Situating Social Inequality And Collective Action In Cognitive Analytic Therapy

Brown, R., 2010. Situating Social Inequality And Collective Action In Cognitive Analytic Therapy. Reformulation, Winter, pp.28-34.

Rhona Brown reflects on her experience of working within communities where the impact of social adversity and inequalities can outweigh benefits of individualised psychotherapy. She considers CAT’s promise as a psychotherapy which can situate the individual within a social context, and draws upon community psychology perspectives, and the key concepts of psychopolitical literacy and validity, in asking how CAT might take a stronger stance on social inequalities and enable collective action towards social justice. She refers to the some of the dialogue on these issues to date within the CAT community, and proposes a collective and multivoiced approach to developing the model further.

The limitations of Eurocentric and individualised psychotherapies have been starkly illuminated to me in the process of working in an inner city primary care psychology service over the last 16 years. Manchester is home to many diverse communities, which offers a richness of identity, perspective and experience. However for many communities this can coexist alongside marked social and material deprivation, social inequality, and discrimination in the present. Some individuals and communities additionally carry with them histories and heritages of disadvantage and trauma, often linked to such inequalities.

While individual psychotherapies can impact positively upon psychological distress associated with such societally located adversity, therapeutic benefits are often attenuated by the ongoing challenges of living in an unequal society. The therapeutic models and methods at my disposal as an NHS clinical psychologist have little to say about such dilemmas. In the current NHS climate driven by performance and results, it is rare that conversations about these social realities hold a forefront position in service planning and model development. Instead they tend to be relegated to more private conversational spaces with colleagues in clinical supervision, or quieter and more informal “corridor”-type interactions; or are more freely voiced with peers, friends and partners outside a work context.

This is not to say that there are no available therapeutic models which name and incorporate social inequalities. On the contrary, approaches such as feminist therapy (e.g. see Watson & Williams, 1992) and intercultural therapy (e.g. Carter, 1995, Thomas, 1992, Kareem & Littlewood, 1992) have made their mark on practitioners, but tend not to figure strongly in the evidence base which forms the basis for clinical guidelines.

Community psychology (e.g. see Orford, 1992 & 2008) offers an alternative perspective on mental health, the prevention of ill health and the promotion of wellbeing. Bostock & Diamond (2005: 22) summarise its principles:- “Community psychology is essentially concerned with the prevention of psychological distress. This requires the recognition of entrenched social injustices, the adverse impact of these on people’s wellbeing and health, and the need for organisational and social change. The means for community psychology to contribute to such change comes through the development of alliances with marginalised groups and community interests, so that collaborative work can redress power imbalance and abuse. A community psychology perspective can be applied in diverse clinical psychology settings in the National Health Service (NHS) in order to inform individual interventions, advocacy work, group work, developments, campaigning and action research. Underpinning this endeavour are the principal values for community psychology of focusing on people’s strengths, taking a universalistic perspective on people’s experiences, working inclusively and devolving professional power.”

They also draw attention to some of the conflicts and tensions that can exist when attempting to incorporate community psychology approaches within a professional context where organisational processes may act to preserve rather than challenge established power hierarchies. For example, the notion of expert therapeutic knowledge may maintain professional survival in a difficult climate; but this may serve to subjugate other forms of knowledge, such as service user or broader community perspectives on what causes, maintains or helps to remedy distress. Such tensions perhaps help to explain how community psychology perspectives have remained on the margins of therapeutic thinking despite being available for several decades, and how an individualistic approach continues to be privileged within mental health services.

For me, CAT holds much appeal as an individual therapeutic approach which has potential to situate and acknowledge adequately the individual within a social context. It actively promotes a collaborative and power-sharing therapeutic relationship; and is offered within a short-term model congruent with the demands of an NHS primary care setting. However, through and since practitioner training, I remain struck by how it falls short of realising its full potential by developing a stronger focus on social inequalities and social change.

I chose to explore this area as part of my training requirements, initially with a view to clarifying my own thinking, and have been very heartened since to have engaged in a number of dialogues with CAT and other colleagues who share such interests and concerns. I am particularly grateful to colleagues in Manchester and the North East, trainers and trainees within ACAT North, and to Tony Ryle, who has been supportive and challenging in equal measure, in discussing and considering this area further. His recent article (Ryle, 2010) offers a direct invitation to the CAT community to more directly acknowledge and articulate the broader impact of political forces upon the psychological distress of recipients of CAT, in his terms to “attend to the ultimate as well as intimate” in reformulations. I would suggest that CAT practitioners might potentially extend their activities by considering how the uniquely sociocultural theory upon which CAT is built may help us extend the model to incorporate other ways of working. This cannot be a solitary undertaking, but requires a collective, collaborative and multivoiced approach.

To this end, the concepts of psychopolitical literacy, and psychopolitical validity (see Prilleltensky & Fox, 2007, Prilleltensky, Prilleltensky, & Voorhees, 2007), are useful in describing and making sense of this territory. Psychopolitical literacy refers to “people’s ability to understand the relationship between political and psychological factors that enhance or diminish wellness and justice” (Prilleltensky & Fox, 2007: 799).

