s case with either irritation or reassurance), she was offered a new kind of dialogue.

Playfulness is also a model of how we like to work in supervision, engendering trust and enabling supervisees to take more risks. It promotes honesty and risk taking on the part of the supervisee, as the lightness of touch offers, paradoxically, the opportunity to explore the more difficult and darker places.

Cautionary Notes

Using play needs to be practised with respect and caution. This is demanding but is also energising. It requires therapeutic competence, capacity to experience genuine compassion, ability to self–reflect and a clear understanding of our own map and how this can play out in the room. It is essential we remain curious about what our motives are. We must manage our anxiety and our own understandable need to be good therapists. Whilst we are preoccupied with our performance, we remain distant and unavailable to our clients. It is about being prepared, when we get it wrong, to move quickly to repair and to explore in supervision. If we use this style in order to serve ourselves, to vent our grievances or unconsciously humiliate our clients, then we would exacerbate already destructive procedures and invite such reciprocations as teasing-to-teased or abusing–to-abused.

Therapy requires being serious, being present and genuinely sad and concerned, as much as it means at times chivvying people along and taking risks in order for clients to reach their goals. Effective therapy requires staying with pain, grief and discomfort; we are not attempting to be fun and charming as a means to avoid painful emotion or trivialise the therapy. This is when play is not so much exciting and precarious as ineffective at best, dangerous and harmful at worst.

When our clients are angry or contemptuous of us, it is natural and understandable that we would have an emotional response to this as our own threat system is triggered. Naturally, we might wish to defend ourselves to justify to them, or alternatively we might feel angry and the urge may be to attack (go on the offensive). Our task is to notice our reactions so we can be aware and revise our own destructive default procedures, so that we are able to enter the exits on our map by always keeping the needs of the client present in our minds. If we use humour in order to be on the offensive or defensive, then we are no longer present together in the space with our client; we do not see them, we only see our own need to be away from our emotional pain.

Our experience of using a playful style has, on the whole, been rewarding, fulfilling and effective. When not the case, then it is essential to respond mindfully to rectify the situation. Therapeutic ruptures are grist for the therapeutic mill and can create helpful opportunities to develop greater trust through resolving ruptures well. We would always use therapeutic ruptures as an opportunity to model how to repair and preserve relationships, but we would never intentionally encourage ruptures as that would be deemed controlling and potentially abusive.

Play may initiate a rupture when it is ill-timed, but also may be used as a tool to repair, as with the earlier example of Cynthia complaining again about her therapist going off sick. The reason playfulness can feel so precarious is knowing that such an intervention may cause a rupture and, in order to dare to take such risks, we need to trust in our ability to recover.

Conclusion

We have been using play in our therapy for some years now and our practice is continuously evolving. The dialogue that we have shared with each other and with colleagues has been the lifeblood of this article. Play in therapy is not a new concept, yet the ideas seem fresh and contemporary. We have both had experience of being trained in ways that minimise self-disclosure, but now have broadened our therapeutic repertoire through our experience of working with people with Borderline Personality Disorders. Our greatest successes with clients are with those we have deep genuine caring relationships with and the flavour of therapy has invariably focussed on being present to the emotional pain, giving ourselves over to the therapy and having some fun on the way. When we tell our clients that it was a privilege and a pleasure to have worked with them, it is a genuine statement of fact.

Sophie Rushbrook is a Clinical Psychologist and Nicola Coulter is an Occupational Therapist working at the Intensive Psychological Therapies Service (IPTS), a Beacon service in Poole, Dorset. The service provides CAT and Dialectical Behaviour Therapy (DBT) to people with personality disorders. IPTS is a University Department of Mental Health, linked to Bournemouth University, part of Dorset HealthCare University NHS Foundation Trust.

Sophie Rushbrook and Nicola Coulter
E Mail Addresses for Correspondence
sophie.rushbrook@dhft.nhs.uk
nicola.coulter@dhft.nhs.uk

References

Bakhtin, M. M. (1981). The dialogical imagination. (M. Holquist, Ed.) Austin: University of Texas Press.

Bakhtin, M. M. (1986) Speech genres and other late essays. C. Emerson and M. Holquist (Eds., V.W.McGee, Trans.), Austin, TX: University of Texas Press.

Fawkes, L. (2006) Participating in a meaningful dialogue: How the conversations between Leiman and Ryle have augmented and enriched the way we work as CAT therapists. Unpublished Paper from CAT Conference Presentation.

Gilbert, P. (2010) The Compassionate Mind. Constable and Robinson UK.

Leiman, M. (1992) The concept of sign in the work of Vygotsky, Winnicott and Bakhtin: Further integration of object relations theory and activity theory. British Journal of Medical Psychology, 65, 209-221.

Leiman, M. (1994b) Projective identification as early joint action sequences: A Vygotskian addendum to the Procedural Sequence Object Relations Model. British Journal of Medical Psychology, 67, 97-106.

Rogers, C. (1967) The interpersonal relationship in the facilitation of learning reprinted in H. Kirschenbaum and V.L. Henderson (eds.) (1990). The Carl Rogers Reader, London: Constable, pages 304-311.

Ryle, A. (1991) Object relations theory and activity theory; a proposed link by way of the procedural sequence model. British Journal of Medical Psychology, 64, 307-316.

Vygotsky, L.S. (1978) Mind in society: The development of higher psychological processes. Cole, V. John-Steiner, S. Scribner, E. Souberman (Eds.). Cambridge, MA: Harvard University Press.

Winnicott, D.W. (1971) Playing and Reality. Routledge.

Full Reference

Coulter, N., Rushbrook, S., 2010. Playfulness in CAT. Reformulation, Winter, pp.24-27.

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