Therapeutic Change that is Dialogically Structured, Mediated by Signs, and Enabled by a Relationship – A Case Example

Bristow, J. and Reason, A., 2010. Therapeutic Change that is Dialogically Structured, Mediated by Signs, and Enabled by a Relationship – A Case Example. Reformulation, Summer, pp.31-33.


Introduction to Context and Purpose:

John has written commentary at the beginning and end, from the perspective of a CAT supervisor with an interest in the application of Bakhtin’s ideas, especially as applied to psychotherapy and CAT by Mikael Leiman. Angela has presented the client’s story and described some of her own interventions as the therapist. The client then checked the story and made small changes, and agreed to publication. We are grateful to Tony Ryle and Mikael Leiman for reading this.

This account attempts to illustrate how signs and the memories, images, feelings and meanings associated with them can change as the (traumatic or problematic) experiences they trigger are revisited with the therapist in a safe context and then by the client on their own. It also shows how, in turn, changes in these signs and images, and their meaning, are essential for the therapeutic process to reach a point of completion: it needs to be a felt, expressed, enacted and embodied experience to lead to different, felt consequences. With the therapist it is an external dialogue with the joint use of signs, in relation to a memory, and at the same time a non-verbal subjective and inter-subjective experience. This is accompanied by the client’s and therapist’s internal dialogues. After a therapy session the client may continue with a series of internal reflections, dreams and experiences in relation to a memory. In this example this process takes place over 16 weekly sessions, and changes the client’s relationship with herself as a little girl, teenager and adult, through the reformulation of the meaning of the experience as an adult. These are dialogically structured processes, both internally and interpersonally. It is clear that changes in images and signs can express changes in meaning, so that the implications are felt and experienced fully in all parts of the person, impacting on the memory of the experience as it is felt in the body, and in muscles and sensations.

Case Example:

The client had been asked by the therapist to write down triggers that reminded her of the trauma with which she struggled. She did this and also brought to the session a photo of herself as a young girl at the age when the trauma was happening. When asked for a memory of herself as a little girl, she recalled an image sitting on the edge of her bed, fearful, expressionless and silent, waiting. She had witnessed some horrific events, and had felt she was actively involved and had done something awful. She used to tie knots in her handkerchief to remind herself that she might do harm to people. This feeling continued to plague her as an adult, filling her with dread, which she often felt at night time. This was the first time she had disclosed this to anyone. The therapist asked gently whether she was quite sure that this (her active involvement) had happened.

At the next session the client said that she had never questioned her belief about herself doing harm then. The realisation that it may not be true had an effect on her imagery; her recurrent memory of herself as a little girl in her bedroom changed. While awake, she pictured herself as a little girl smiling and playing rather than fearful and expressionless; she also pictured being tucked up in bed with soft pyjamas with some lights on rather than in a prickly night dress in the dark, her previous image.

Mikael Leiman raised an interesting question here: whether these semiotic phenomena were part of the original event, or reconstructions that became possible by the new observer position that was generated by the therapist’s question. It seems that these were reconstructions. He suggests that it shows the power of a jointly created “eye-land” in creating new meanings in relation to memories.

Later she incorporated this with an image of herself as a teenager and as an adult – all three lying in separate beds in the same room. This seemed to be a sign of a greater integration of her sense of self at different ages.

Some significant somatic changes also occurred. She had suffered from a locked jaw for years, associated, it seems, with the trauma as indicated by another dream a little later. A week or so later she had a dream of her mouth opening fully. When she woke up she could actually open her mouth fully for the first time in years. She interpreted this to mean that her self as a little girl had felt helped by her as an adult (during the therapy), and that she was now helping her as an adult in return.

There was still the belief left that she could be cruel to people (despite never having acted on this) – and violently powerful, in contrast to the powerless victim. Since her jaw release, she had felt vulnerable, as if there was a threat to her life. She and the therapist made some sense of this in terms of being restricted to two roles of the powerless, vulnerable victim or the powerful, harmful abuser. A week or so later she suddenly had a realisation while driving one day that she was not as powerful as she had thought, and not so powerless either. At about the same time she realised that the “bad me” belief from childhood did not apply to her as an adult as she could see this belief from a different perspective. She described this like a “penny dropping”.

The frequency and intensity of the flashbacks decreased considerably. Almost at the end of her therapy time she said the child and teenager in her had gone quiet; they were in the background and did not demand anything of her any more. A dream that she reported, toward the end of therapy, was of her being much bigger as an adult, (she’d had frequent dreams of being small), standing on prosthetic limbs that seemed to be a sign of change in her sense of self.

