Whose Reformulation is it Anyway?

Jenaway, Dr A., 2011. Whose Reformulation is it Anyway?. Reformulation, Winter, pp.26-29.


Introduction

I have been thinking for some time about the disparity between the aim of the therapeutic stance in CAT, that of collaboration and dialogue, and the writing of the Reformulation Letter by the therapist alone.  Typically the therapist presents a draft letter at around session 4 or 5 and invites the client to comment on it, make changes, or rewrite it in the first person.  Several things, which I read, left me feeling a little uncomfortable with this part of CAT, even though I instinctively feel it is very valuable to write letters to clients in this way.  I have recently changed my practice and decided to write this article to explain how, with the help of one of my clients Meg.

Growing discomfort

The first thing which worried me was a research project by some of the IRRAPT trainees (Newell et al 2009).  They used an anonymous questionnaire to explore the impact of the reformulation letter received by their fellow trainees in their training CAT therapies.  I was a little shocked at the results.  Perhaps IRRAPT trainees are a particularly difficult lot to please, as research on the impact of the reformulation letter on patients has not been so negative (Refs 1,2,3 and 7), but perhaps they were also more confident in making negative comments about the experience.  Of the 26 trainees, 7  rated the experience of receiving the reformulation as a negative experience.  Even when the experience was positive overall, ratings of accuracy and empathy were very low (only 7 out of 26 rated it as very accurate and only 8 out of 26 as very empathic).  Also, 10 of the trainees felt there had not been enough time to discuss the letter.  Were some of my clients experiencing their reformulation letters in this way but not feeling able to report it?  How would I really know if all I was inviting them to do was to make corrections?  This might feel overwhelming if I had got it all wrong, upset them, or just missed the point somehow.

The second thing which I read, somehow striking a similar chord, was Jason Hepple’s article in the winter 2010 issue of Reformulation, about Bakhtin and dialogue.  I don’t think I had never quite got the point of Bakhtin, and Jason’s aim was to try and simplify some of his ideas and apply them to CAT.  He writes that for Bakhtin “dialogue is a joint activity that is unfinalisable, indeterminate and ever-unfolding.  Any particular moment in a dialogue is simply that: the current state of play – a work in progress”.  So why is the Reformulation letter treated as a document to be finalised?  The patient is invited to make corrections and changes but, in a way, encouraged to see that as the end of the process, a job completed in order for us to move on to the rest of the therapy.  I began to wonder if there was a way of making the process more of a genuine dialogue, less finalised, allowing more time for reflection and discussion.

Lastly, I was reading a book at this time called The Gift, written by Lewis Hyde.  It is impossible to summarise this whole book in a paragraph but Hyde’s main idea is that art, poetry and all creative work operates in what he calls a gift economy rather than the commercial economy of the market place.  A gift is defined as a thing that we cannot get by our own efforts, it is bestowed upon us.  Even if we have paid for the work of art, if it moves us then we are moved by the creative gift of the artist through the work and that has nothing to do with the price paid.  The artist receives inspiration in the form of a gift and passes it on to us.  As I read this book, I started to feel that our Reformulation Letters in CAT were somehow like a gift in this way.  I am paid to do therapy but, through the letter of Reformulation, some creative inspiration enters the process, which feels over and above what I am paid to do.  Hyde goes on to describe the anthropology of gift exchanges in primitive tribes, and also folk tales.  One major theme is that the giving of a gift establishes a relationship between the giver and the receiver of the gift.  In order to keep the gift alive, it must either be passed on to another, or be reciprocated with a gift of equal worth.  If the gift is not reciprocated then the receiver remains beholden to the giver.  It’s a fascinating book and it made me wonder what our clients can give us back in exchange for the gift of reformulation.

A possible solution?

At around this time, one of my CAT clients spontaneously wrote me a letter back, in response to my Reformulation letter to him.  His letter moved me, and seemed to deepen our therapeutic relationship in a way that no corrections or comments ever had.  Admittedly, he was an ex English teacher so he was used to writing, but I wondered if my other patients would also be willing to write back?  Would that help them to feel that the story was still unfolding, that they still knew things about themselves that I could never know in just four sessions?  Could it give them permission to say more openly “no, it’s not like that…it’s like this”?

I began to finish most of my Reformulation letters with “These are my thoughts and I’m sure that you will have some of your own.  Please write back to me with your response to this letter.”

Not everyone has written back, of course, and I have not asked those who struggle with literacy, but I have had some amazing letters.  Of the ten clients I have invited to write back so far, eight have done so, and the two who did not write back were not the ones who were most unwell.  One client wrote back from a kind of inner child self that we had not yet touched on in therapy, teenagers sometimes write to reveal an unexpectedly mature, reflective position that I didn’t know they had.  One lady wrote to me about how the reformulation letter felt accurate, but the task of change made her feel totally hopeless and this letter helped me to slow down for a bit and really take that on board.  I think this might have been glossed over if she was just commenting on my letter.  Often when someone who is bright and articulate does not write back it says something about their level of collaboration in the therapy – a kind of clear statement that they are wanting me to do the work and are waiting for some kind of magic.

