Bradley, J., 2012. A Hopeful Sequential Diagrammatic Reformulation. Reformulation, Summer, pp.13-15.
At the recent Conference for the British and Irish Group for the Study of Personality Disorder that I attended, it was very inspiring to see Steve Kellett presenting a piece of research, shortly to be published, on the effectiveness of CAT with clients who had been diagnosed with Borderline Personality Disorder and another presentation on a case study using CAT with a client who Steve described as having Paranoid Personality Disorder. Hearing Steve Kellet’s presentation prompted me to share some of my own experiences of working in a specialist PD service, particularly the use of the hopeful SDR in conjunction with techniques from Mentalization Based Therapy and Compassion Focused Therapy.
CAT is a rapidly developing therapy within secondary care mental health services. I work in a tertiary specialist personality disorder service and as a trained CAT Practitioner use CAT with my clients. However, referrals to the specialist PD service usually come as a result of a recognition that some clients’ needs cannot be met by the more traditional 24 sessions, particularly as most of these clients have been in the service for some considerable time, and building up a therapeutic alliance with often very distressed people with complex problems requires longer than the usual number of CAT sessions. The fear of abandonment can frequently prevent a client who has experienced extreme neglect, inconsistencies and rejection, from wanting to engage in a short, time limited form of therapy. However, CAT offers an excellent framework for reformulating these issues and, rather than be deterred by this time restriction, I have adapted CAT to work within this service by contracting for 48 sessions with a review around 24 sessions to remain focussed on the goals that we have agreed on during the assessment phase. The longer time frame enables me to draw on the skills that I have in other models, particularly MBT (Mentalisation Based Therapy) and CFT (Compassionate Mind Focussed Therapy). I will elaborate further below on my use of MBT and CFT and how I use them within the framework of CAT.
According to Bateman & Fonagy (2011), mentalization is the ability to step back and think about our thoughts, feelings, beliefs and wishes, whether inside or outside of our awareness, and the thoughts, feelings, wishes and beliefs of the other, ideally at the same time. Our awareness of these in ourselves and others helps us to understand our own behaviour and the behaviour of others, which is central to human communication and relationships. Without mentalization there is more potential for misunderstandings and thus disruption in relationships. MBT suggests that we all try to predict and influence our interpersonal and intrapersonal world in order to create understanding of each other’s behaviour and understand the intention of the other. Mentalization:-
For something as simple as maintaining a dialogue, we need to monitor our conversational partner’s state of mind. Perceiving and responding fluidly to their emotions ensures that our conversation goes smoothly. Our complex clients, particularly clients with personality difficulties, frequently have a very limited repertoire of reciprocal roles, which often creates unrealistic expectations of, and false assumptions about, the other. Being misunderstood often generates powerful emotions that result in confusion, frustration, hostility, defensiveness and rejection. I use my MBT skills to guide clients through the process of mentalizing – thinking about what is going on for them and what might be going on for the other. In order to activate their capacity for mentalisation, I take a curious stance, demonstrating my wish to understand and to help clients understand how they may have arrived at a certain conclusion about the other that may not, in reality, be what was going on for the other. Whenever possible, I use the SDR to facilitate this understanding. The process involves being respectful of the client’s narrative and expression, seeing things in the client’s framework, taking an unknowing, curious stance to generate the exploration of the client’s feelings, thoughts, wishes and beliefs whilst, at the same time, examining those of the other including mine as the therapist. Whilst one of the aims of CAT is to encourage self reflection using the SDR, MBT stimulates self reflection by guiding the client through the very complex mental processes, which become more restricted the more highly aroused a person becomes. The therapist therefore has to be attuned to this and recognise when to pause the process and try to reduce arousal through validation and support.
The Sequential Diagrammatic Reformulation (SDR) can, at times, be hugely overwhelming for some of our very complex clients, and some of my clients cannot tolerate looking at the SDR once it is completed. For clients to be faced with reciprocal roles such as abusing to abused, which are derived from hideously traumatic events in childhood, when they were completely helpless and powerless, can be a very distressing reminder of past traumas. This can lead to the re-traumatisation of very distressed clients. This poses a dilemma for the therapist, as the SDR is not only a map to facilitate understanding of the damaging relationships our clients can find themselves in , but also a potential source of further distress. For some clients, the recognition of abusive and traumatic RRPs in the SDR is so distressing that reformulation and revision becomes impossible.