Psychopolitical validity is differentiated into a) epistemic psychopolitical validity, which is, in relation to research (and, I am assuming, theory), “the extent to which studies of wellness and justice take into account both positive and negative political and psychological dynamics that affect personal, relational, and collective needs”; and b) transformative psychopolitical validity which is, in relation to mental health interventions, “the extent to which interventions reduce the negative and strengthen the positive political and psychological forces contributing to wellness and justice” (Prilleltensky & Fox, 2007: 801 – 802).

I would argue that the dialogical theoretical underpinnings of CAT give it strong epistemic psychopolitical validity. However, at this stage in its development, its transformative psychopolitical validity is limited. I believe this could be strengthened firstly by a more active and explicit focus on enhancing the psychopolitical literacy of both its practitioners, and its recipients. Secondly, the model could be further developed to provide a platform for collective action and change, by empowering clients to find means by which to influence those circumstances which directly contribute to their (and/or others’) personal distress.

I will use the term “collective action” rather than “social action”, as in recent months appropriation of the latter term has led to current and specific party political meaning.

Looking Out: Examples Beyond CAT

Examples below may further our consideration of how this might be achieved. The models described attempt to more directly incorporate transformative psychopolitical validity within their therapy approaches.

Social Action Psychotherapy

Sue Holland developed Social Action Psychotherapy (SAP) through her work with the White City Mental Health Project over a number of years. This set out to meet the needs of depressed women resident in a multiracial inner city estate. She situated her own struggle as a Tavistock-trained psychotherapist living and working in this environment “trying to use psychotherapy in a way which would help them not only to change themselves but to change things around them” (Holland, 1990: 259).

She developed a model which identified four stages through which women might move “through psychic space into social space and so into political space” (Holland, 1995: 141). She termed these positions “Patients on Pills” (individual, symptom-focussed, her identity as a medicalised patient); “Person-to-Person Psychotherapy” (a focus on the intrapsychic and interpersonal self, developing awareness and understanding of the meaning of distress through a one-to-one psychotherapeutic relationship; a stronger self-determined identity); “Talking in Groups” (now entering a social and inter-relational space, meeting with other women in groups to discover common histories); and finally “Taking Action” (using a collective social voice to take action or negotiate for required change in communities in the interests of health and wellbeing).

Holland describes the establishment and nurturance of interpersonal connections beyond the therapy relationship, with similar others, as a form of “conscientisation” (Freire, 1972). The process of naming and unraveling a “common, shared, but hidden, history…emphasizes not only the women’s shared sense of suffering and loss, but also their collective strengths and mutual interdependence in their struggle for change and emancipation” (Holland, 1990: 263).

This more actively dialogical and intersubjective process is contrasted with individual psychotherapy, which without addressing social inequalities Holland views as “merely adaptation, not emancipation, and so by default becomes…another weapon in an oppressive social system’s armory of social control” (Holland, 1990: 259)

Power Mapping

These themes are echoed in Hagan & Smail’s account of power mapping (Hagan & Smail, 1997a & 1997b), which draws upon Smail’s (1993) concept of “the impress of power” (see Diagram 1).

The authors describe macro-level “distal” influences as highly influential upon well-being, but often invisible to, and beyond the influence of, the solitary individual. More “proximal” influences are less powerful, but more immediately visible, and are therefore commonly perceived and experienced as more powerful by the individual. Individual psychotherapies commonly target changes at the level of the person (e.g. shifts in experience, perception, symptoms), and sometimes at the proximal level, but Hagan and Smail highlight the

“sheer futility and unintentional cruelty involved in a psychological practice which insists that clients change without providing them with the means to bring about that change” (Hagan & Smail, 1997b: 277).

They describe work with adult survivors of sexual abuse involving group-based therapeutic activity, using power mapping techniques as a means of client-generated reformulation of life stories, making visible and explicit sources and degrees of power and powerlessness, both in the past, and the present. This aids survivors in contextualizing survival strategies adopted, and validating “ways of experiencing, interpreting and relating in later life” (Hagan & Smail, 1997b: 270). This helps clarify and revise problematised accounts of the self, and perceived responsibility for early abuse.

Hagan & Smail also emphasise the limits of such revision, and the potentially unhelpful assumption of most psychotherapies (including CAT) that the adult is necessarily significantly more powerful as an adult than when a child. Mapping power in the present elucidates areas where power continues to be limited or absent. They advocate a key therapeutic focus as the extension of current power horizons. The inter-relational group context facilitates the development of what they term “proximal solidarity”, an “essential form of power” (Hagan & Smail, 1997b: 279). It should be noted that the term “proximal” differs from its use in CAT language (I.E. zone of proximal development), in this context referring to the experience of inter-relational connectedness, enhancing both social validation, and worth. A key element in the value of proximal solidarity is the survivor’s transition from identifying herself as ‘client in need’ (akin to the first 2 quadrants of Holland’s model), to provider-and-recipient of reciprocal support. The survivor’s access to social resources is enriched, and group membership can additionally confer access to material, ideological and institutional resources.

Diagram 1: David Smail’s Conceptualisation of the Impress of Power

Reproduced from Smail (2000) Power Responsibility & Freedom (Internet version) retrieved from 10.19 3rd April 2008 [Diagram originally published in Smail (1993)]

Narrative Approaches

Narrative Therapy approaches developed by White & Epston (1990), have consistently maintained a therapeutic gaze on culture, privilege, and inequality, and also share with CAT the use of therapeutic letters as tools in the re-authoring of individual histories and meaning.

