Dunn, M. and Dunn, S., 2012. Concerning the Future of CAT and Other Relational Therapies. Reformulation, Winter, pp.10-13.
We are all concerned for the survival of CAT within the NHS. Here we wish to comment on that but also to draw attention to the bigger picture, in which we can see an attack upon relational values that underpin, not just relational therapies, but also liberal democracy – an attack upon the concept of relationship itself.
Underlying this is a philosophical problem that our culture and society seems unable or unwilling to come to terms with – the philosophical understandings that surround our notion of individuality. The concept of ‘mind’ and ‘self’ have for perhaps too long been left to philosophers and religious mystics. Recent developments in neurobiology bring us, as psychotherapists and counsellors, squarely into this arena. We must get to grips with our understanding of ‘mind’, ‘self’ and consciousness and what these concepts mean to individual mental health and the notion of relational community.
The most recent and thorough attempts at definition can be found in the current neurological and psychological research that underpins the work of Dr. Daniel Siegel and colleagues – the Interpersonal Neurobiology (IPNB) framework (see Siegel 2010). Here, ‘mind’ is described as the developing product of the complex interactions of a brain in relationship with other brains/minds. Within the IPNB understanding, as mind develops, a sense of ‘self’ emerges, and with that a sense of ownership of the mind. The key issue for us here is the notion of relationship in the formation of mind and self. Ryle’s writing clearly defines CAT as an inter-subjective or relational therapy – a therapy that acts through the medium of relationship. He emphasises an important philosophical distinction: that we are not enclosed, bounded selves - Cartesian objects in relation – bumping into each other, influencing and being affected by each other like snooker balls. Rather, CAT, like Interpersonal Neurobiology, posits dialogical selves in relation, subjects in a dance of voices, role-positionings and multiple ongoing relational processes.
The distinction is important, not only because it is central to how we understand each other, but also because it is vital to how we understand our society and in how we treat each other within our communities. In particular it informs and defines our relationship to those who are ill, impoverished, disabled, disenfranchised or otherwise compromised and dependant. Either we are divided into ‘us’ subjects and ‘them’ objects, or we are all together as interpersonal-subjects.
As CAT very clearly recognises, we are the stories we tell of ourselves and these stories are developed within and about relationship. Our integrity as individual minds and selves is determined by our relationship with other minds and selves and, quite literally, defined by how we treat each other. Unfortunately, this relational view of mind and self is far from mainstream. So, in a recession, when resources are squeezed and financial push comes to provisional shove, we find ourselves as therapists forced to play snooker. When we try to argue for the provision of relational treatments we get the response, “You’ve got a snooker table; why do you need dance classes?”
In recessionary times when threats to personal and community economic security are great and anxiety is running high, we see a retreat to former, simpler models of understanding. Liberal philosophies and ethical debate are abandoned for simplistic rules and extremist creeds. Economically we see a retreat from the complex and expensive to the simple and cheap. This retreat is affecting all branches of state provision, particularly the NHS. In mental health provision, this retreat is from relational therapies towards educational models, psychiatric drugs and forms of hypnotherapy.
We can avoid discussing the sucking of eggs with the readers of Reformulation, but it is useful to remind ourselves of those who have researched and written about what really goes on between mother and baby – and by extension, between human beings in relationship – which includes therapist and patient. Winnicott (1971), Bowlby (1988), Stern (1985), Schore (1994) and other research therapists, including Ryle (2002) and Leiman (1995), have shown clearly how relationally attuned mother-baby interactions produce emotionally secure and resilient children and further, how relationally attuned therapeutic interactions allow patients to acquire emotional security and resilience in adult life. One of the key research findings across all models is that the quality of the relationship between patient and therapist is the vital common predictor of successful therapeutic outcome (Roth et al 2006).
What does relational really mean? Responsive attunement is a harmony, a dialogue or dance of listening and speaking. It is a two (or more) -person process of careful, active, responsive attention, through which are developed two vital human capacities: empathy - the reflective emotional capacity; and insight - the reflective cognitive capacity, toward oneself and others. CAT’s value lies in its integration of these two factors – empathy and insight – the sense of being heard that a written Reformulation can allow, plus the making-sense-of-things that diagrammatic Reformulation of Procedures, Roles, Voices and Exits facilitates.
Skilful, attuned listening and responding allows therapist and patient to engage in two ways: to witness, validate and process trauma, pain and suffering; and to work collaboratively in the development of mental maps, cognitive and emotional mapping skills and mindful awareness, or meta-mind. Through this process we learn to trust both ourselves and each other. We become capable both of securely attaching (loving) as well as developing and being able to provide the emotional stability secure attachment allows. We can then provide this process and its positive effects to ourselves and others.