It seems that by using signs, images and memories in these ways she was coming to have a different interpretation of the original events and a different sense of, and relationship with, herself. As Tony Ryle put it, the meaning of the image of the guilty child on the bed was transformed and this was assisted by the therapeutic perspective adopted.

Further Discussion:

Aristotle said that “the eyes are the window into the soul”. It would appear that images, a reflection of what we see, can have a similar function in expressing something that cannot be made explicit in words in other ways. Images (and other non-verbal forms of expression – used in the arts), can act as bridge between feelings and thinking. Signs can bring up images and memories of experiences as they, as signs, are part of those experiences too, both at the time and in reflection afterwards. In bringing back these experiences and their meaning for re-evaluation, they have an “epiphanic” propensity as Leiman puts it. “Epiphanic” literally means (from the Greek, “epi-phaino”) to “make manifest” or “throw light on” (only with a capital “E” does it mean make a “divine presence” manifest!). Helen Keller (See Miss Keller’s autobiography of her early years, The Story of My Life,) writes how, while deaf and blind from the age of 19 months, she learnt the function of word signs to convey meaning when her “teacher” put her hand in water and then wrote the letters for water on her palm. This opened up a whole new way of making and communicating meaning for her, just as it probably does when an infant learns how his or her movements can be signs, as gestures, through the meaning given to them by the (m)other.

Signs, that are a key part of the experiences forming a sense of self in relation to others and the world, are also key in transforming the meaning of the memories of these experiences and the sense of self resulting from them. What is formed in relationship with others, also seems to be changed in relationship with others (in this case with the therapist): what the therapist expressed non-verbally and verbally here set off a dialogically structured process that the client could carry on between sessions, remaining supported by the therapist throughout. This led to reformulating and integrating these experiences, now framed in the context of a different relationship and dialogue. A key response from the therapist occurred again when pointing out the restrictions of the two positions or roles around power and its expression and use, starting off another process that was completed later. As Bakhtin writes, there are nevertheless other meanings that can come from an experience if revisited at another time; the dialogue can continue.

The therapist was able to use the signs used by the client, close in appearance and description to their original experience, and to talk and think about it with them – using more abstract conceptual metaphorical signs, including the C.A.T tools of letter and diagram, and create with the client a different position from which to look at the experience. Some signs evoke feelings or sensations, others (such as metaphors), represent perceived patterns and others again invite thinking or feeling about the experience – and the therapist can choose what to use at different moments. This is similar to what Bruner and Jung describe as different forms of cognition or knowing from experience. The therapist here combines them and helps the client to do so: first sensing – using signs close to the five senses together with intuitive perception of pattern, as in stories and drawings. These can then lead on to exploring meanings with feeling and thinking, as forms of judgement or evaluation of the experience, the conclusions drawn about the world and others, and oneself in relation to them. This illustrates how making sense of the senses is originally learnt through joint activity – carried on by oneself after that. This contradicts the view of humans as individual rational sense-makers (Aristotle and the subsequent prevailing western cognitivist tradition). This disregards or plays down the established fact that our initial emotional, social and cognitive development is dependent on learning through relations with others, and that our continuing development and activity takes place always within a social context even if enacted alone.

Representations can be part of the more explicit processes of cognition and signs are of course used for them too. In the original meaning of re-presenting (bringing to the “mind’s eye” and thinking about an experience as if reflected in a “mirror”), signs of all kinds help objectify the experience which then makes talking or thinking about it possible. Neuroscientists and cognitive psychologists use the word “representation” to refer to aspects of the subconscious organising processes of the brain and mind such as organising and storing experiences and behaviour as memories for adapting and learning. The storing, organising and recalling of these memories occur in different parts of the brain and at different stages of processing. The organisation of cognitive-affective, often state-specific, memories shape the use of our senses and the preconscious appraisal processes that mobilise our procedures (in CAT terms), our learnt perceptions and associated feelings and motor responses. They also enable internalisation and generalisation of what is learnt and remembered; in CAT terms, both roles can be enacted not only to others but also towards ourselves, affecting our sense of self – as illustrated in this case example. These preconscious processes bias any conscious sense making that follows. The initial output is available for further (higher) processing and sense making, which phylo/ontogenetically develops over the first three years of life and beyond. This may be similar to CAT metaprocedures at subconscious and reflective levels. Re-organising aspects of all these kinds of structure is seen as essential to embedding therapeutic change. In CAT this is seen as revising distorted or dysfunctional procedures, adding to a restricted repertoire or/and creating a more integrated, less fragmented, self-structure. The embedding seemed to occur with this client.