I will leave it to Meg to introduce herself and reflect on her experience of being invited to write back.  I want to thank her for allowing her letters to form part of this article.  She has chosen a false name and we have cut some parts out of the letters to make them more anonymous.

Meg’s Introduction to letters

I am very pleased to be asked to contribute to this article as CAT has been really helpful for me and if my experience of it can potentially help inform / improve the experience of others that would be a very positive additional outcome.

Having reflected on being asked to write back (as I did not know that this was not the norm at the time of writing my initial letter) I believe that it was very important for me to be articulating in my own words the issues I was agreeing to work on.  There are a number of levels to this.

For me, using someone else’s words, even if they mean the same thing, can never be as effective or create the same sense of ownership as using my own words.  Particularly in the case of therapy, surely the problem has to be owned by me as the patient?  If I hadn’t felt ownership I don’t think I would have bought in to really working with Alison to get to resolution – and I did have some doubts about the possible success of CAT and therapy in general when I started this process.

I also feel that writing my own letter helped me to think through exactly what I was wanting to try and change.  If I had simply received a letter from Alison she would have shaped the articulation of the issues.  If that formulation had not been quite right I think I would have found it hard to rearticulate / redefine the situation more accurately.  At that stage of the CAT process I was a real novice as to what CAT was all about, how therapy works etc and also still building a relationship with Alison.  Having what may have seemed like a challenging conversation to “correct” a letter, while still feeling a bit fragile and quite unqualified as to what therapy is, might have felt difficult at that point, and I imagine in an extreme this could have caused disengagement or even drop-out from the process.

So writing my own letter gave me an opportunity to take time to reflect on my own understanding of the things I wanted to address, and importantly for me also gave me an opportunity to reflect on and connect with my feelings about those things.  I have typically found it hard to recognise and listen to my feelings so that was important, and subtly the start of trying to change some of my old behaviours and ways of operating.

In addition, linked to the reference above to gifts, the exchange of letters is like a form of contracting.  For me it helped shape the relationship as an adult-adult relationship rather than adult-child in any way.  I was not in debt to Alison and my view of the situation was equally valid.  I believe this was also important in setting up our sessions for success.

Meg’s Reformulation Letter

Dear Meg,
This is a letter to describe what we have learnt about your problems so far.  Please let me know if anything does not make sense, or needs changing or adding, so that it can become our shared understanding of what you might want to work on.

You were referred for therapy after treatment for cancer, which had left you feeling exhausted and depressed.  Your mood has improved and your life is going well now but you feel as if the cancer will always be hanging over you, threatening to interfere again, and you would like to be able to cope better with this threat.  You would also like to be less upset about your relationship with your mother.

You had thought that your childhood was a happy one, but, as we have talked about it in more detail, and seeing your friends with their children, it seems that there were problems.  You love your father dearly but he is not an emotional man – more reserved and old school, and he was away much of the time when you were young.  You were left with your mother and your younger sister.  Your mother is a difficult lady to please.  She seems not to have learned how to be a compassionate or accepting parent.  She constantly finds fault with everything you do, your housework, the way you coped with your cancer, your choice of career, your new chest of drawers!  Nothing is ever good enough.  You never visit them for long enough, or invite them round often enough.  You feel as if she is trying to take you over, to suffocate you.  It is hard to show any upset or vulnerability around her as this would be taken as proof that you cannot cope and she must take control.  When your sister died of cancer, you lost the person closest to you – the one person who you could talk about your mother to, without feeling guilty and disloyal.  Her death also left you as “all they had” and it is as if you had to suppress your own feelings so that you did not upset them anymore.  How were you able to grieve for your sister in your teens when you did not have a parent who was available emotionally to help you express your feelings?  Perhaps there is a new stage of grieving to do for each life stage that you reach without her by your side?  You feel angry that she died before you got to say goodbye properly.

Growing up with a constant feeling of being not good enough has interfered with your relationships with yourself and with others.  You are very self critical, needing to be perfect, and never quite achieving it (not surprisingly!).  During your cancer treatment, you were able to be kinder and more compassionate towards yourself and you found that a much nicer way to be.  However, as you have recovered, the old patterns have crept back in.  We tend, instinctively to parent ourselves in the way that we were parented.  Your old patterns are the familiar ones of control and criticism (like your mother) and not really there for me (like your father).

In relationships with friends, you tend to feel not worthy of care or kindness.  You can only ask your parents for help, as they would never say no!  With men you have often chosen “second best”, knowing that you were out of their league.  However, after a while you become critical and find fault with them and so the relationship does not last.  It is hard for you to risk being with someone who you really admire, as you would feel not worthy of them and fear them discovering this.