A particularly interesting model within this body of work is that of “Just Therapy” (see Waldegrave, 1990, Tamasese & Waldegrave, 1993), developed within a multicultural organization in New Zealand, where Maori, Samoan and Pakeha therapists and community workers reflect the multicultural communities served. Key elements include explicit attention to historical and current injustice amongst communities, through the dedication of “institutional space” and time where injustice is named and heard. This includes the concept of “caucusing” where similar groups (e.g. cultural or gender-identified groups) meet independently of each other to discuss shared perspectives, before these are presented to each other. “Converging of meaning” is achieved through the collective consideration and authentication of pain by those associated with perpetrating injustice. Groups work together to develop shared practices, and systems of accountability, which honour each other’s culturally imbedded perspectives. This process models carefully developed, genuine partnership for the families and communities served.

This approach is radical in its structural and institutional implications, and therefore perhaps harder to easily imagine translating into practice in common therapeutic services in the UK. However there are many other useful ideas and approaches within narrative therapy which may be easier to translate into practice in CAT (E.G. see Wade, 1997).

What the above examples share is an explicit focus on the inter-relational social environment as a vehicle for individuals to develop the psychological, relational, and material resources to access and increase their personal power.

Listening In: Conversations within CAT

The CAT community has a history of dialogue around issues of social power and inequality, including a strong focus on how power operates within the therapy relationship. Its theoretical bases, drawing on Vygotsky’s activity theory and Bakhtin’s dialogic model of the self, guarantees its place as a psychotherapy firmly rooted within a cultural, societal and inter-relational framework. Key Vygotskyian concepts include the social formation of the mind, shaped via relationships with others; sign mediation, whereby the word is understood as a “jointly elaborated interpsychological sign” (see Leiman, 1992); internalisation, whereby conversations using jointly derived signs between infant and carer are practiced in an external manner, then form the basis for externally silent, internalized self-talk, thought and definitions of self and other; and finally, the zone of proximal development.

Bakhtin’s contributions are discussed by Ryle and Kerr (2002) with particular emphasis on his focus on a multiplicity of voices in interlocution (not just those of infant and carer/parent), and the concept of the “superaddressee”. This is described as the message of “the wider culture or some part of it” (Ryle & Kerr, 2002: 45) transmitting important aspects of societal norms and values via the messages of the first voice (e.g. parent, teacher, therapist) to the second (e.g. child, pupil, patient). Ryle and Kerr grapple with the issue of “Who does the therapist speak for?” (Ryle & Kerr, 2002: 54 – 55) acknowledging the differential distribution of power and privilege, and the dominant values and attitudes associated with a given culture. “In this way every individual’s internal regime (including the psychoanalytic “unconscious”) will contain the voices of the external social and political reality as refracted by parents and teachers.” They go on to acknowledge the therapist’s internalisation of given cultural norms, but express optimism that the therapist will make efforts to “offer a different perspective”, and eschew those practices which act against wellbeing and justice.

Pollard (2004) notes the appeal of Bakhtin’s concepts, particularly in relation to “acknowledging, respecting and valuing human cultural diversity” (Pollard, 2004: 8). However she also raises concerns about the degree to which a multiplicity of voices can be assumed to find areas of common ground and resolve conflicts:- “Not all diverse voices are tolerant of diversity. Bakhtin’s dialogism does not necessarily bridge the gap between diverse voices that do not or cannot tolerate each other’s convictions and beliefs” (Pollard, 2004: 8). She goes on to draw on Hermans (1996) work noting:- “Many dialogical interactions are asymmetrical between people with differing amounts of social power…People do not have equal access to the power of words.” (Pollard, 2004: 9).

This resonates strongly with my own clinical experience, and those who highlight the struggle of some clients to find ways to negotiate a professional language in therapy. Toye (2003) highlights the potential for misunderstandings in the therapeutic relationship and for a privileging of the therapist’s understanding and conceptualizations. Donna (2000: 231), describes in her experience of undergoing therapy:

“At times I struggled with the language. Even though we all speak English, I find that professionals and white people do not understand Black English – my language. That means therapy and what I could benefit from can be blocked and nothing develops. I felt it was up to me to change my language to try to be understood. Sometimes I thought my therapist didn’t really understand what I was saying or meaning and so I needed to check her out on it.”

This does not begin to incorporate the additional complexities of working across languages in a therapy context with the support of an interpreter (e.g. see Tribe & Ravel, 2003), or through the additional competencies afforded by a bilingual CAT therapist.

Wertsch (1998) draws attention to Bakhtin’s discussion of authoritative versus internally persuasive discourse, the former “demands that we acknowledge it, that we make it our own; it binds us, quite independent of any power it might have to persuade us internally; we encounter it with its authority already fused in it” (Bakhtin, 1986: 342). Ryle and Kerr would aspire that psychotherapists engage in internally persuasive discourse; inviting their clients to engage in a dialogue:

“the authoritative word presupposes and enforces a kind of distance whereas the internally persuasive word encourages contact and dialogue” (Wertsch, 1998: 66).