Unlike representations, signs are co-created or learnt between people to convey meaning which then becomes associated with the sign; they have an existence of their own, within a culture, as Bakhtin states. “Semiotics” originates from the Greek word for sign and the verb that means to show by a sign. They are then used to convey or signify meanings in our internal mental states and processes as well as in our communications with others. Signs both as sensory signals and memories, and also as words with different levels of abstraction, are co-created or learnt in interaction with others, even from hearing the sounds of voices while still inside the womb. They are also key in our non-verbal communications from birth on and play a part in the organisation of our subjective and inter-subjective experience, our socio-emotional development and the behaviour that stems from it.

Allan Schore has brought together findings from cognitive and affective neuroscience and studies of infant-caregiver interactions that show how emotional and social development is dependent on experiences in the first 20 months, with key attachment figures, that shape the organisation of experience and behaviour at the preconscious level: how we experience, moderate and express our feelings and restore emotional equilibrium and how we relate to others and ourselves. (Vygotskian principles seem applicable to socio-emotional and right brain development too.) The key ingredients of a good enough attachment relationship that enable infants to develop emotionally and socially, and recover from distress, unmanageable feelings or rupture, Schore points out, also apply to the therapeutic relationship. Here the client was able to approach traumatic memories and make new sense of them, from a different, more adult position.

For therapy to work the whole person needs to be involved, all key parts of the nervous system, brain and mind – sensing, feeling, seeing, thinking – just as music apparently reaches most parts of the brain too. Some signs can make more links in us than others and resonate more fully, often working, like metaphor, through similar or analogous patterns (again perhaps like the mix and sequence of vibrations in music). Some signs have more universal or culturally shared effects, others more idiosyncratic or personal meanings. As CAT therapists we can attend to and explore which ways memories of experiences can be accessed and meanings expressed and conveyed, verbally and non-verbally, with a client, using signs and tools. In this example the image of herself as a child was the most relevant to finding a medium through which to relate to her traumatic early experiences from a revised adult position, with the help of the therapist.

I would be delighted if readers send in comments to the editors of the Reformulation journal, or direct to me john.bristow1@btopenworld.com

References

Leiman, M: Papers on Bakhtin, Voloshinov and their application to psychotherapy and CAT and on DSA in supervision: see ACAT website www.acat.me.uk and University of Joensuu website/Leiman www.joensuu.fi scroll down to English and then search for Leiman.
Schore, A. N. Minds in the Making: Attachment, the Self-Organising Brain and Developmentally oriented Psychotherapy – 7th Annual Bowlby Lecture. Ch 1 of Conigall. J. and Wilkinson, H. (eds) (03) Revolutionary Connections: Psychotherapy and Neuroscence Karnac
Michael H. Thaut (07) Rhythm, Music and the Brain: Scientific foundations and clinical applications Taylor and Francis. Music and mathematics have been called the best forms of sign and language for conveying meanings about the nature of our world.
For those of you who want to explore the concept of self-organisation mentioned by Schore further – see the excellent 1 hr BBCTV Channel 4 programme by Furnace Films: http://furnacetv.com/programmes/secret-life-of-chaos (Click on the picture). Everything in nature and the known universe seems to follow the principle of order together with unpredictability (chaos) through self-organising that follows simple patterns that can be described in terms of rules, often expressed mathematically, while producing complex systems that adapt to the environment through feedback. Evolution follows these principles, over generations in species and historical stages or periods in societies. These ideas have been developed over the last 70 years and are likely to revolutionise the way we see the world and our place in it.

Dr Angela Reason BA (Hons), MSc (Dist), D Clin Psych. is a Clinical Psychologist and CAT Practitioner. Since qualifying in 2002 she has worked with both Adults and Older People. She currently works in East Sussex in a Psychological Therapies Service with adults with severe and enduring mental health difficulties, with a special interest in complex trauma, and in a specialist Memory Service for older people with memory problems and suspected dementia.

John Bristow (BA, BSc, UKCP) is a CAT Pschotherapist, in private practice in Brighton while supervising and training others in CAT in the NHS. He is also a Chartered Organisational Psychologist working with leaders and managers, who are currently initiating innovation towards a low carbon economy, while continuing to coach and supervise executive coaches and (within the BPS mainly) organisational psychologists.

Full Reference

Bristow, J. and Reason, A., 2010. Therapeutic Change that is Dialogically Structured, Mediated by Signs, and Enabled by a Relationship – A Case Example. Reformulation, Summer, pp.31-33.

Search the Library

Related Articles

Change of State: Learning How To Manage Unmanageable Feelings and States
Bristow, J., 2006. Change of State: Learning How To Manage Unmanageable Feelings and States. Reformulation, Summer, pp.6-7.