I hope that through this therapy you may be able to start valuing and validating your feelings more, rather than doubting them.  I hope that you can learn to be a more compassionate and more accepting parent towards yourself, helping you to feel good enough and worthy of love and care.

These are my ideas and I am sure that you will have some of your own.  Please write back to me with your response to this letter.

Alison Jenaway

Meg’s Letter in reply

Dear Alison,
Thank you for your letter which makes complete sense and I am amazed at the understanding you have developed in such a short time.

It was, and is, quite hard to read, as it is so true.  And because I guess I would like to think that things are fine and I have been working quite hard to make that be so.  It’s quite hard to accept that they are not OK and that my childhood wasn’t the perfect childhood that I would like to think I had.

I have felt quite flat this week and have gone into what I recognise is the usual pattern of seeing myself as rubbish because of this.  So I would like to put in writing that actually I am amazing for having got through the death of my sister and carried on, through feeling like I have to support my parents and my quite difficult mother and carrying on, and for dealing with my own full blown treatment for cancer and coming out the other side with a better balance on life overall.

I would also like to capture here that I feel it is a positive thing and a sign of strength that I am doing this therapy, not weakness (as I might previously have automatically thought).

So although I have got loads of mechanisms for not addressing the things you have highlighted and which I know are causing me problems, I would like to take this opportunity to actually do this, to properly find a way to deal with these things and be able to move on.

I really miss my sister, but since my cancer diagnosis I think I have suppressed that.  In the past I have grieved for the life stages and big events she wasn’t with me and for her children and my nephews / nieces that I won’t have, but now there is so much I have lost – my body, having my own children, expectation of long life – that I can’t concentrate on grieving for her.

I do not know how to deal with my mother.  Now that I am so aware of all that she says I realise that practically every conversation has some form of put-down.  I don’t think she will change.  But if I genuinely no longer accept her being so negative and refuse to take it any more then I can’t see any other way round this than to stop seeing her.  But I don’t want to lose my mother and ultimately my father too.  I already feel quite alone.

I would also like to remember how to give myself a break and be kind to me, as I was able to do when I was ill.

I think that this and my relationship with my mother are probably now bigger than the issues I have about not being able to have children and about how to cope with the ongoing threat of cancer coming back.  But those issues are still there and ultimately also make me sad, so if we have time (or after our sessions) I would still like to deal with those.

Hope this makes sense.

Meg

Conclusion

The idea of agreeing a shared understanding of the problems the client is experiencing in their life and relationships is one of the vital cornerstones of CAT.  I feel that it deepens the therapeutic relationship and engages clients in the process of trying to understand themselves like nothing else I have come across in my training.  However, there are clearly some clients who find the reformulation letter upsetting, or just plain wrong.  Perhaps it is when the therapist has moved a bit too fast, put in things which have not yet been fully discussed or digested, perhaps the therapist was busy or stressed when they wrote it and did not get the gift of inspiration in time.  I have started to invite patients to write back, and I have found myself feeling less pressured to “get it right” and make sure I have put everything in.  It feels more tentative, more like a letter which seeks a response from the other.  Perhaps this is particularly important when offering a therapy to those on the IRRAPT course!  I would love other people to try it and let me know what happens.

Finally, these are our thoughts and I am sure that you will have some of your own, please write back to Reformulation with your responses to this article!

References

Bennet, D. and Parry, G.(1998), The accuracy of reformulation in cognitive analytic therapy:  A validation study.  Psychotherapy Research, 81, 84-103.
Evans, J. and Parry, G. (1996) The impact of reformulation in cognitie analytic therapy with difficult to help clients.  Clinical psychology and psychotherapy, 3(2), 109-117.
Hamill, M., Reid, M. & Reynolds, S. (2008)  Letters in cognitive analytic therapy: the patient’s experience.  Psychotherapy Research 18(5), 573-583.
Jason Hepple, “A Little bit of Bakhtin – from Inside to Outside And Back Again”, Reformulation issue 35,winter 2010, 17-19.
Lewis Hyde, The Gift, Canongate Books Ltd (2007).
Adrian Newell, Aileen Garrihy, Karen Morgan, Cora Raymond and Harriet Gamble, “Receiving a CAT Reformulation Letter: What makes a Good Experience?” Reformulation issue 33, winter 2009, 29.
Shine, L. and Westacott, M. “Reformulation in cognitive analytic therapy: Effects on the working alliance and the client’s perspective on change” Psychology and Psychotherapy: Theory, Research and Practice (2010) , 83, 161-177.

Full Reference

Jenaway, Dr A., 2011. Whose Reformulation is it Anyway?. Reformulation, Winter, pp.26-29.

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