Dialogue between two people – that is, not just taking turns to talk, but taking turns to talk, listen, reflect and build on a shared understanding – is the foundation of mind, relationship, community and ultimately - democratic society. We are social beings who need to communicate, especially about our pain. When partners, parents, GPs and other professionals, or government won’t listen, we can feel alienated, and angry; we can also perversely begin to believe that pain and suffering in isolation are necessary and good for us. Human, relational values become downgraded. A person on a waiting list for therapy is hoping, not just that their problems may be solved, but that someone values them enough to listen and reflect; that someone will accept and validate how they are feeling; that someone cares enough to bear witness to trauma, pain and suffering. This careful witnessing is the basis of healing.
CAT is not the only therapy under threat in the current restructuring of the NHS. Nearly all meaningful provision of psychotherapy is being stripped out; it has already been excised from the Prison Service and elsewhere. The government, using the excuse of the quantitative research underpinnings of CBT, has named it the Gold Standard of therapy treatment, to the virtual exclusion of other models. Because the somewhat formulaic ‘cause-and-effect’ structure of CBT is easily quantifiable, it lends itself readily to quantitative research and analysis, which in turn through a wholesale reductionism, can provide tidy numbers and statistics that seem convincing. Thus, CBT has come to be seen as the ‘only’ model backed up by outcome research – which as we know, is utter rubbish. This, in many cases spurious and reductionist ‘outcome research’ - often rendered nearly meaningless by the need to exclude many untidy and subjective relational variables - has been extrapolated by various media to ‘demonstrate’ that CBT is the only model that is or can be research- based and further extrapolated to mean that only research based therapy is or can be effective.
This notion, which is thoroughly and dangerously wrong, has been provided to both government and media. As a result, it is this simplistic ‘flat-earth’ notion that is being consumed and adopted by the public. The general public, in ignorance of decades of qualitative research proving the compassionate efficacy of relational models of therapy, see no reason to raise their voices to protest the excision of relational therapies from mental health treatment.
Here it is important to remind ourselves that CBT and its cousin REBT can be performed in a relational manner as their originators intended. However, this does not often appear to be the case in practice now. The so-called ‘Gold Standard Treatment’ is being perversely twisted into a weird and impersonal arms-length educational model, piled high and sold cheap through the IAPT system. CBT-informed ‘classroom education’ is being offered instead of one-to-one relational therapy by young graduates ‘learning-on-the-job’. In some instances this educationally based CBT (CBT-Ed - see Feinmann, J. 2012) is being provided by long term-unemployed people, having been given 6 weeks ‘training’. This is the state of affairs that now threatens our profession and the healing we can provide.
As a result of all these issues, we find ourselves in an ugly paradox as we move forwards into the past. Those with personality disorders and addictions will eventually end up in prison, or with sadly truncated lives. The traumatised will get EMDR or hypnotherapy, and will be left to get on with a permanently crippled self. The depressed and anxious will get the above-described model of ‘CBT-Ed’. Despairing of NHS help, patients are likely to beg, steal or borrow money for private treatment – as we already see them doing. Both of us have now set aside 15% of our working time as unpaid in order to accommodate those who can pay little or nothing. Many of us operate a ‘Robin Hood’ model, in which we ‘steal from the rich’ in order to treat the poor. In doing so, we are in effect subsiding the government’s neglected responsibilities in our own small way. Several examples of ‘refugees’ from ‘CBT-Ed’ have turned up in our practice over the past few months. One such, presenting to her GP with anxiety and depression and seeking therapy, was given a CD of CBT ‘exercises’ to do on a computer in the waiting room. She promptly went home and took a severe overdose requiring expensive hospitalisation.
As participants and observers of mental health care over the last 25 years, we have seen how the values of the NHS have shifted in response to pressure from successive governments; perhaps the values of our society have shifted as well. What appears most valued now is the contract: the equation of pounds spent with numbers of patients ‘treated’ (not actual results) - that is, how many treatments for how much money. This has begun to define all social activity in business terms: in education, justice and healthcare – more is required for less; efficiency rules the day. Actual, valuable results don’t seem to even enter the equation. The values of humanity, compassion and well-being are excluded from the calculations because they require time, and time = money. In this kind of equation all valuable discernment ceases. It is no longer a matter of whether our children are well educated and prepared to take their places in the modern world; only school league tables and A* statistics matter. It is no longer a matter of whether our society is just, fair, morally responsible and safe; it is only crime statistics that matter. Similarly, in our profession, it is no longer a matter of providing mental health care or of healing those with mental health suffering but rather the statistics of waiting times and patients ‘treated’.