Attachment, The Body and Trauma
Diamond, N., 2005. Attachment, The Body and Trauma. Reformulation, Autumn, pp.25-26.

Comment on James Turner’s article on Verbal and Pictorial Metaphor in CAT
Hughes, R., 2011. Comment on James Turner’s article on Verbal and Pictorial Metaphor in CAT. Reformulation, Winter, pp.24-25.

Book Review of: How Infants Know Minds. Reddy, V. (2008). Harvard University Press.
Ryle, T., 2009. Book Review of: How Infants Know Minds. Reddy, V. (2008). Harvard University Press.. Reformulation, Summer, pp.33-34.

History and Use of the SDR
Ryle, A., 2003. History and Use of the SDR. Reformulation, Autumn, pp.18-21.

Other Articles in the Same Issue

Australia and New Zealand Unites Again; This Time to Consolidate the Promotion & Practice of CAT in the Region
McCutcheon, L., 2010. Australia and New Zealand Unites Again; This Time to Consolidate the Promotion & Practice of CAT in the Region. Reformulation, Summer, p.50.

Book Review: Self-Harm Assessment in Young People – A Therapeutic Assessment manual By Dennis Ougrin, Tobias Zundel and Audrey V. Ng Published by Hodder Arnold, 2010
Jenaway, Dr A., 2010. Book Review: Self-Harm Assessment in Young People – A Therapeutic Assessment manual By Dennis Ougrin, Tobias Zundel and Audrey V. Ng Published by Hodder Arnold, 2010. Reformulation, Summer, p.49.

Cognitive Analytic Therapy and the Role of Brief Assessment and Contextual Reformulation: The Jigsaw Puzzle of Offending
Mitzman, S. F., 2010. Cognitive Analytic Therapy and the Role of Brief Assessment and Contextual Reformulation: The Jigsaw Puzzle of Offending. Reformulation, Summer, pp.26-30.

Confidentiality and Good Record Keeping in CAT Therapy - A Discussion Paper
Brown, H., 2010. Confidentiality and Good Record Keeping in CAT Therapy - A Discussion Paper. Reformulation, Summer, pp.10-12.

International CAT News
Potter, S., 2010. International CAT News. Reformulation, Summer, pp.51-52.

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

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

Reflections on ACAT Relational Skills in CAT Supervision Course – December 2009
Coombes, J., Dunn, M., 2010. Reflections on ACAT Relational Skills in CAT Supervision Course – December 2009. Reformulation, Summer, pp.46-47.

The Development of a 12-Session CAT Therapy for Use in a Workplace Setting
Collins, J., 2010. The Development of a 12-Session CAT Therapy for Use in a Workplace Setting. Reformulation, Summer, pp.13-16.

The Development of a Cognitive Analytic Therapy (CAT) Relational Framework for Bipolar Disorder (BD)
Shannon, K. and Swarbrick, R., 2010. The Development of a Cognitive Analytic Therapy (CAT) Relational Framework for Bipolar Disorder (BD). Reformulation, Summer, pp.17-25.

The Political Sources of Reciprocal Role Procedures
Ryle, T., 2010. The Political Sources of Reciprocal Role Procedures. Reformulation, Summer, pp.6-7.

Therapeutic Change that is Dialogically Structured, Mediated by Signs, and Enabled by a Relationship – A Case Example
Bristow, J. and Reason, A., 2010. Therapeutic Change that is Dialogically Structured, Mediated by Signs, and Enabled by a Relationship – A Case Example. Reformulation, Summer, pp.31-33.

Thoughts and Experiences of the Application of Cognitive Analytic Therapy to Clinical Work with Adolescents
Mulhall, J., 2010. Thoughts and Experiences of the Application of Cognitive Analytic Therapy to Clinical Work with Adolescents. Reformulation, Summer, pp.34-36.

What Happens After “Happy Ever After”?
Jenaway, A., 2010. What Happens After “Happy Ever After”?. Reformulation, Summer, pp.8-9.

Will ACAT Join Other Professional Bodies in Calling for an End to the Detention of Families with Children?
Toye, J., 2010. Will ACAT Join Other Professional Bodies in Calling for an End to the Detention of Families with Children?. Reformulation, Summer, pp.47-48.

Words With Arrows The Benefits of Mapping Whilst Talking
Potter, S., 2010. Words With Arrows The Benefits of Mapping Whilst Talking. Reformulation, Summer, pp.37-45.

Help

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 support@acat.me.uk and we'll look into it. Thank you.