CAT therapists are unlikely to utilize intentionally an authoritative discourse in these terms. However the social power held by the therapist, or attributed to the therapist on the part of the client, may imbue a therapeutic discourse with such characteristics, whether intended or not. A therapist with little awareness or comfort with his or her own identity and social positioning may struggle to recognise and explore such issues in a collaborative manner.

Aitken (2000) provides a useful and detailed description of how she managed differential power positionings and processes using CAT with Black women in forensic settings, illustrating ways in which power was articulated and explicitly shared through the flexible and creative use of CAT tools. Interestingly, she describes how feminist therapy approaches proved more useful to her in understanding and negotiating these issues than ‘stand-alone’ CAT.

Around this time within ACAT membership publications, a conversation took place about how issues of cultural diversity and racism might be incorporated into CAT thinking, practice, and organizational structures. Lomax (1999), Toye (1999) and Harris (2000) shared thoughts and experiences of working in intercultural contexts and unraveling “real, elicited and imagined threats” including the real threat of racism (Toye, 1999) in the therapeutic conversation. Others within the CAT community were invited to respond, share experiences, and collectively consider the issue of racism in relation to training, selection of trainees, and representation within CAT.

Throughout Ryle’s key texts on CAT, he has made consistent reference to social context, social power, and injustice, although he argued that the assumptions and social controls which establish and maintain inequalities “are largely enforced by psychological, not material means” (Ryle 1997: 163). I would argue that this position fails to acknowledge sufficiently the inter-relationship between political and internalised psychological oppression (e.g. see Prilleltensky & Gonick, 1996, and Oliver, 2004). He ended this volume with a rallying call to fellow NHS psychotherapists to resist political and economic influences upon mental healthcare delivery, threatening to create further barriers to those with borderline presentations. Welch (2000) responded, highlighting economic and political frustrations within the NHS, and considering ways in which therapists may work for or against the interests of those enjoying material privilege. Welch wrote how the “complex relationship between the political and the psychological is central to how we intervene with clients”; and noted the value of the concept of reciprocal roles as a “connecting tool” to aid to understanding commonly shared responses to institutionalized inequalities and brutalities. He ended with a call to collective action “to transform the conditions giving rise to our common unhappiness”.

In their 2002 volume, Ryle & Kerr made a determined effort to situate CAT within a landscape of social context, inequality, and cultural relativity. Discussion of the cultural formation of the mind was expansively covered. Themes of social inequality and the role of culture in determining self and the expression of distress were developed more comprehensively, with direct reference made to “history, power relations and dominant ideology of different societies” (Ryle & Kerr, 2002: 26). However they linked “social phenomena such as racism, aggressive nationalism and stigmatizing behaviour” to aversive early experiences on the part of those expressing such prejudice. In doing so the issue of commonplace expressions of racism, enacted as a cultural norm within the UK, and those more subtle and instititionally enshrined aspects of racism inherent in society, remained unacknowledged.

They emphasised how the norms and values of Western cultures contrast with those of other cultures, suggesting CAT can offer something towards the consideration of cultural issues in conceptualizing the self and distress. They gave examples such as different cultural manifestations of distress, and the impact of gender roles. They made laudable recommendations on the desirability of attempts at “culture mapping”, and the generation of “some meaningful account of cultural and ethnic diversity within all psychotherapy models”
(Ryle & Kerr, 2002: 38).

Their position that “all psychotherapists should aim to be free of normative cultural values” (Ryle & Kerr, 2002: 38) is in my opinion rightly questioned by Toye (2003). Indeed it contrasts with their statement later that “the neutral therapist is a myth; tacitly he or she is either challenging or identifying with current social power” (Ryle & Kerr, 2002: 55). They helpfully suggest that awareness of one’s own “tacit social assumptions” is as important as other outcomes of personal therapy.

It is my impression that an ambivalence exists. Ryle & Kerr express a co-existing commitment to acknowledging and naming social context and inequality within the model; deserved optimism that its intersubjective and dialogical theoretical framework can provide a structure which will further this aim; but also perhaps some discomfort and denial about “owning” the potentially damaging aspects of occupying a relatively privileged societal position. Precisely how these values can be realized and translated into action in CAT practice remains unclear, and this invites a broader collective consideration by those within ACAT.

Welch’s (2003) wide-ranging discussion of “socializing the personal, personalizing the social” made a serious attempt to integrate the Vygotskian basis of CAT’s theory with contemporary critical theory, and developments in infant research, in relation to both intersubjectivity and the role of social realities in the causation and experience of psychological distress. In Welch (2004), he turned his attention more specifically to Marxism and global capitalism, linking the distal influence of class relationships to reciprocal roles observed in one-to-one relationships. His writing is a clear attempt to develop a psychopolitical literacy within CAT. However it illustrates for me one of the challenges of entering more fully into this frame of reference, that of the different types of language in which the individual must become sufficiently fluent in order to ‘hybridise’ his or her thinking. The challenge is not insignificant; certainly it highlights for me the outer edges of my own zone of proximal development.