The quality of our caring professions and services are declining. Patients are increasingly seen as ‘diagnoses or problems on legs’ rather than people. We see this clearly in recent instances of companies running nursing homes for the elderly or learning disabled, in which they have been – in the service of ‘efficiency’ – allowed to employ monstrously unsuitable people, with little or no empathy, on minimum wage. We are then outraged that patients in these homes end up being neglected and abused. It seems as if it is now becoming acceptable for those in the caring professions – GPs and hospital staff included – to avoid developing any relationship with patients as people. It is becoming the status quo that we do not value empathy as a skill. As a result the caring professions are no longer seen as a vocation – the relief of suffering is not valued as a ‘calling’. These vocations are now less attractive to those most talented and skilled to enter them. All staff, NHS and private, are now expected to focus on the contract (the money and the number of treatments), often at the expense of the quality of outcome and inevitably at the expense of relationship.
It is hardly surprising that many, including ourselves, have left the NHS in order to sustain relational values within a private practice. However, we are all ultimately going to find ourselves in the hands of ‘bean-counting’ civil servants and health managers one way or another. As we age, we will find ourselves at the receiving end of either ‘efficient management’ or, if we make our voices heard now, some quality care.
In particular, it is now time to campaign for legislation that will properly criminalise wilful neglect in the provision of effective, humane treatment and care, covering not just those with dementia and other serious and enduring mental health issues, or those struggling with chronic and terminal illness, but also those suffering the torment of mental illness and crippling emotional instability. These sufferings can and must be mitigated in a humane and responsible society. Proper relational psychotherapy must be available to those whose lives have been blighted by abuse, neglect and trauma.
As psychotherapists, we have too long allowed ourselves to be fatally divided by our differences rather than to stand united by our similarities. We have also allowed ourselves to be divided and ruled by Government, Health Authority and Service Managers, both within the NHS and the private sector. We have allowed ourselves to be stripped of a role and a voice, to the extent that our pay is laughably poor considering the length of the post-graduate training our profession requires and considering the complexity, difficulty and responsibility that our chosen work entails. Other professions, requiring similar or even less training, experience and dedication and requiring the same or less shouldering of personal and professional responsibility, are much more richly recognised and remunerated. This is an indication of how our society has come to value relational healing. What lawyer, architect, doctor or accountant is remunerated as poorly? Which of these professions is as threatened in a failing economy as ours?
We have so far failed to mount a serious public argument for our effectiveness and therefore our existence. The research evidence exists for effectiveness of relational therapies (eg Roth et al 2006; Schore, 2012); it is now time to cite its existence publically, to draw attention to the value of what may be lost to our democratic-dialogic society, both in human and monetary terms. If we must speak the language of the bean-counters than so be it. The efficacy can be shown, but we must show it. We need to speak up in any and every way we can, and use all the research we know about, across models, as a flag to stand behind.
CAT is still a relatively cheap treatment, given the power of its ability to bring about change in often difficult-to-treat-clients. The old argument is still valid: left untreated, those euphemistically deemed ‘hard to help’ cost the NHS (and ultimately the taxpayer) a great deal of money. The lost productivity, the wastage of time and resources on endless crises and emergencies, the failed treatments and chronic attendance, the detrimental impact of chaotic and often abusive behaviour toward others at work and at home, the cost of violence and neglect, and the associated costs in the family and criminal courts is enormous. Multiple and chaotic family constructions and dissolutions spread the destruction wider and we all see the antisocial impacts of associated addictions and disorders.
The argument must be made that relational treatments work –and money must be spent on them to save much money elsewhere. In the short term, our government does not want to pay for relational treatments. But in the long-term, it can’t afford not to; they are the only thing that will produce humane, and ultimately money-saving, results. We must fight for our profession and the healing our society so vitally needs by making our voices heard. Now.
Bowlby, J. (1988). A Secure Base: Clinical Applications of Attachment Theory. Routledge.
Feinmann, J. (2012). ‘Coping with anxiety – on the cheap’. The Daily Telegraph, 1st October edition, p23. (Search for Jane Feinmann on The Telegraph website www.telegraph.co.uk)
Leiman, M. (1995). ‘Early Development’. In A. Ryle (Ed.) Cognitive Analytic Therapy: Developments in Theory and Practice. Wiley.
Roth, A et al (2006). What works for whom: A Critical Review of Psychotherapy Research. (2nd Edition) Guilford Press.
Ryle, A. and Kerr, I.B. (2002). Introducing Cognitive Analytic Therapy. Chapter 4: ‘Normal and Abnormal Development of the Self and its implications for Psychotherapy’. Wiley.
Schore, A. N. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. Lawrence Erlbaum Associates.
Schore, A. N. (2012). The Science of the Art of Psychotherapy. Norton Series on Interpersonal Neurobiology. See this series generally.
Siegel, D. (2010). Mindsight: The New Science of Personal Transformation. Random House.
Stern, D. N. (1985). The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. Basic Books
Winnicott, D.W. (1971). Playing and Reality. Tavistock Publications.
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