In Compassion Focused Therapy Paul Gilbert (2010) draws on evolutionary theory, which asserts that the brain has been designed to protect us as a species. The brains of our distant ancestors could only deal with the more primitive processes needed for physical survival while the more evolved brains of modern humans have a much greater capacity for imagination, planning, rumination, mentalization, self awareness and identity, which are needed for psychological, emotional and social survival . CFT suggests that motives are the key to the organisation of our minds and that emotions guide us to our goals and regulate our responses according to whether we are succeeding or feeling threatened. CFT outlines three types of emotional regulation:
CFT acknowledges that for positive emotional health these three systems must be balanced. However, most of our clients are stuck between the threat system and the drive system with little connection with the more compassionate system. When the threat system is activated, the drive system is activated to avoid feeling the painful emotions associated with the threat, but as the SDR demonstrates, this can then reactivate the threat system and clients remain stuck in traps, dilemmas and snags.
I feel a vital part of the work we do with our clients, particularly those with a personality disorder, is to offer and hold on to hope. Without hope there is hopelessness and despair. Along with understanding, validation, acceptance, containment, empathy and encouragement, hope is required as a prerequisite for change as it motivates, energises and drives us forward, making what can at times feel unachievable, feel achievable. Hope enables us to believe that things could be different. I feel it is possible and necessary to demonstrate this diagrammatically in the form of a ‘healthy’ SDR, or in CFT terms, activating the more compassionate emotional regulation system. I use the whiteboard to list the aims of therapy down the left hand side of the board. I then ask the client to think about how they would need to be able to relate to themselves in order to achieve these aims. Sometimes clients need help with this in the form of “I’m wondering if instead of being critical/blaming towards yourself, it would be kinder to be more encouraging/supportive of yourself just as you might do with your friends, since we have seen how your old patterns can leave you feeling in a very painful place”. I will then map this on the white board. I will move along mapping out other reciprocal roles such as:-
‘Caring/kind/loving/gentle – cared for/ loveable/nurtured
‘Attuned/available/receptive – listened to/understood’
‘Respectful/accepting – respected/accepted/’.
The importance of highlighting these ‘healthy’ reciprocal roles is to encourage our clients to internalise them self to self. In my experience, clients are sometimes experts at enacting these reciprocal roles, self to other, particularly when these are part of an appeasing problematic pattern. As therapists, we try to model these ‘healthy’ reciprocal roles in our relationships, not only to our clients but to ourselves. We can then use the ‘healthy’ SDR to illustrate these ‘healthy’ relationships and the ‘unhelpful’ SDR to recognise those times when we are being pulled into a dysfunctional reciprocal role. I then map out patterns on the new SDR to identify how these ‘healthy’ reciprocal roles can be sustained. I find that using BAPAF ( belief, aim, plan, action, feedback) is often helpful. For example, the ‘Caring/kind/loving/gentle’ position is sustained by the belief ‘looking after myself makes me feel better’; Aim: ‘to identify what gives me comfort when I am feeling unhappy’; Plan: ‘to give that to myself’; Action; Feedback: acknowledge the positive feelings associated with giving myself what I need. The BAPAF process can, of course, be adapted to suit the individual client’s personal preferences. An example of a ‘healthy’ SDR is given below:
In essence the healthy SDR becomes the EXIT strategy but in a diagrammatic form. I have therefore devised a strategy to help clients who are able to tolerate the ‘unhelpful’ SDR to move across to the ‘healthy’ SDR. When clients find themselves caught up in a snag or a trap on the ‘unhelpful’ SDR, I use a list I have compiled called ‘Looking after me’ for clients to refer to in conjunction with the ‘unhelpful’ SDR as follows:-
If clients are unable to access the ‘unhelpful’ SDR this list can still be used to help them access the ‘healthy’ SDR from the distressed place they find themselves in. I have also used the list and the ‘healthy’ SDR when doing 5 session CAT consultancy. Both the list and the SDR’s can then be given to both the client and the care coordinator for their future work together.
Having worked for several years in a service where most clients have longstanding and complex problems that give rise to high levels of distress and associated unhelpful coping patterns, I have found that an SDR that only represents abusive and damaging reciprocal roles and procedures is often insufficient and, for many people, causes further distress. Such work requires the therapist to be highly attuned to the client’s feelings and to be flexible in the tools they use to facilitate the client’s capacity for self-reflection and change. I have found using the ‘healthy’ SDR can be very effective in helping clients, who might otherwise feel ‘stuck’ or unable to continue with therapy, develop a capacity for self care that enables them to recognise and change the reciprocal role patterns that have been the source of so much distress. I have written this account of my work in this area as I think it would be very helpful for other CAT therapists working with people with complex problems.
Jane Bradley, CAT Practitioner, Tees-wide
Specialist Personality Consultation and Therapy Service, Tees, Esk & Wear Valleys NHS Foundation Trust.
Bateman, A. W. & Fonagy, P. (2011), Handbook of Mentalization in Mental Health Practice, American Psychiatric Publication.
Gilbert, P. (2010), Compassion Focused Therapy. Routledge, London
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