Janet Toye’s work (Toye, 2003) exploring cultural diversity in relation to CAT was similarly broad-ranging, drawing on theoretical perspectives from the worlds of intercultural psychotherapy, cultural psychology, and social constructionism. Like Welch she supported the concept of reciprocal roles as a useful means of understanding and articulating internalized aspects of societal relationships.

A CAT publication which demonstrates strong psychopolitical literacy, epistemic and transformative validity, is the account given by Shannon, Willis, & Potter (2006) of developing a therapeutic model for working with violent men. This is clearly rooted in a sociological perspective on the gender roles assigned to men in contemporary British society, how these intersect with boys’ identity formation, psychological and inter-relational development and the limited repertoire of social roles and behaviours that can arise in the context of narcissistic disturbance. The model describes not only provides a broad contextualised reformulation to bear in mind when working with men with this type of presenting difficulty, but also suggests a therapeutic model that matches fairly closely Holland’s SAP model. They describe delivering a CAT-informed model of group therapy whereby men are invited to share and reflect together upon their own personal SDR’s, perhaps developing a “proximal solidarity” for collectively considering the more vulnerable and needy aspects of themselves, and the possibilities for challenging gender role expectations within their lives outside of therapy. A possible extension of this model might be the facilitation of mentoring programmes within communities of origin, which could offer men alternative roles as mentors post-therapy, and offer community members alternative models through which their role repertoires might be expanded.

Looking Forward; Developing Psychopolitical Literacy and Validity in CAT

The development of the Psycho-Social Checklist in 2004 by Yvonne Harris and Janet Toye was a tangible milestone towards facilitating discussion around the personal impacts of social positioning within a CAT therapy. Pollard & Toye (2006) report on its further revision. As an adjunct to the Psychotherapy File, it invites the client to reflect on and consider a range of social, political and cultural attributes in relation to how these may have influenced their development and the issues that brought them to therapy. Importantly, its inclusion as a standard tool in the CAT model facilitates the early invitation to consider and name such issues, and differences in perceived positionings, within both the reformulation and the therapy relationship. One implication of its standard use is that more time may be needed within the already busy reformulation period in order to give adequate space to discuss and incorporate the issues arising. Another is that raising such issues in therapy assumes that we then know what to do with them, and it is not clear to me that there is a shared sense within CAT of how to work with difference when this is raised in the therapy relationship.

However, strength lies within the CAT community’s existing diversity if we are to take seriously the dialogical model. The multivoicedness of those practicing and training in CAT, where many different perspectives inform practice, offers rich opportunities for collaborating towards exploring these issues further, and developing new approaches. Many training models for intercultural work are currently available, some even with a Vygotskyan theoretical basis and dialogical underpinning, which may have particular relevance for CAT training (e.g. see Pederson, 2000).

An important omission, in my view, is that of the client voice. CAT’s psychopolitical validity would be enhanced, both epistemically and transformatively, by the development of an arm within ACAT representing recipients of CAT, which can be used as a conduit for further collaborative dialogue and participatory research around these issues. Additionally, groups with shared heritages and identities who may not have experienced CAT but are interested and able to provide specific cultural perspectives on the model could enrich perspectives further. Perhaps these could help seed a “Just CAT” initiative.

Were we to build a broader CAT community it may be possible to use some of the ideas and approaches offered by third generation Activity Theory (E.G. see Engeström, 1999 and Cole, 1996) which focuses on macro-level systems of activity, aiding understanding of how tensions, conflicts and contradictions within complex activity systems can engender change. Daniels (undated: 4) notes. “It is not only the subject, but the environment, that is modified through mediated activity” and writes of the use of this approach in promoting hybridisation within multi-agency settings. Stahl (2000) conceptualises similarly grounded models for computer-supported collaborative knowledge building. This may not seem immediately relevant to the psychotherapy world, but perhaps offers an additional means for caucusing, negotiating difference, developing shared meaning and promoting proximal solidarity across virtual communities.

Returning to the issue of how social influences might be woven into a reformulation, a project in its own right might be a survey or conversation amongst CAT practitioners to share how they have attempted to do this using letters and diagrams. In my experience, a 2 –dimensional SDR can feel inadequate to the task. I have used SDR’s which incorporated a distal ‘second skin’ around the more proximal influences, naming, for instance, “hostile, labeling, racist” to “hated, labeled, attacked” as a backdrop to reciprocal roles derived from family relationships. However the spatial relationship of this within a 2-dimensional diagram can seem inappropriate; for me the distal reciprocal role cuts through the rest at somewhat of an angle. Computer-aided representation may help us to construct more flexible diagrams. Alternatively, a more actively relational and fluid “map-and-talk” approach is described by Potter (2010) whereby “a life map can help tell the wider social stories of me in the world by making links to class, culture and national identities” (p 42).

Finding meaningful shared language to describe social inequalities pertinent to the individual’s reformulation may be challenging, especially when practitioners may themselves be in a process of becoming psychopolitically fluent, and perhaps when aspects of these may be uncomfortably felt and re-enacted in the therapy relationship. Pollard (2008: 211) notes how “therapists giving greater and more explicit recognition to the social, rather than individual, pathological origins of mental distress [can] in so doing [undermine] the nature of their own knowledge and authority and the relative balance of power in the therapy relationship”. Bearing in mind the risk of the therapist’s word being experienced as overly powerful, or patronizing, the skill of writing accessibly, authentically, and dialogically is clearly essential (E.G. see Potter & Sutton’s (2006) useful article and appendices).

A final area to consider is how CAT might enable the development of proximal solidarity amongst its users, assuming that inequality and oppression will still face them outside the therapy room. An obvious solution is the development of more group work in general, to which clients could graduate following individual CAT. However the group environment postulated by the SAP model would be less professionalized, and more participant-led. The feasibility of establishing such groups might be limited, but true to a community psychology approach, it may be possible to draw on the strengths of existing, perhaps naturally-occuring groups already in communities. This calls for increased partnership work amongst statutory and community agencies, and again, may require practitioners to develop new skills.

The potential of virtual communities, whereby people with shared concerns can communicate electronically, is a further possible area for exploration (assuming increased digital inclusion across communities). As an example, Pledgebank (see is a free online public participation service describing itself as “….a site to help people get things done, especially things that require several people…We believe that if a person possesses a slight desire to do something, and then we help connect them to a bunch of people who also want to do the same thing, then that first person is much more likely to act.” A voluntary and anonymised online “Exitbank”, where recipients of CAT can post end-of-therapy exits related to challenging or resisting shared experiences of oppression could provide individuals some sense of connection with (or inspiration by) others engaged in shared struggle.

To summarise, some possibilities for realising more fully CAT’s potential as a vehicle for articulating inequalities and enhancing social justice include:-

  • developing our psychopolitical literacy as therapists;
  • developing language(s) and respectful approaches in introducing, or responding to, psychopolitical literacy within the therapeutic dialogue;
  • developing skills and comfort in acknowledging difference and inequality within the ordinary conversations and dynamics of the therapeutic relationship, including tolerating the discomforts and uncertainties this can provoke;
  • developing and making use of tools to this end, including mapping, diagrammatic and written reformulation tools;
  • mining the professional and personal diversity within the CAT community to explore and develop dialogically based training models for addressing and responding to inequalities;
  • expanding the diversity of the CAT community by inviting dialogue, creative challenge, and collaboration with a range of different communities whose perspectives may enrich and broaden those currently cherished; and
  • exploring means to facilitate the broadening of power horizons of recipients of CAT (or of communities more widely), through developing opportunities for dialogue, connection, the active sharing of personal exits and collective action. Particularly within the current economic climate, this is likely to demand creativity in securing and defending the material resources required to make effective collective action possible and sustainable.

These are just some possibilities for developing CAT’s transformative psychopolitical validity. If the most likely route towards realising this is one of collective action, and the convergence of many different positions and paths, I would not expect such a venture to be possible without some degree of conflict and disagreement along the way. That guarantees an interesting journey at least.

Rhona Brown

Reformulation would like to acknowledge the kind agreement given by David Smail to reproduce his diagram here. Rhona Brown and the Editors would be interested in hearing the opinions of readers about this topic and how we could develop this further in our CAT practice.


Aitken, G. (2000) Women Working with Women: Differences and Power in Forensic Therapy Encounters. Changes 18 (4), p 254 – 263.

Bakhtin, M., (1981) The Dialogic Imagination: Four Essays by M. M. Bakhtin. ed. by M. Holquist., translated by C. Emerson and M. Holquist. Austin, Texas: University of Texas Press.

Bostock, J.& Diamond, B. (2005) The value of community psychology: Critical reflections from the NHS. Clinical Psychology Forum, 153 (September), p 22 – 25.

Cole, M., (1996) Cultural Psychology: A Once and Future Discipline. Cambridge MA: Harvard University Press.

Daniels, H., undated. Studying Shifts in Subject Position from the Perspective of Activity Theory. Centre for Sociocultural and Activity Theory Research, Department of Education, University of Bath. Available at: (Accessed 13.26, 30th March 2008).

‘Donna’ (2000) Donna. Changes, 18 (4), p 230 – 231.

Engeström, Y. (1999) Innovative learning in work teams: analysing cycles of knowledge creation in practice. In: Y. Engeström, R. Miettinen & R. Punamäki, eds. 1999. Perspectives on Activity Theory. Cambridge: Cambridge University Press. p 377-406.

Freire, P. (1972) Pedagogy of the Oppressed. Harmondsworth: Penguin

Hagan, T. & Smail, D. (1997a). Power-mapping – I. Background and Basic Methodology. Journal of Community & Applied Social Psychology, 7, p 257 – 267.

Hagan, T. & Smail, D. (1997b) Power-mapping – II. Practical Application: The Example of Child Sexual Abuse. Journal of Community & Applied Social Psychology, 7, p 269 – 284.

Harris, Y. (2000) Race & CAT. ACAT News Article.

Hermans, H. (1996) Voicing the Self: From Information Processing to Dialogical Interchange. Psychological Bulletin 119 (1), p 31 – 50.

Holland, S. (1990) Psychotherapy, oppression and social action: gender, race and class in black women’s depression. In: R.J Perelberg & A.C. Miller, eds. 1990. Gender and Power in Families. London: Routledge. Chapter 14, p 256 – 269.

Holland, S. (1992) From social abuse to social action: A neighbourhood psychotherapy and social action project for women. In: J.M. Ussher, & P. Nicolson, (eds), 1992. Gender Issues in Clinical Psychology. London: Routledge. Chapter 3, p 68 – 77.

Holland, S. (1995) Interaction in women’s mental health and neighbourhood develelopment. In: S. Fernando, ed. Mental Health in a Multi-ethnic Society: A Multidisciplinary Handbook. London: Routledge. Chapter 9, p 139 – 147.

Kareem, J. & Littlewood, R. eds. (1992) Intercultural Therapy: Themes, Interpretations and Practice. London: Blackwell.

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

Lomax, C. (1999). A White Therapist’s Tale. ACAT Newsletter Article.

Oliver, K. (2004) The Colonization of Psychic Space: A Psychoanalytic Theory of Social Oppression. Minneapolis: University of Minneapolis Press.

Orford, J. (1992) Community Psychology: Theory and Practice. Chichester: Wiley.

Orford, J. (2008) Community Psychology: Challenges, Controversies and Emerging Consensus. Chichester: Wiley.

Pederson, P. (2000) Hidden Messages in Culture-Centred Counselling: A Traid Training Model. Thousand Oaks: Sage.

Pollard, R. (2004) Are there limitations to the dialogical approach o psychotherapy? Reformulation, Summer, p 8 – 14.

Pollard, R. (2008) Dialogue and Desire: Mikhial Bakhtin and the Linguistic Turn in Psychotherapy. London: Karnac.

Pollard, R. & Toye, J. (2006) Updating the Psychosocial Checklist. Reformulation, 27 (Winter), p 19 -21.

Potter, S. (2010) Words With Arrows: The Benefits of Mapping Whilst Talking. Reformulation, 34, Summer, p 37 – 45.

Potter, S. & Sutton, L. (2006) Making the dialogic clearer in the practice of cognitive analytic therapy. Reformulation Article.

Prilleltensky, I. & Fox, D. (2007) Psychopolitical Literacy for Wellness and Justice. Journal of Community Psychology, 35, p 793-805.

Prilleltensky, I. & Gonick, L. (1996) Politics change, oppression remains: on the psychology and politics of oppression. Political Psychology, 17, p 127 – 147.

Prilleltensky, I., Prilleltensky, O. & Voorhees, C. (2007) Psychopolitical validity in the helping professions: Applications to research, interventions, case conceptualization, and therapy. In: C. Cohen, & S. Tamiami, eds., Liberatory psychiatry: Towards a new psychiatry. New York: Cambridge University Press. p. 105-130.

Ryle, A. (1990) Cognitive-Analytic Therapy: Active Participation in Change. Chichester: Wiley.

Ryle, A. (2010) The Political Sources of Reciprocal Role Procedures. Reformulation, 34, Summer, p 6 – 7.

Ryle, A. & Kerr, I. (2002) Introducing Cognitive Analytic Therapy: Principles and Practice. Chichester: Wiley.

Shannon, K., Willis, A., & Potter, S. (2006) Fragile states and fixed identities: Using Cognitive Analytic Therapy to understand aggressive men in relational and societal terms. In P. Pollock, M. Stowell-Smith, & M. Göpfert eds. Cognitive Analytic Therapy for Offenders: A New Approach to Forensic Psychotherapy. New York, NY, USA: Routledge/Taylor & Francis Chapter 17, p 295-314.

Smail, D. (1993) The Origins of Unhappiness: A New Understanding of Personal Distress. London: Harper Collins.

Smail, D. (2000) Power Responsibility & Freedom (Internet version) Available at: (Accessed: 10.19, 3rd April 2008).

Stahl, G. (2000) A Model of Collaborative Knowledge-Building. In B. Fishman & S. O’Connor-Divelbiss, eds. Fourth International Conference of the Learning Sciences. Mahwah, NJ: Erlbaum. p. 70-77.

Tamasese, K. & Waldegrave, C. (1993) Cultural and Gender Accountability in the ‘Just Therapy’ Approach. Journal of Feminist Family Therapy, 5(2); reprinted in The Dulwich Centre Newsletter 1994, 2 & 3, p 55 – 67.

Thomas, L. (1992) Psychotherapy in the context of race and culture: an inter-cultural therapeutic approach. In S. Fernando, ed. Mental Health in a Multi-ethnic Society. London: Routledge. Chapter 11, p 172 – 190.

Toye, J. (1999) Working with victims of racism. ACAT Newsletter Article.

Toye, J. (2003) Cultural Diversity and CAT. Reformulation Article .

Tribe, R. & Raval, H. eds. (2003) Working with Interpreters in Mental Health. Hove: Brunner-Routledge.

Wade, A. (1997) Small Acts of Living: Everyday Resistance to Violence and Other Forms of Oppression. Contemporary Family Therapy, 19(1,) March, p 23 – 39.

Waldegrave, W. (1990) Just Therapy. Dulwich Centre Newsletter 1, p 5 – 46.

Watson, G. & Williams, J. (1992) Feminist practice in therapy. In J.M. Ussher & P. Nicolson eds., 1992. Gender Issues in Clinical Psychology. London: Routledge. Chapter 10, p 212 – 236.

Welch, L. (2000) Private Misery, Public Rage and Poor Soundproofing - Seeking Happiness in the NHS. Reformulation Article.

Welch, L. (2003). Turning ter into tra: socialising the personal, personalising the social. Paper presented at ACAT International conference Valamo, Finland, 4-7 June 2003. Unpublished.

Welch, L. (2004) Thoughts on the Inner Dialogue Between a CAT Therapist and Karl - I am not a marxist – Marx. Reformulation Article.

Wertsch, J. (1998) Mind as Action. New York: Oxford University Press.

White, M. & Epston, D. (1990) Narrative Means to Therapeutic Ends. New York: Norton

Full Reference

Brown, R., 2010. Situating Social Inequality And Collective Action In Cognitive Analytic Therapy. Reformulation, Winter, pp.28-34.

Search the Library

Related Articles

The ethical implications of social class in the practice of CAT
Lucy Howe, 2013. The ethical implications of social class in the practice of CAT. Reformulation, Summer, p.36,37,38,39.

Concepts of the Self, Social Inequality, Culture and Power in reflecting on therapeutic work with Asylum Seekers and Refugees: A Cognitive Analytic Approach
Dr Claire Wilson, 2017. Concepts of the Self, Social Inequality, Culture and Power in reflecting on therapeutic work with Asylum Seekers and Refugees: A Cognitive Analytic Approach. Reformulation, Winter, pp.44-47.

Austerity, Power and CAT’s Opportunity for Change
John Cartmell, 2017. Austerity, Power and CAT’s Opportunity for Change. Reformulation, Winter, pp.5-7.

Cultural Diversity and CAT
Toye, J., 2003. Cultural Diversity and CAT. Reformulation, Autumn, pp.25-29.

Updating the Psycho-Social Checklist
Pollard, R. and Toye, J., 2006. Updating the Psycho-Social Checklist. Reformulation, Winter, pp.19-21.

Other Articles in the Same Issue

A Little Bit Of Bakhtin - From Inside To Outside And Back Again
Hepple, J., 2010. A Little Bit Of Bakhtin - From Inside To Outside And Back Again. Reformulation, Winter, pp.17-18.

A Suggested New Diagrammatic Formulation for Narcissists
Nehmad, A., 2010. A Suggested New Diagrammatic Formulation for Narcissists. Reformulation, Winter, p.44.

Accessible Snags
Melton, J., 2010. Accessible Snags. Reformulation, Winter, p.40.

Aim and Scope of Reformulation
Hepple, J., Lloyd, J., 2010. Aim and Scope of Reformulation. Reformulation, Winter, p.45.

‘When I’m The Dark Angel I Feel Worthless And Don’t Deserve Love’
Kirkland, J, 2010. ‘When I’m The Dark Angel I Feel Worthless And Don’t Deserve Love’. Reformulation, Winter, pp.19-23.

Creatively Adapting CAT: Two Case Studies from a Community Learning Disability Team
Smith, H., Wills, S., 2010. Creatively Adapting CAT: Two Case Studies from a Community Learning Disability Team. Reformulation, Winter, pp.35-40.

Financial Practicalities
Harvey, L., 2010. Financial Practicalities. Reformulation, Winter, p.46.

How Can Cognitive Analytic Therapy Contribute To The Understanding And Treatment Of “Sex Addiction”
Watson, R., 2010. How Can Cognitive Analytic Therapy Contribute To The Understanding And Treatment Of “Sex Addiction”. Reformulation, Winter, pp.13-16.

International CAT
Curran, A., Potter, S., 2010. International CAT. Reformulation, Winter, p.5.

Letter from the Chair of ACAT
Westacott, M., 2010. Letter from the Chair of ACAT. Reformulation, Winter, pp.3-5.

Letter from the Editors
Hepple, J., Lloyd, J., 2010. Letter from the Editors. Reformulation, Winter, p.3.

Letter to the Editors
Pollard, R., 2010. Letter to the Editors. Reformulation, Winter, p.5.

Mirror Workshop Summary Held On The 9th July 2010
Elia, I., 2010. Mirror Workshop Summary Held On The 9th July 2010. Reformulation, Winter, p.47.

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

Situating Social Inequality And Collective Action In Cognitive Analytic Therapy
Brown, R., 2010. Situating Social Inequality And Collective Action In Cognitive Analytic Therapy. Reformulation, Winter, pp.28-34.

The “Piacentino” Context In Which We Work As Aspiring CAT Practitioners In Italy
Fiorani, C., Poggioli, M., Provenzano, A., Romanelli, S., Sogni, A., 2010. The “Piacentino” Context In Which We Work As Aspiring CAT Practitioners In Italy. Reformulation, Winter, pp.6-11.

The Reformulation ‘16 Plus One’ Interview
Hepple, J., Lloyd, J., 2010. The Reformulation ‘16 Plus One’ Interview. Reformulation, Winter, pp.46-47.

The West Midlands CAT Practitioners Course 2009-2011
Darongkamas, J., Griffiths, Dr T., Williams, O., 2010. The West Midlands CAT Practitioners Course 2009-2011. Reformulation, Winter, pp.41-44.


This site has recently been updated to be Mobile Friendly. We are working through the pages to check everything is working properly. If you spot a problem please email and we'll look into it. Thank you.